Posts Tagged 'NHS'

Election focus: Avoiding Another Failed NHS Experiment

In the next post in our Election Focus series, David Hunter, author of The health debate, explains that the election must not become an excuse for shelving much needed health system transformation.

David Hunter

“A possible unwanted side effect of this most avoidable of unnecessary general elections, and the accompanying purdah into which everyone has slumped, is the impact on the NHS reforms initiated by the NHS Five Year Forward View published in 2014 and its update in the Next Steps delivery plan published last month.

One can only hope the NHS Chief Executive, Simon Stevens, is correct when he asserts that ‘there is no version of reality’ in which his changes will not be needed and actively pursued. Even if he is proved right there could still be disruption if a new health secretary replaces the current post-holder, Jeremy Hunt.

Or if the all-consuming Brexit negotiations divert the government’s focus and slow down the pace of change as seems likely. Or if a new administration decides to replace Stevens. As the chief architect and champion of the changes, he is critical to their success, especially at such a delicate stage in their evolution and before they have been fully embedded.

New Care Models and Sustainability and Transformation Plans

The election comes at a pivotal time in regard to progress with the New Care Models (NCM) nested in the Vanguards initiative and the evolving Sustainability and Transformation Plans (or Programmes if you prefer) (STPs) agenda.

“…opens up the prospect of further stalemate and a failure once again to get to grips with long overdue changes to reshape the NHS for the new challenges it faces.”

In the case of STPs, Labour has stepped back from its rather foolish pledge announced in the leaked manifesto to impose an immediate moratorium on them if elected. But while the final manifesto now states that Labour will merely ‘halt and review’ STPs, the move still heralds a return to heavy-handed ministerial meddling from the centre.

As a way of running the NHS, it has rarely if ever been desirable or worked. Moreover, it opens up the prospect of further stalemate and risks failing once again to get to grips with long overdue changes to reshape the NHS for the urgent and complex challenges it faces.

What’s needed?

For the changes to succeed requires sensible resourcing and sustained commitment over a reasonable time period, both of which are already fragile under the current government. If re-elected with a larger majority it is unlikely much will change which could leave the changes in a precarious state, especially when coupled with the desperate pressures the NHS is already under both in terms of financing and staff recruitment.

So, while perhaps not putting the changes at risk in the way Labour’s proposals seem destined to do, a Conservative government with a fresh mandate need not axiomatically be good news for the NHS.

If the political outlook for the NHS changes presently being implemented looks potentially bleak or risky whoever wins, it will be incumbent on senior managers and clinicians, perhaps with the support of the Royal Colleges and others, including local government, to lead and drive the changes.

An opportunity

The Vanguards and STPs represent a chance of a lifetime opportunity to transform the NHS as it approaches its 70th birthday in July 2018. Too often in the past resistance to change has won out and the result has been an NHS which in many respects has become ossified and no longer fit for purpose given the changes in demography, lifestyles and the evidence of growing inequalities.

“Too often in the past resistance to change has won out.”

Successive inquiries and critiques of the NHS have pointed to the repeated failure to take prevention and public health seriously, to integrate health and social care, and to rebalance the health system away from costly, acute hospital care. The Vanguards initiative and STPs are confronting head-on all these deep-seated systemic problems that have persisted in the NHS for decades.

Drawing conclusions from the NCMs is premature and inconclusive. Generalising from very complex and different models and contexts is a hazardous business. But, putting these health warnings to one side, the early evidence emerging shows a passion, enthusiasm and high level of commitment to make the changes work. They are also felt to be the right way to go in terms of patient care.

Once the evidence from the local evaluations starts to appear later this year, there will almost certainly be a mix of likely successes and failures although it will take longer to assess how far the changes have actually impacted on health outcomes. It is also the case that, as the Public Accounts Committee concluded recently, STPs are a mixed bag and of variable quality. In most places, engaging local government and the public should have assumed a much higher priority at an earlier stage.

But when all is said and done, the unprecedented transformation journey on which the NHS has embarked has given permission to local areas to chart their own destinies within a national framework providing support and development know-how. It is not perfect and tendencies for old-style, command-and control behaviour to surface have to be resisted. Nor is the overall financial climate helpful or sustainable although, if one is honest, resource pressures have been an important stimulus for change.

If the changes underway can be maintained post-election and the NHS becomes a genuine health service rather than a sickness one, which it has been since its inception, then that must be the goal of all those who want the NHS to survive and should be embraced enthusiastically.

Warts and all, we should not squander this opportunity to transform the NHS so it can meet the 21st century challenges confronting it. Surely that has to be a 70th birthday present to remember.


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It’s not just about the money: 5 dilemmas underpinning health and social care reform

Following on from the publication of the third edition of Understanding health and social care, Jon Glasby looks at what’s needed for long-term, successful health and social care reform.


Jon Glasby

Open any national newspaper or turn on the news and (Trump and Brexit aside) there is likely to be coverage of the intense pressures facing the NHS.

Throughout the winter, there have been stories of hospitals at breaking point, an ambulance service struggling to cope, major problems in general practice and significant financial challenges.

For many commentators, this is one of the significant crises the NHS has faced for many years, and quite possibly the longest period of sustained disinvestment in its history.

“Draconian funding cuts have decimated services at the very time that need is increasing.”

Continue reading ‘It’s not just about the money: 5 dilemmas underpinning health and social care reform’

Get social care right and the NHS will benefit

How can we improve access to and quality of social care? Catherine Needham, co-author of Micro-enterprise and personalisation, discusses how micro-enterprises and micro providers could improve care services. 


Catherine Needham

At a time when the Red Cross is warning of a ‘Humanitarian Crisis’ in the NHS, there is a growing recognition that pressure on NHS services will not be alleviated unless we get social care right.

Social care services support frail older people and people with disabilities. They are run by local government and have borne the brunt of the local authority cuts in recent years, with around 26 per cent fewer people now getting help than did in the past.

Many care providers have gone bust due to downward pressures on fees and in many parts of the country it is very hard to recruit trained staff to work in care when the pay rates are higher at the local supermarket.

“It is very hard to recruit trained staff to work in care when the pay rates are higher at the local supermarket.”

Together these pressures contribute to older people being stuck in hospitals, unable to be discharged into the community because the support is not available to them.

Fixing social care

Getting social care right is not a quick fix. Access to good quality, affordable care for people with disabilities and older people is a challenging issue.

Continue reading ‘Get social care right and the NHS will benefit’

An Unhappy NHS – Taking the Long View

Today’s guest blogger and author of The Health Debate, now in its second edition, David Hunter, tells us why we need to dig deeper to understand and change the chronic unhappiness in the NHS…

David HunterAs it enters 2016, the NHS is not a happy organisation. It hasn’t been for some time but the problems and pressures that have gathered pace through 2015 are coming to a head.

A threatened strike by junior doctors is already a firm possibility but other issues are mounting by the day, ranging from cash‐strapped hospitals, allegedly underperforming GPs, shortages of clinical and nursing staff, poorly integrated health and social care, non‐existent or threadbare mental health services, the persistence of a bullying culture, to unforeseen cuts in public health funding that threaten to put further pressure on an already over‐stretched NHS. The list goes on.

The quick fix

It is tempting to pick these issues off one by one, reaching for the quick fix while also finding someone to blame for allowing things to reach such a parlous state. That would be a mistake and would fail to understand the forces that have brought the NHS to where it is today.

Taking the long view is a necessary prerequisite to finding appropriate solutions. Continue reading ‘An Unhappy NHS – Taking the Long View’

Do you want a better NHS or more equal health outcomes for all?

Jonathan Wistow, lead author of Studying health inequalities which published this week, explains why a better NHS is not necessarily the answer to ensuring greater health equality.

Wistow4Few things are as important to the quality of life as the number of years healthy life expectancy and overall life expectancy. 

So why, nearly 70 years after the creation of the NHS, do we have wide variations in health outcomes that are related to peoples’ different and unequal positions in society?  We might expect a universal free at the point of delivery health service to narrow these inequalities.  However, this has not been the case.

Social problem

To address this issue, it is necessary to view health inequalities as a ‘social problem’ – a problem that is created by, and exists within, society.  As such health inequalities provide a useful and significant insight into the dynamics of contemporary societies.

They reflect (amongst other things) the distribution of wealth; the way that we live our lives; the way that services are organised; the quality of, and access to, different services and amenities; the history of places; where people want to live; where people actually live; what people do for work; and the opportunities and options people have throughout their different life stages.

“health is too often conceived of as an individual and medical issue in both the way it is resourced and understood”

However, health is too often conceived of as an individual and medical issue in both the way it is resourced and understood. This is significant not only in terms of how public resources are prioritised (particularly during periods of austerity) between NHS, public health, local government and community and voluntary sectors but also in terms of how we view rights to services and/or outcomes.

Following a general election when resourcing of the NHS was a major issue and priority for all of the main political parties it is reasonable to ask whether we want a better NHS or more equal health outcomes for all?  These are not necessarily mutually reinforcing goals.  The former is about service delivery and the allocation of public funds and the latter is about redistribution as well.

A key issue to consider here is the nature of the social contract and how the balance between individual and social rights is prioritised. In the UK over the past 30-40 years a more or less free market based capitalism centred on individual rights has been pursued and we have witnessed a substantial increase in socio-economic inequalities in this period.

This shapes how equality is viewed and the extent to which there is a challenge to divisions of power, wealth and security in society. In turn this has implications for both the existence of inequalities in health and policy solutions to these.

“we are more concerned with individual rights to services than with collective rights to more equal outcomes”

Consequently, despite the existence of the NHS we are more concerned (in policy at least) with individual rights to services than with collective rights to more equal outcomes. Such a move to more equal health outcomes would require a much more fundamental redistribution of health across society and a return to the European tradition of pursuing equality of condition.

There is a further methodological issue that is important for framing how we understand and, as a result, respond to health inequalities. At an individual level potential causes of health inequalities relate to a complex combination of lifestyle behaviours which influence the socio-economic distribution of health risks associated with, for example, smoking, diet, exercise, bodyweight, and exposure to sunlight.


It is very difficult to isolate these behaviours and attribute causation to them as individual variables. Indeed we can question whether this is a desirable strategy given that in practice people do not live their lives in neat and separate component parts: diet, frequency of exercise, social and work activities, alcohol and nicotine consumption, are all parts of the complex whole that make up individuals’ lifestyles.

But this is still not the whole picture. Lifestyle, in turn, relates to (but is not wholly determined by) the contexts in which people live their lives. Different people react to these different contexts differently.

When we talk about contexts here we take a broader approach, including family, workplace, neighbourhood settings, towns, cities and regions – all important contextual characteristics within which people lead their lives.  It follows that we should take a research approach that concentrates on the complex interactions between people and settings.

To develop more equitable health outcomes in society our understanding of health needs to be based on the kinds of policy, ideological and methodological issues identified above.  Without such a broad consideration achieving fairer health for all seems particularly challenging.  However, there is scope to consider health as a key focus for redistribution and one that may help to move equality back up the political agenda.

Jonathan Wistow is a researcher and teaching fellow, in School of Applied Social Sciences, Durham University.  His interests include health inequalities, governance and local government.


Studying health inequalities [FC] 4webStudying health inequalities published on 30th June 2015 and you can order your copy from our website here (RRP £24.99).

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Personal health budgets in long term health care: how will the NHS adapt

Vidhya Alakeson

Vidhya Alakeson

by Vidhya Alakeson, author of Delivering personal health budgets: A guide to policy and practice, published this week 

Luke has Batten’s disease, a rare degenerative condition which means that he needs day-to-day support from a team of six. For six years, he worked with the same team employed by his family, using a direct payment from the local authority. But when Luke turned 18 and his care transferred from Children’s Services to NHS Continuing Healthcare, his family was told that they could no longer employ the team they knew. The NHS would instead select an agency to care for Luke and his family would no longer be in control.

Fortunately, from April this year, fewer families should find themselves in the distressing situation that Luke and his family experienced, thanks to the introduction of personal health budgets. From April, the 56,000 people like Luke with significant health and support needs who qualify for NHS Continuing Healthcare will have the right to ask for a personal health budget rather than receive care commissioned on their behalf by the NHS. From October this year, that right will be strengthened further into a right to have a personal health budget.

Personal budgets have become an established part of the landscape in social care. The same approach is now being extended into the NHS to provide individuals with long term conditions and disabilities greater choice and control over how their healthcare is delivered. Personal health budgets allow them to decide how best to meet their own needs with the resources the NHS allocates to them. For some people, small changes, such as having care staff come to their home at a different time of day, make a significant difference. Others want to make bigger changes, putting together a different mix of services and supports from the one the NHS would purchase for them.

A three year national pilot programme compared outcomes for 1000 people with a personal health budget across a range of conditions, and a control group of 1000 people receiving care commissioned as normal by the NHS. The evaluation found that individuals with personal health budgets had a better quality of life and better psychological well being than those in the control group. Taking control did not result in budget holders experiencing any deterioration in their clinical health. In fact, budget holders made less use than those in the control group of other NHS services such as Inpatient, Accident and Emergency and GP services.

However, the evaluation was also very clear that the way in which personal health budgets are implemented can determine whether or not they have a positive impact. Personal health budgets must offer real choice and flexibility to allow individuals to maximise their creativity and not bind people to pre-determined menus or clinical notions of evidence-based practice. Delivering personal health budgets offers a definitive guide of how to make personal health budgets work well for people, as well as setting out for clinicians and commissioners the positive role they can play in improving the management of long term conditions.

Delivering personal health budgets: A guide to policy and practice by Vidhya Alakeson is now available with 20% discount at

The art of introducing organisational innovations

Organisational innovation in health services coverIf only politicians and policy makers learnt from the experiences of their predecessors. Especially, one might argue, if the consequences of that experience have been rigorously researched.

In our book published last month, Organisational innovation in health services, based on a study of the introduction of treatment centres across the NHS, we followed the way eight of the pioneering NHS centres were created and run in the early days of the last government. The aim was to see how organisational innovations work out in practice. What emerged instead, was a set of detailed stories about the way a major national programme of change was implemented.

These stories showed time and again how easily local circumstances can subvert the policy makers’ best intentions. How a plethora of policies can unintentionally but fatally undermine each other. How ill thought-out central policies can clash with the local running of services. And yet how, despite all these tensions, front line staff can sometimes bring about real improvements.

None of this will come as any surprise to anyone familiar with implementing change in the NHS. Alas, though, it seems the politicians and policy makers are carrying on blithely as if none of it were true.

Our study led to a wide range of suggestions about the art of introducing organisational innovations. Several of our numerous general recommendations were aimed specifically at policy makers and yet, it is plain to see the same mistakes being repeated in the government’s current attempts to reorganise the NHS.

One example of the fairly obvious suggestions supported by our research was that “specific training may be required among managers at all levels of the service. Successful implementation of organisation-wide innovations requires a high level of both strategic and frontline change-management skills, which are often in short supply”.

One wonders how GPs, suddenly finding themselves in the forefront of strategic management of commissioning for which they have never been trained, will be able to solve the problems of running the NHS more effectively. Policy makers seem to assume that GPs, because they understand their patients and problems of health care, will naturally have the right skills. The policy makers and politicians designing the current proposals no doubt found GPs agreeing that NHS managers and commissioners were redundant because the doctors themselves could do the job. But managing the intricacies of commissioning care for a whole population and running one of the largest and most complicated organisations in the world is much more taxing than they assume.

And of course, because there has been too much top down interference, too many wrongheaded targets, and enough maddeningly dozy bureaucrats to give NHS management an unfairly bad name, such a message fitted well with the current political and economic trends. But that doesn’t mean that GPs will actually turn out to be better at designing and running the service than the people who are actually trained to do so.

A simple analogy shows how naïve that would be. We recently had a group of contractors doing various works around the house and found them each of them to be superbly skilled and knowledgeable. Like many people, the builders and plumbers thought that architects, local councillors and solicitors are an expensive waste of space. Yet we would be out of our minds to therefore ask them, in addition to their current jobs, to design our next house, award the planning permission and do our conveyancing. And yet, by analogy, this is exactly what policy makers are planning for the NHS.

Politicians and policy makers claim to be “listening” to concerns about the White Paper. But it is not enough just to hear the arguments (even if they could do so, given that their main listening device seems to be a microphone on a podium). One also has to react rationally. The lack of capacity and relevant skills among GPs is just one of many concerns that have been repeatedly raised but which the policy makers seem to be dismissing.

Which brings us to another of the recommendation that came out of our research: “There should be more rigorous evaluation of innovative policies while they are on the drawing board. Where this reveals strong evidence … that problems will arise from the widespread implementation of an innovation, due caution should be diligently exercised, not swept aside.”

If only…

by John Gabbay, Andree le May, Catherine Pope, Glenn Robert, Paul Bate and Mary-Ann Elston, authors of Organisational innovation in health services

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