At the well-attended launch of CIPFA’s PF Perspectives: Funding a Healthy Future in January, three of the authors expanded on the issues covered in their essays:
Peter Smith set Greater Manchester's devolution plans in the context of health inequalities, for example the average Surrey resident has 68 years of healthy life compared with 56 years in Manchester. That emphasises the importance of considering economic and social determinants as well as direct health spending, and drives much of the agenda in Greater Manchester.
The 37 partners which make up the partnership create a constitutionally complex set up, but one driven by simple principles: integration, prevention and appropriately differentiated service to the ten local care organisations established along council footprints. Each of these ten now has the chance to bid against £450m additional funding for transformation plans.
The Greater Manchester document Taking Charge contains the partnership's health targets, its title reflecting both that the area has taken on £6bn of central health funding and the hope that individuals will do more to take charge of their own issues by lifestyle change.
Richard Humphries referred to the three challenges for social care set out in his perspectives paper: lack of money (in spite of substantial achievements in getting more for less); the upward trend in the population of over 85s; and workforce shortages. He feared the government will continue to acknowledge the issues, feel the need to do something, but not do enough to make a real difference. The social care precept, for example, brings in £280m but the cost of implementing the National Living Wage alone is £600m.
Moreover, the distribution is skewed in the wrong direction: the ten least deprived authorities in the country will raise two and a half times more per head through the precept than the ten most deprived authorities. Richard felt we need radical consideration of how to address the financial consequences of our success in achieving a longer-living population, through an honest conversation with the public about the options: what it costs, what you might have to pay, what are the funding options, and the reduced service alternatives.
Matthew Cripps emphasised the need to concentrate on the issues which are within your gift: he mentioned a hospital director bemoaning the blockage of beds by social services – when two thirds of delayed discharges were actually down to other factors.
The RightCare program emphasises three streams which align to 'the three Es:
A survey of surgeons showed that 70% believe breast cancer patients’ first priority is keeping their breast, whereas patient surveys put that at 7%, the main concern being not to have to worry about a recurrence. This illustrates the culture change needed in the medical profession to listen to the public in a more meaningful way, with patients typically preferring less invasive procedures which are cheaper for the NHS.
Matthew also suggested that it is vital (yet rare) to prioritise improvement programmes properly, explaining that it’s best to implement a mix of projects so that short, medium and long-term savings are generated by different streams. He was also sceptical of improvements driven mainly by a desire to achieve service integration – rather, the best start is to ask ‘what works best?’ and then arrive at implementation as an answer – a point related to Richard Humphries’ observation that the best practice he has seen around the world has always developed from the bottom up.
Rob Whiteman set out three conundrums from his experience:
Do we spend too much – as argued in Atul Gawande’s book Being Mortal – on giving false hope to the dying?
Yes, the panel felt, there should be more emphasis on ‘dying well’ in accordance with the views elicited from patients – 10% of acute spending goes on providing (often inappropriate) care for people in the last year of their life, yet most could be better and more economically served by a dignified end out of hospital.
How should the voluntary sector be involved? Not just, the panel believed, as a (potentially economical) deliverer of services, but as a key player round the table when setting up infrastructure and policies.
How does ‘learning from the best’ sit alongside ‘responding locally’?
They are compatible, said Mathew Cripps, as there is a role for warranted variations: in response to local cultural and demographic factors, or to allow for personal choice. That is why RightCare asks that the generics are implemented but that local preferences are built into the specifics.
Is now the right time for a ‘big conversation’?
The panel thought so, on such matters as charging, rationing, funding options, whether to require passports to prove patient identity. They felt there had never been such unity of voice as now on NHS finances, albeit, in Peter Smith’s view, there was no new information to be revealed, it was more a matter of presenting the consensus position with more impact. No-one could say, though, what caused the apparent resistance to the message in central government.
Can Greater Manchester act as the blueprint?
The importance of leadership was stressed, and there was some doubt about whether what was happening in Greater Manchester was ‘scalable’ – the combination of long-term joint working and strong leadership over the last decade could not be seen elsewhere. Rob Whiteman backed up the importance of leadership by citing examples of good initiatives which were allowed to fall away once the individual behind them left the organisation.
We need to invest more systematically in the skills needed for integrated working, so that the right approaches become ingrained organisationally. At the political level, it is very difficult for politicians to lead, rather than follow, public opinion. That leads to the perception that they hijack the issues to gain popularity or publicity, so making it harder to sell the logic of change to the public, and so they need to be supported towards the leadership role.