The NHS – a view from outside a think tank

It’s a new year and the ‘think tanks’ have been busy. So some more of the same – productivity, joining health and social care and leadership – well that didn’t take much thinking then. So we can all put our feet up for another year, do a little research and come up with the same three things next year. After all it is a ten year plan going across at least two terms of government so we would expect some flux and some of the changes are difficult – what a load of tosh!

Contracts – we have far too many of the things and with payment by results – now called the tariff – some of them are too complex to operate properly. We don’t ‘manage’ contracts well and have developed a monster that is inspection. We employ a veritable army to check and verify coding and payments and then inspect and rate. We have to make life simpler.

So how about dumping the tariff, returning to a block contract system. Perhaps we should dump the CQC and invest that money in better contract management. And then work out ways of combining contracts and including increased performance management within the contract to help us manage them better.

Hospitals – we have far too many of these and too many beds. I equally love and fear the Dalton report. But let’s support hospitals to merge, combine services and deliver better care with better management. Balance the drive for this and exert control to prevent Foundation Trust groups becoming too dominant and removing choice. However, I do believe that people want a good quality local hospital rather than the choice, but we must keep some competition in the system to retain commissioning levers.

Let’s transfer elderly care facilities to the Local Authority in the form of ‘Cottage Hospitals’ and see care of the elderly as a natural element of social care – just noting that aging is not an illness. There becomes a natural flow between home, care home and cottage hospital, all under one organisation – the Local Authority.

Primary Care – increasing pressure on primary care has been partially successful in driving change, but the unintended consequences in secondary care have been unfortunate and we haven’t really broken down the siloes – in fact we have made them worse, by separating core contacts from locally enhanced services. We can fudge this with co-commissioning, but we really need to take this to another level.

Perhaps it is time to drive multi-professional provider contracts. We have the emerging federations – so make them a requirement, but they must include all four primary care independent contractors, the community services, mental health and all other local providers. And then we can start linking elements of the contracts together to create the interdependency that we need – where the successful delivery of a contract needs all providers pulling together to be rewarded.

Individuals and Communities – we are all responsible for our own health and we are jointly responsible for the health and wellbeing of our communities. But it is all slipping; people are getting poorer, unhealthier and more isolated. Public Health isn’t working. Something has to start at a more fundamental level. This is about poverty, education, food, crime and safety and it creates an unsustainable impact on the NHS. It is what would make us as individuals care about ourselves and others and the community that we live in. I have seen some superb, astonishing results created by organisations like C2, but I still wouldn’t know how to roll it out nationally. Perhaps it is about accelerating pockets until they coalesce into one nation.


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