Blog following Reform's recent report, Seismic shifts in the welfare state.

Blog following a Reform roundtable seminar on "High volume, low cost healthcare: The case of the Aravind Eye Care System", on 11 April, led by Sanil Joseph, Hospital Management Consultant. 

Reform lecture on “High quality, accessible, affordable healthcare and the role of the private sector" on 27 March 2013, with Dr Damien Marmion, Managing Director, Bupa Health Funding, Professor Paul Corrigan CBE and Nick Timmins, kindly sponsored by Bupa.

Reform major policy conference on 5 March 2013, "Implementing a model for funding social care", with Norman Lamb MP, Lord Norman Warner and Heather Wheeler MP, kindly sponsored by the CII, Gen Re, Just Retirement and Partnership. 

Reform roundtable seminars on "Hinchingbrooke NHS Hospital: Lessons from the first six months", with Ali Parsa, Managing Partner, Circle, on Thursday 13 September 2012.

Reform panel debate on the role of housing equity, with Heather Wheeler MP, Member of Parliament for South Derbyshire

 By Kimberley Trewhitt 

Ea rlier this week Reform held a panel debate in partnership with Just Retirement to discuss “Next steps for equity release”.  The speakers at the event were Heather Wheeler MP, Nigel Waterson, Chair of the Equity Release Council, Michelle Mitchell, Charity Director at Age UK, David Budworth, Deputy Personal Finance Editor at The Times and Rodney Cook, Chief Executive of Just Retirement.

It often comes as a shock to people that if they have assets above a certain amount (£23,250 in England in 2011/12) the costs of entering a care home fall entirely onto them.  Many people feel that these costs should be met by the State because they have paid tax and National Insurance contributions their whole lives.  But there is a need to dispel the myth that care is free at the point of use.  Liam Byrne noted at the end of the last Parliament that “there is no money left”, and with population ageing the limits to what can be publicly funded are only going to grow.  As Lord Warner, a Member of the recent Dilnot Commission, commented at a Reform conference in 2011, “Any fantasy about 100 per cent universal state provision – forget it.”

The question then becomes how can people be encouraged to play a greater role in providing for their own care needs?  An obvious source for these contributions is the wealth people build up during their working lives, especially in property. Estimates show that homeowners aged 65 or over own nearly £750 billion worth of unmortgaged property. This can raise hard questions, especially as families have traditionally aspired to pass their housing wealth onto the next generation. But some politicians are facing up to these tough choices and considering housing wealth as a way to pay for care. The culture of passing wealth on to the next generation is also changing, with people becoming more inclined to spend their money on having a comfortable retirement.   

 For  this approach to succeed, more awareness, financial education, transparency and innovation will be essential.  Products such as care fees annuities and equity release already exist, but they make up a very small proportion of the market of self-funders.  Currently 8 per cent of people who take out equity release use it to pay for their care needs. In 2011 the Dilnot Commission identified that this may reflect problems on both the demand side – poor awareness leads to low demand from individuals – and on the supply side – the uncapped potential costs of long term care prevent the financial services sector from developing products. 

On improving awareness, honesty is needed about the scale of the challenge and the tough decisions that will have to be made.  The precise role of government raises debate.  While some argue that government may have a crucial role (along with the private sector) in raising awareness, others argue that government should not promote specific products. Mistrust of the financial services sector is also a challenge.  Scandals including the mis-selling of equity release and endowments in the 1980s, the recent mis-selling of PPI and the current LIBOR investigations have tarnished the industry’s reputation.  Rebuilding trust is essential.  Indeed, the Financial Secretary to the Treasury, Mark Hoban, recently announced the Government’s plans “to restore honesty, integrity and stability to the sector” so that “consumers are empowered… to participate in the sector on an equal footing, both through improved regulation and greater competition.” 

 To encourage greate r choice of products, more certainty over future funding from government is required. In this sense, the Care and Support White Paper and Progress Report released this week, which did not set a cap on an individual’s contribution to the costs of care as recommended by the Dilnot Commission, were a disappointment.  Setting a cap would have given the sector the ability to innovate and develop new products as there would be a clear maximum liability.  But the opportunity to build a stronger market was missed.

Reform roundtable seminar on "The future shape of the health and social care workforce". Introduced by Peter Sharp, Chief Executive, Centre for Workforce Intelligence.

The NHS is in the midst of a perfect storm of rising and changing demand, rising costs and reduced resources to pay for those costs. As the International Monetary Fund suggested, “rising spending on health care is the main risk to fiscal sustainability, with an impact on long-run debt ratios that, absent reforms, will dwarf that of the financial crisis”. All health systems now need to “bend the cost curve” and recent reforms aim to move to a model of care that is less reliant on hospitals with more care provided in the community and coordinated around the needs for patients. The workforce accounts for between 60 and 70 per cent of costs in health systems, which means that to deliver efficiency in the short term and become sustainable in the long term, reform of the workforce is essential. To explore these themes Reform convened a lunch with Peter Sharp, the Chief Executive of the Centre for Workforce Intelligence. The event was held under the Chatham House rule but these were the headline points:

Time for an honest debate. In past decades rising demand was met by increased resources and particularly more doctors and more nurses. This is no longer sustainable. Given the length of time needed to train healthcare professionals, particularly doctors, workforce planning needs to take place four to five Parliamentary terms ahead. Therefore decisions on what healthcare workers the NHS needs by 2030 need be taken now. Otherwise existing trends of recruitment and training will not enable the flexibility for different models of care to emerge. However there was a concern that despite the needs to think for the long term, short term cost pressures and objectives will shape the choices on the healthcare workforce.

Tactics to improve productivity. Over the last decade the NHS workforce grew by nearly 30 per cent, with the number of doctors rising by 45 per cent. Quality did not keep up with the pace. Improving the productivity of the workforce is therefore essential. Adopting the habits of high performing providers can increase productivity by 20 to 40 per cent. In particular, the best organisations often have a strategic focus on patient value, empowering clinical professionals through autonomy and responsibility, mandatory training in innovation and clinical redesign and active staff performance management. However many NHS employers have been slow to adopt the habits of leading organisations. Moreover there is often resistance on the part of the professions to more rigorous performance management such as performance based pay.

Role shift. A key tactic of innovative providers is reforming the skill mix to maximise the productivity of the highest trained professionals and using different kinds of workers to perform tasks that were traditionally reserved for doctors and nurses. Starting from the patient perspective to understand their actual care needs can demonstrate what skill mix is needed. While in the past doctors were the lead caregivers, care services need to be “demedicalised”. Changing healthcare needs mean that carers and healthcare assistants will need to fulfil expanded roles, with greater focus on multi-disciplinary care teams in place of doctors as solitary practitioners.

Flexibility. The long timescales involved in medical training (15 years from A-levels to consultant status) mean that greater flexibility is needed in training pathways. This is particularly important if the NHS wants to increase the number of generalists over specialists. Junior doctors in particular concerned that moving between specialities would require restarting their training. Flexibility in the training pathway would also need to consider more diverse steps in doctors’ careers rather than a single trajectory to consultant status.

Role of regulation and professional organisations. Reforming the workforce demands a new approach to regulation. Traditional approaches to the regulation of workforce have sought to define and control boundaries between professionals, and thereby limit role shifting and innovation in the delivery of care. For instance the Royal College of Nursing and Nursing and Midwifery Council campaign to extend regulation to healthcare assistants would maintain the roles of nurses and create additional costs. Other Royal Colleges have recognised that more flexible approaches to training and greater focus on team based care needed.

Healthcare is human capital intensive, which means that it is not possible to transform the model of care without reforming the workforce. Such changes will challenge the model of the professions and existing ways of working. The front line needs to lead the way. 
 

Reform roundtable on how local NHS organisations are responding to national initiatives and tighter budgets held on 27 June. Introduced by Alastair McLellan, Editor, Health Service Journal

Reform roundtable on quality and value in health on 29 May.  Introduced by Jim Easton, National Director for Improvement and Efficiency, National Commissioning Board.

Reform roundtable seminar introduced by Dame Julie Moore, Chief Executive, and Dr David Rosser, Medical Director, University Hospitals Birmingham NHS Foundation Trust, on Tuesday 1 May 2012.

By Thomas Cawston

Despite the advances in medical science and clinical best practice, poor quality still persists in parts of the NHS. The challenge of how to maintain and improve quality will exercise policymakers for much of this Parliament, with the long awaited Francis Inquiry on Mid Staffordshire hospital due to be published in October. While there is no single and all-encompassing solution to better quality, there are proven tools, such as the effective use of data and technology. To explore these issues we convened a lunch with Dame Julie Moore, Chief Executive of University Hospitals NHS Birmingham Foundation Trust and the Medical Director, Dr David Rosser. The lunch was held under the Chatham House Rule, but these were the headline points.

University Hospitals Birmingham has high quality outcomes. The Trust has reported a 16.9 per cent reduction in 30 day mortality, the equivalent of 100 lives saved per year, a reduction not seen in the rest of England. Key to this achievement has been UHB’s philosophy of reducing errors. Rather than connecting errors to outcomes and focusing on significant mistakes and errors in clinical practice, the Trust took the view that all errors are important. Consequently IT systems were designed to reduce all errors.

One of the key programmes that UHB has introduced has been the Prescribing Information and Communication System (PICS), a decision support tool for front line clinicians. The system has over 4,000 registered users, manages 25,000 new prescriptions and 125,000 drug administration events a week. Clinicians use the tool through 450 handheld tablets. Each and every decision made by clinicians working in wards is run through an “error filter”, which screens the decision made, such as changing a patient’s therapy, ordering tests or discharging. The system automatically records the decision and either confirms the order, warns the clinician of the potential error, requires the clinician to re-enter their password in the knowledge they take responsibility for the order, or stops the order. Medication errors were cut by 66 per cent, preventing up to 450 individual errors a day.

However information systems alone are not sufficient to improve quality. The Trust had to combine measuring data on clinical performance with rigorously enforced clinical accountability. This requires strong leadership to shift the culture towards excellence and hold senior clinicians to account. UHB addressed poor performance in its hospital by effectively managing clinical teams that were not meeting the necessary standards. Unfortunately, in this it is the exception rather than the rule. There is no “quick fix” to achieve better quality, but for doctors and nurses responsibility must accompany power.

The freedom to pursue excellence has been important, while my impression is that central diktats have been a distraction. Rather than waiting for the National Programme for IT in the NHS to bring IT to the Trust, UHB went alone in investing in a purpose built in-house system. Commissioning and quality incentives have not been able to drive improvement by providers. Too often the system has failed to generate the incentives for Trusts to invest in effective IT systems. UHB had to take responsibility on itself to deliver better quality. All of this means that we need a permissive system that allows more experimentation, that encourages high performing trusts to excel, that encourages new entrants to challenge existing models, and that recognises and deals with failure when it occurs.

Reform roundtable seminar introduced by Lord Warner of Brockley, Former Health Minister, on Wednesday 18 April.

By Nick Seddon

After all of the noise surrounding the NHS reform Bill – or to give it its official name, the Health and Social Care Bill – which recently received Royal Assent and became law, you could be forgiven for having forgotten what it was all about. So we convened a lunch, led by Lord Warner, a former Labour Health Minister and Bill expert, to examine some of the detail and see if the Government can use what is in the Bill to achieve positive reform. The lunch was held under the Chatham House Rule, but these were the headline points. 

Firstly, the clauses relating to the failure regime and amendments including the “pre-failure failure regime” (i.e. a black list of trusts which will flag up early warning signs and create a pressure to improve or be dealt with) are good news. Dealing with failing hospitals will either be through outsourcing, radical reconfiguration, or closure. All will require local and national political will. The role of the tariff will be important: the Independent Commissioning Board (ICB) will define the currency (e.g. episodes of care or bundled), while Monitor will set the cost. 

Secondly, the Health and Wellbeing Boards may turn out to be an effective catalyst for greater integration between health and social care. There is already evidence of HWBs carrying out joint strategic needs assessments, which is good. Joining up the silos will probably require financial and legal tools, which are not currently in place, but there was optimism all the same.

Thirdly, the Bill is so ambiguous that much will rely on interpretation. The Secretary of State will not be able to let go and – to use the phrase in the original white paper – “liberate the NHS”. This is not only because power resides where the money is raised and spent, but because there will need to be constant political pressure if either competition or integration are to be achieved.

Fourthly, when it comes to competition, the Bill will not push change, but its provisions might permit change. The interpretation by Monitor of the relevant clauses will matter. Right now, the signals about the private sector have been hostile and the Government rejected a review of barriers to entry for new entrants, which is negative. The investor community hates uncertainty, but there is a lot of that around. Ministers must send out clear signals and be unwaveringly in favour of new entrants.

Finally, rationing will become a big issue – and a matter of public debate. There was a strong sense that real, radical reform of the system has been deferred, but remains necessary.