Great NHS reform needs new perspectives on how care is commissioned

All political parties now recognise the need to address the significant fractures in our care services and the need to integrate, or join up, care. Despite this, there is much less consensus on how this should be done.

This is the principal question addressed in a new Social Market Foundation essay collection A Problem Shared? Essays on the Integration of Health and Social Care published earlier this month, which brings together leaders from across politics, the care community and local and national commissioners.

The case for reform is compelling. The current disjointed arrangement between health and social care leaves patients and family carers confused; undermines standards of care; and leads to huge inefficiencies.

An ageing population, the growth of long term conditions, the increasing prevalence of multiple conditions and the opportunities in new technologies render our current system increasingly anachronistic by the day.

‘It is not simply that the care disciplines are separated by a “Berlin Wall”’

But, as former health secretary Stephen Dorrell notes in his contribution, it is not simply that the care disciplines are separated by a “Berlin Wall”. It is more than this.

He points to an “institutional dysfunction which corrupts the heart of the care sector”.

Under this diagnosis, not only is the system partitioned, but each part is looking in the wrong direction. This leads to a system where, rather than “investing in health, we rely on rationing the treatment of disease”.

The essays chart a range of imaginative ideas for reform, including pilots on the ground in Cornwall, new financing tools, and innovative digital and technological practices. But, scaling these up require major change to how care is commissioned.

• The system-wide approach to turn around a struggling health economy
• Coalition health reforms ‘damaging and distracting’, says think tank
• Next government must recognise that acute need is part of whole person care

Whole truth

On this point, Sir John Oldham reports from the Independent Commission on Whole Person Care, which he was invited to form by the Labour Party.

He describes the existing tariff structure, whereby providers are paid for each episode of care, as a significant obstacle to better care.

Current approaches should be abandoned in favour of “collective commissioning”, he suggests.

Under his model a single local commissioner would take responsibility for all care needs and thus be able to shift resources from reactive secondary care to preventative care in the home and the community. Such a shift meets with widespread agreement among our contributors. 

‘How can we accept an NHS that is free at the point of use while expecting individuals to cover their own social care?’

But past experience suggests we are likely to encounter significant opposition from professionals (who may wish to preserve the current role of their disciplines) and national politicians (who may prioritise the “N” over the “HS” in the NHS).

If the commissioning and provision of health and social care is irrational, current funding is neither less illogical nor sustainable. The NHS Five Year Forward View showed a mismatch between resources and patient needs of nearly £8bn a year by the end of the next Parliament.

As former coalition care minister Paul Burstow acknowledges: “The inevitable conclusion is that the next government will have to commit more cash for health and care.”

Starting small

He suggests two radical prescriptions: first, the government should “commit to staged funding increases as the economy allows, equating to £8bn by 2020”.

Interestingly, he argues that this money should be conditional on a 2 per cent productivity gain.

Alongside this, Burstow calls for “a fundamental review of NHS and social care finances” ahead of the next spending review.

This is surely a shrewd suggestion. It might prompt a more thorough diagnosis of the infirmity of our current care funding than past governments have been ready to countenance.

‘How can we incentivise greater focus on prevention rather than cure?’

How can we accept a health service that is free at the point of use while expecting individuals to cover their own costs of social care, with only those with the highest level of needs receiving any means tested support?

How can we ensure that our funding base is sufficiently broad and dependable to enable us to continue to resource growing care costs into the future?

And how can we incentivise greater focus on prevention rather than cure?

The perspectives in this book of essays may not answer all these questions but they certainly provide some points from which we can start to think about solutions.

Nigel Keohane is research director of think tank the Social Market Foundation and editor of A Problem Shared? New Perspectives on Integrating Care