Public health must lead a public system

The NHS may have been designed by a Liberal, William Beveridge, but it remains the UK’s clearest manifestation of socialist politics in popular action. And the NHS is popular: repeatedly near or at the top of opinion polls of reasons for national pride.

So what does the Socialist Health Association, founded before the NHS, want to see in a 21st century health service?

‘We need a long-term solution to the crisis in social care, with progressive funding to make it free at the point of need’

First, we want a care system where improvements in wellbeing come through action on the social determinants of health. We want the service to be an integral part of our public services: closely linked to education, housing and social care − not a separate island where the sick are fixed.

Public health must become the local driving force, led by a powerful director of public health in every local authority. The directors could remove the barriers that separate different aspects of care and align it around the patient, not around organisational units.

Second, we need a long-term solution to the crisis in social care, with proper, progressive funding to make it free at the point of need − for the same reasons that apply to healthcare.

Real clinical leadership

We need to see things less in terms of changing structures, and more in terms of changing how clinicians and others train and develop to work with patients and communities (seeing both as assets, rather than needs). This suggests greater professionalisation of the care workforce, rather than the minimum-wage race to the bottom seen in social care.

‘We must have genuine public accountability for our care: something the NHS has fought since its inception’

Supporting clinicians as champions of best clinical practice is essential; striving to drive improvement, designing better care pathways, supporting reconfigurations and reducing unnecessary variation across the system. We don’t see them as managers and accountants. Restoring staff morale and rebuilding public and patient trust in the NHS will be vital.

We must have genuine public accountability for our care: something the NHS has fought since its inception. Key decisions about allocating public resources and setting funding priorities must be made by those we elect, who are accountable through proper public scrutiny.

Better information

We need to prioritise access to our health records and to independent information, to help support choice of treatment options and care plans. This is not the same as information to compare hospitals (or even GPs) in dubious league tables designed to promote market-type organisational competition.

Armed with access to meaningful information, shared decision making and informed community development can prove real challenges to professional domination and a key route to health improvement.

We need to support and, where necessary, restore people’s pride in our care system as one of the most accessible and equitable structures in the world, offering good value for taxpayers’ money. 

Money matters

And we must be honest about the obvious − that moving care closer to home, removing the worst of the internal market, reconfiguring hospitals and integrating care are all potentially important in improving care quality, but do not save huge sums of money. Mostly, they need more money (at least in the short term). And there will be no more money for some time.

The 1940s and early 2000s saw a great consensus for change in healthcare. We need a similar broad consensus now − a 10-year plan for care and an acceptance that little can be promised in the early years.

There must be a period of relative stability − no more wasteful top-down reorganisations; longer-term financial settlements and a major redesign of payment by results; and an end to the year-end financial rollover farce. We must align commissioning (or planning) so that all public services genuinely cooperate, removing trade-offs between social care and healthcare and the blight on adequate funding for mental health and community care as secondary care dominates.

‘Ideological hostility to large private companies and paranoia about plots to privatise the whole NHS are equally misguided’

Two decades of experimentation with internal markets, competition, privatisation and providers as businesses show high costs and few benefits. We think the latest lurch into a regulated “real” market will do likewise, and so we see the immediate priority after the 2015 election as repealing the Health and Social Care Act, as markets (whatever their virtues) don’t deliver equitable, cost-effective healthcare.

We should promote NHS providers as demonstrably public bodies. Control of provider mergers, acquisitions and takeovers should be by strategic planning rather than market failure. If we continue to grant some autonomy to parts of the system then that autonomy must be earned; it can never be allowed to ignore the local public and patients’ voice. NHS providers should collaborate and exchange best practice, not compete and hide their data. And the idea of some competition regulator stopping two hospitals from sharing best practice is beyond absurd.

But ideological hostility to large private companies or to GPs as small businesses, and paranoia about plots to privatise the whole NHS, are equally misguided.  There are and always will be parts of our care system that are provided by non-public providers, and our great public care providers should be free to subcontract parts of what they do.

Where public provision is not good enough the first recourse should be to try and make it better − but not at any cost.

Richard Bourne is chair of the Socialist Health Association, a membership organisation affiliated to the Labour Party