Is the NHS sustainable? The philosophy of prevention

Marcus Longley Professor of Applied Health Policy and Director,

Welsh Institute for Health and Social Care, University of South Wales Vice Chair, Cardiff and Vale University Health Board

marcus.longley@southwales.ac.uk Cardiff, October 2014

The New National Health Service Text of the public leaflet February 1948

‘Your new National Health Service... It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child – can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness’

Central Office of Information for the Ministry of Health (83077) Wt39168 2/48Hw

The argument

Old principles...

1. The NHS is great

• Funding is a red herring

...new world

2. But it must change fundamentally in two ways:

• A new compact between the NHS and the citizen

• A new modus operandi

The real funding challenge

Resources are now, have always been, and always will be, finite and less than perfect. So... The first question is: What are our priorities? ‘Socialism in the language of priorities’ - Aneurin Bevan

Then we need to decide: What’s the best way of delivering them? Wasting finite resources condemns people to unnecessary suffering

FUNDAMENTAL CHANGE IS VITAL

The cost of continuing as we are

• The cost of getting older:

– 2009/10: NHS = 8.0% of GDP

– 2039/40: NHS = 10.2% of GDP?

• The cost of abusing ourselves:

– 2008/9: obesity and alcohol in Wales = £140m

– 2038/9: ?

Some key universal truths...

1. The NHS is about more than health... and health is about more than the NHS

2. Health policy is all about tricky choices

3. Services are a long way short of being ‘efficient’

4. Healthcare is dangerous

5. More of the same isn’t good enough

The Main Determinants of Health

Agriculture

and food

production

Education

Work

environment

Living

and

working

conditions Employment

Water &

Sanitation

Health care

services

Housing

Age, sex

&

hereditary

factors

Values of a Civil Society

Some key universal truths...

1. The NHS is about more than health... and health is about more than the NHS

2. Health policy is all about tricky choices

3. Services are a long way short of being ‘efficient’

4. Healthcare is dangerous

5. More of the same isn’t good enough

You can’t have your cake and eat it

Universal Comprehensive

Affordable

Some key universal truths...

1. The NHS is about more than health... and health is about more than the NHS

2. Health policy is all about tricky choices

3. Services are a long way short of being ‘efficient’

4. Healthcare is dangerous

5. More of the same isn’t good enough

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Some key universal truths...

1. The NHS is about more than health... and health is about more than the NHS

2. Health policy is all about tricky choices

3. Services are a long way short of being ‘efficient’

4. Healthcare is dangerous

5. More of the same isn’t good enough

Day of the week: mortality

Crude Mortality Rate by Day of Admission

Health Board Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Abertawe Bro Morgannwg 5.7% 5.8% 5.8% 6.3% 6.2% 6.3% 6.9%

Aneurin Bevan 4.3% 4.7% 4.6% 5.1% 4.8% 5.4% 6.4%

Betsi Cadwaladr 5.9% 5.9% 5.9% 5.6% 5.4% 5.7% 5.8%

Cardiff and Vale 5.5% 5.5% 5.6% 5.5% 5.8% 5.2% 5.8%

Cwm Taf 6.0% 5.7% 5.7% 5.9% 5.7% 6.3% 7.2%

Hywel Dda 6.3% 6.1% 5.3% 6.2% 6.3% 7.1% 6.0%

Powys 19.5% 13.8% 24.8% 30.7% 22.6% 25.9% 6.5%

Velindre 7.6% 4.6% 8.6% 7.3% 6.0% 1.6% 2.3%

Wales Average 5.6% 5.6% 5.5% 5.8% 5.7% 5.9% 6.3%

Source: PEDW - Data subject to further validation Emergency admissions only – excludes paediatrics, obstetrics and maternity

‘In the next room you could hear the buzzers sounding. After about 20 minutes you could hear the men shouting for the nurse, “Nurse, nurse”, and it just went on and on. And then very often it would be two people calling at the same time, and then you would hear them crying, like shouting “Nurse” louder, and then you would hear them just crying, just sobbing, they would just sob and you just presumed that they had had to wet the bed’ Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust p53

…and in Wales?

‘She leant forward only inches from my mother’s face and said… “Listen, love, I have 38 other patients to see to, you’ll have to wait”’

‘When asked if her pad could be changed as it was wet we were told that they could only change them after

they have been wet five times as they were very expensive and were designed for this’

Older People’s Commissioner for Wales (2011) Dignified Care?

Some key universal truths...

1. The NHS is about more than health... and health is about more than the NHS

2. Health policy is all about tricky choices

3. Services are a long way short of being ‘efficient’

4. Healthcare is dangerous

5. More of the same isn’t good enough

Some key universal truths...

1. The NHS is about more than health... and health is about more than the NHS

2. Health policy is all about tricky choices

3. Services are a long way short of being ‘efficient’

4. Healthcare is dangerous

5. More of the same isn’t good enough

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Shifting the paradigm...

From

• Cure with Care = transactional

To

• Cope with Care = relational

1948

• Illness, diagnosis, cure, rehabilitation, back to fitness

2014

• Supported to cope, predictable threat, minimum intervention, back to coping

Integration and funding

‘The prize of our new settlement is huge: a more integrated service, a simpler path through it, more equal treatment for

more equal need, and a far less distressing experience for those trapped in the confusions of today’s arrangements’ - Kate Barker

• Single, ring-fenced budget for NHS and social care; single

commissioner for local services • New care and support allowance for people with low to

moderate needs • Much simpler path through health and social care system

to reflect changing levels of need • Much more social care free at the point of use • Public funding (generational adjustments, wealth tax + NI)

not charges/insurance

Partnership and choices

‘Generate a culture of care built on more creative public involvement in the setting and monitoring of standards, and in the resolution of ethical issues and practical choices that arise from the need to make decisions within limited resources’

Obesity: A ‘more wicked’ problem than smoking

‘Of course, there is no good tobacco smoke but we all need food. So we can't solve the problem by saying 'no food' or 'don't eat'. It's a more complicated set of behaviours that need to be considered... we are building up impossible demands for the health service within the next 20 to 30 years’

Mike Kelly, NICE

Environmental change vs. evolution

Problem

Calories in > calories out

Obese people need more healthcare

Solution?

Educate people more/better

Ban fast food outlets

Make school dinners compulsory

More PE in schools

Tax sugar

Punish parents

Sue your parents

Tackle social inequalities

Make communities ‘play friendly’

Industry innovation

Shared responsibility?

The Holy Trinity for Wales Co-Production, Prudence and Integration

A system which ensures:

1. Prevention: targeted, individual, coordinated

2. Partnership: clinicians/patients/citizens as partners

3. Integration: NHS, social care, 3rd sector, for-profits

4. Outcomes: co-defined and co-measured

5. Coping as important as curing

6. Proportionality: More is not necessarily better

7. Intelligence: Doing the right thing, as well as doing things right

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Key challenge

Stop fire-fighting…

…and reduce the risk of fires

But beware...

‘We said last year that reconfiguration and radical service changes offer the best opportunity to put the NHS on a sustainable footing. NHS Wales now needs to markedly increase the pace of progress if it is to make its aspirations for sustainable services a reality. But it is hard to see how this change can be achieved without a greater degree of political consensus’

– Auditor General for Wales

A proposition…

1. The NHS is great

2. Funding is largely a red herring – it will always be ‘underfunded’

3. But its modus operandi must change dramatically – co-production, prudence, integration

4. And most important of all: we need to re-think the compact between the NHS and the citizen