Victor Adebowale was one of the first group of people appointed as People’s Peers in 2001 and became a life peer on 30th June 2001. In 2012 he established Collaborate (for social change), a year after the publication of The Christie Commission (2011). The vision of Collaborate is of a collaborative society: equitable, caring, and sustainable. Such a vision echoes the essence of The Christie Commission which stated that reforms must aim to empower individuals and communities receiving public services, by involving them in the design and services they use.
In December 2023 Collaborate published an update on Towards a Manifesto for Public Services. The manifesto urges a shift in services from paternalistic silos which retain power, doing to rather than with communities, to a shift that requires services which are enabling, sharing power and moving from silos to a system based on learning and adaptation.
The Christie Commission best reflects such ambition by the statement ‘recognising that effective services must be designed with and for people and communities’ – not delivered ‘top down’ for administrative convenience.
The starting point for both recovery and reform needs to recognise the failure of an approach owned by institutions in control. Integration means nothing to ordinary people. Integrated services for elderly people with progressive illness, where being at home is the norm and treatment, or care, as close as possible means everything. Up to the present time integration has been dominated by structural change with control retained by the public bodies, with little evidence of shifting care at scale to a model where people have a service to support them at home, with hospital admission only when needed.
A national conversation is an opportunity to rethink the term integration and the associated failing structures and plans. Integrated Joint Boards are designed to fail in their current form and function, the evidence speaks for itself. The National Care Bill has reached its second stage. The first stage evidence was dominated in some quarters by opposition, and in others fundamental concerns over cost and efficacy. Diverting time, effort, significant resource, and potential cost is more likely to simply repeat the mistakes of the past. Put simply it entrenches the persistent drive to centralisation with no detail of the anticipated benefit. What is needed is the development of a truly national service, free from even more legislation, control, and centralisation. A service that truly meets the needs of the population.
This article looks at an international case study and offers an alternative to our current approach to recovery and reform and demonstrates solutions which have overcome the complexity of the structures and finance regimes that have dominated systems of care almost universally.
On the 22nd of February 2011, Christchurch in New Zealand experienced a devastating earthquake with the loss of 185 lives and enormous damage to the infrastructure of the city. Much commentary suggests that the event in 2011 was the catalyst for such transformation of their system of care. This is not the case.
In 2007 Canterbury District Health Board (DHB) was in deficit. Analysis showed that if the system did not change, by 2020 it would need a hospital twice the size, 20% more GPs and an increase of 40% in residential care beds for the elderly. This was unaffordable, unachievable, and not the right thing to do.
The Canterbury DHB is an integrated system of health and social care. However, like Scotland, despite the structure, there was little evidence of integration leading to real change in the services delivered to their communities. The Canterbury DHB Board was clear that it required one system, and one budget, in which a dollar could only be spent once. They concluded that cost shifting was unsuccessful and unsustainable.
Within a structure and financial regime that would not change, they determined that their reforming principles would be based on professional leadership and ownership, characterised by partnership, and supported by data that demonstrated real evidence of success.
The Kings Fund report (2019) provides a detailed summary of the Canterbury journey. The report makes no claim that Canterbury DHB has transformed but rather is on a continuous journey of changing how services are provided to their population. It does not claim that there have been dramatic reductions in acute care beds, but rather it demonstrates the avoidance of both capital and revenue costs associated with models of care that would have continued the cycle of deficit, with little effective change in the delivery of services.
There are two key learnings from this case study.
Firstly, the Board agreed to support the principles of the strategy, not the detail of the plan. The Board recognised the timescale for achieving financial sustainability and the need for investment to support innovation and change would require a long-term commitment. They expressed the view that “What we have tried to do is not focus on the marginal edge of money that we have not got…. Rather we have tried to say we have $1.4bn here and how we use it is what matters”.
The second learning point is the role of primary care. Significant investment was made to support general practice development. Importantly this investment was owned and managed by the GP consortium, a vital driver of the entire programme of reform. Pegasus is the business entity for the GP consortium in Canterbury. GPs were at the centre of the programme. Canterbury DHB recognised the vital need to maintain and continue to develop the sustainability of general practice, a vital part of their plans. Significant funding and investment were made available to Pegasus for the necessary time commitment and professional development required. Canterbury DHB also determined that the development of care pathways would be a pivotal part of their programme. A fully funded Health Pathways Programme became central to building the much-needed alliance across primary and secondary care.
To summarise a quote from the King’s Fund report “Arguably the biggest change Canterbury DHB has made however, is to re-invest in the pride of clinicians and other staff, taking significant steps to re-empower them to make changes themselves after a long period of managerialism”.
The overall point to consider is that structure, central control, and excessive scrutiny from government are all barriers to reform. Despite these issues being beyond the direct control of Canterbury DHB, they designed a local programme of change and innovation that reflected the needs of their local communities.
The learning from this for Scotland is that a national conversation needs to look beyond national structures and systems to inform the way forward.
The Lancet Global Commission on Primary Care (2022) conclusions and recommendations on the organisation of primary care in health systems, underpins the considerable strengths of primary care in the Scottish health system, a vital part of future reform.
Its central, most important recommendation was the need to increase the allocation of resources to primary care, a view that has been consistently reinforced by representative organisations in Scotland.
Scotland’s allocation of total sums to primary care has been circa 8%, across many years. The case has been made that this needs to increase to circa 11%, a figure reinforced in the Lancet report.
We face two challenges. The first is an absolute commitment to shift to an increase in the allocation of share to primary care. The second is more immediate. We need to face the challenge of rapid, sustainable recovery, doing so in a way that creates the conditions for meaningful reform that succeeds in shifting the balance of care from hospital to home.
The 2018 General Medical Services Contract is in deep trouble. The BMA are in dispute with government over the lack of progress on the expansion of GP numbers and concerned about the support to general practice development. The BMA, having secured the development of GP clusters, argue that there has been a lack of real investment and support.
The RCN have raised persistently the impact of the introduction of the contract and the development of multi-disciplinary teams. Their concerns range from the incentives and grading of roles and the professional development of nursing in the community. Their members are concerned about the fragmentation of the primary care team and its impact on patients. Rural GPs also voice difficulties regarding the multi-disciplinary team approach embedded in the contract and the breakup of the practice-based teams, a vital component of rural services.
More concerning is the number of General Practices returning their contracts to Health Boards who feel unable to respond adequately to reprovision given the pressures they themselves are under.
The above problems are now even more acute given the challenges post pandemic.
Despite this, the NHS Recovery Plan makes only one significant reference to primary care, the 2021 joint agreement on the ongoing implementation of the 2018 contract. There is little in the Recovery Plan of the investment required to deal with the post pandemic pressures. There is a need to re-engage with all parties involved in the key elements of the national contract. Further investment is needed to deal with the post pandemic pressures as an immediate priority.
Reform presents different challenges and solutions. The second most important recommendation of the Lancet Commission was the need for allocations based on population and need. Scotland has an international reputation for such an approach. The current view is that the approach in primary care is wrongly weighted and does not reflect the broader determinants of health. The Deep End Practices express concern about the failure to make a difference to the inverse care law. They recognise that there has been considerable funding support from government, however, in their most recent briefing, they call for an end to “pilot-itis”, a plea for allocations that recognise the wider determinants of health.
There may be concerns that such a change may destabilise general practice. However, Scotland has a long-standing track record of a population based approach to allocations and equal share in a sustainable way. Through a long history of share allocation and the Arbuthnot formula, Scotland has achieved equal allocation rather than a reduction of the base allocation. With this experience there is every possibility of preserving the benefits of a national contract, the independent position of general practice and the redistribution of increased resources tackling the wider determinants of health. An important part of any future national conversation might be that the National Care Bill is an example of continued centralisation and control despite the irrefutable evidence of failure of such an approach. The alternative is to a real shift of power to leadership and innovation based on a coalition of effort on those best placed to drive reform. Have the confidence that investment in primary care, in the first instance, is vital to recover and stabilise our general practice services. In the second instance, trust the investment to drive the reform and development of our system of care, while starting the journey of a model that deals with the challenges of inequalities and deprivation.
Gerry Marr, is the former Chief Executive of South Eastern Sydney Local Health District, Sydney, Australia taking up the position in February 2014 until he retired in August 2018. Prior to this position, Gerry held Senior Executive roles with the NHS Tayside, firstly as Chief Executive Tayside University Hospitals Trust, then Chief Operating Officer/Deputy Chief Executive Officer, and then Chief Executive from 2010 until 2013. Prior to his work with NHS Tayside, Gerry held senior roles in the areas of system performance and human resources management with the NHS Scotland Department of Health. In his early career, Gerry held senior management roles at major tertiary hospitals, including Yorkhill Hospitals NHS Trust in Glasgow and the Women and Children Services, Greater Glasgow Health Board.
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