Whole-Person Care: I'm Liking The First Outline of ‘One Nation Healthcare’

Defining Labour’s approach to the NHS is going to be one of the most important parts of the One Nation Labour agenda as 2015 approaches. Only the armed forces, the BBC and the royal family rival it as a shining example of a ‘One Nation’ institution and polls of public attitudes show that even after a near-unprecedented drop in patient satisfaction with the NHS in 2012 (the result of anxiety over the coalition health plans) more than any other institution the NHS still makes people feel “proud to be British”. Labour’s longstanding commitment to putting solidarity and quality care at the heart of our healthcare remains one of the strongest parts of our party brand, while the Lib Dems, including my local MP Simon Hughes, have proven happy to take a reckless gamble with the NHS. While there’s a current temptation to obsess over Europe, we must keep our heads screwed on and remember that the NHS is consistently second only to the economy as a priority for actual, living, breathing voters. It is also one that will be a boon to us in 2015 if we get our tone right.

However, as good as it is as an ideal and an institution, there are aspects of the setup of the NHS that still require reform, and the service as a whole faces huge challenges in the form of restricted budgets, the government’s ill-planned reorganisation, public health crises and the ageing population. Further, as disastrous as much of the Tory-Lib Dem reorganisation plans have been from a standpoint of productivity, coalition supporters of the reforms often defended them by claiming Labour were failing to put forward any ideas of our own as to how the service should meet these challenges. We must admit that they were right on this – running against the coalition reorganisation isn’t in itself enough, and this creates a need for us to put forward an inspiring vision of our own. Moreover, we must do so in a way that is mindful both of the severe fiscal constraints we will face well beyond 2015 and of the difficulty of proposing further reorganisations, given the detrimental impact the coalition reforms have already had in terms of focus, productivity and staff morale in the service.

Enter Andy Burnham, stage left, and his speech on whole person care late last week. Politicians have wrangled for years over how to deal with social care, the “missing piece of Beveridge’s jigsaw” as one commentator called it. At a Progress seminar on social care I attended in December, Burnham compared the situation with social care in the UK with that faced by America or pre-1948 Britain in healthcare, a parallel he made again in his speech last week. As the inadequate social care provision in the UK struggles to cope with the demands of an ageing population, the elderly increasingly end up being looked after in hospitals rather than in the community, helping to explain why so many NHS hospitals are over their 85% safe capacity threshold. Those that are looked after outside the NHS in the current system face patchy provision as councils are forced to cut back. Michelle Mitchell of Age UK made clear at the same seminar that Labour had not done enough in our last period in office, for example noting that one in ten families still face costs of over £100,000 for social care. Meanwhile, Bobby Duffy of IPSOS-MORI brought another issue to light, in terms of the lack of personal planning on the part of much of the public regarding their later-life arrangements and the general lack of awareness as to how minimal social care provision will be for them. 

The Tories have latched on to the Dilnot cap of £35,000 as a solution, but their approach is ultimately tentative. The costs and strain the current situation create make this the biggest health challenge of our time, and boldly demonstrating that Labour is willing to take it on with a comprehensive plan is best way of showing that we not only have a plan of our own to improve patient-centred care and make health spending go further, but also that we can do so in a manner that is less disruptive and more in sync with national values than what the Tories have come up with.

Andy Burnham cited Torbay as an example of integrated care in his speech. Some favourable studies have been published on Torbay, and it does appear to be a great case study of what bottom-up localism and integration between the NHS and council social care can do when carefully planned and pursued. In a report for The King’s Fund, Peter Thistlethwaite stressed that “all integration is local” and that being clear on what is being expected and what the strategy hopes to deliver for patients is key. In 2011 the Nuffield Trust also helpfully published a study of four newer and smaller-scale, and therefore potentially more transferable, examples of integrated care. One of these was in Maastricht and another two were in America, but interestingly Nuffield found one more closer to home, in North Lanarkshire.

Reference has also been made to the models of integrated care already widely practiced in America, for example in private sector in organisations such as Kaiser Permanente. Bob Hudson’s article in response to Burnham’s speech, noting the similarity between Burnham’s vision and Medicare Accountable Care Organisations (ACOs), is also well worth a read. The single-payer nationalised Veterans Health Administration (VHA), America’s best kept healthcare secret and perhaps the closest equivalent they have to the NHS, also offers an inspiring example of some of the benefits of an integrated approach in a large-scale public health system. In the 1990s the VHA was in a dire state and had to undergo substantial reforms under the Clinton administration, as the NHS had to under Labour in order for it to be rescued from its nadir in the 1990s. Post-reform, the VHA now boasts satisfaction ratings of over 80% with its users, higher than the NHS did even before the Tory-induced drop in public confidence last year. A previously convoluted structure (4 regions, 33 networks and 159 independent centres) was condensed into 21 joined-up Integrated Service Networks, known as VISNs, which were tasked with managing their own budgets and moving the VHA away from acute care and towards primary care. Performance criteria were established, information on performance was published and high-performing VISNs would receive financial rewards and greater autonomy. Moreover, the VHA treats a population that is older, poorer and more likely to have war-related injuries than the average in the US, and yet it still manages to cope to an incredibly high standard.

As some have also noted, integration and whole person care represents a change in Labour’s approach to this issue and somewhat of a convergence with the Lib Dem line pre-2010, creating questions as to how this will effect both Lib-Lab relations and coherency in the coalition on this issue. Labour’s pre-election idea of a National Care Service would have organised and universalised social care, and I supported Andy Burnham as he campaigned on the idea in the summer of 2010 (before proudly casting my second preference for Ed Miliband), but Labour is being brave to acknowledge that organisationally, integration and a greater role for councils is better than having two separate-but-parallel national services. Norman Lamb has been reasonable, both pre-election and post, and could be a potential Lib Dem ally, while the Tories are unfocused on the challenge presented by social care and are saddled with the Lansley reorganisation as their health legacy.

In his speech, Andy Burnham also addressed competition. This is an issue where I do take issue with the direction he, and previously John Healey, have taken (the belief that Labour allowed "too much competition in the NHS", for example). Alan Milburn may not be the most in-vogue voice in Labour these days, but as the man who did so much to make our promise to pull up standards in the NHS a reality, his warnings about Labour’s current line on independent provision should not be dismissed out of hand. 

It continues to be true that if implemented in the right manner, competition can create accountability and thus alleviate some of the problems associated with public monopoly, something that Labour proved in practice in the NHS. Targets and funding increases cannot do it all, especially when funding will continue to be tight for years to come, when the challenges are as great as they are and when Labour's approach to central targets will be undergoing a fundamental reconsideration after Mid Staffs. Andy Burnham and Liz Kendall were strongly in favour of our policy of using Independent Sector Treatment Centres (ISTCs) to deal with waiting times, and our 2010 manifesto contained firm pledges on patient choice. 

I acknowledge that the well-intentioned opposition of many on the left and in the health sector will always make this a dicey issue for the party, but we must nevertheless press ahead with our previous agenda, rather than abandoning it to the Tories. And as Milburn has also made clear, the Tory reorganisation is still messy and will damage NHS efficiency. Cameron falsely presumed he had both a mandate and sufficient public trust to fundamentally reform the NHS, when he lacked both, while Labour is trusted to make such changes.

Overall, Andy Burnham has begun putting us on good ground on health and social care, not least by laying out a vision in which referring to them as though they were separate in this way can become a thing of the past – ‘whole-person care’ will be physical, mental and social. As he acknowledged, there “will be many questions which arise” from the vision he has laid out. The King’s Fund has already fired the starting gun on this, asking crucial questions about how Labour will thread the needle on delivering integration and rolling back some of the Lansley reforms without further disruptive reorganisation, as well as questions about funding. 

I’d also add that while Torbay and elsewhere have proven to be powerful examples of the potential for community leadership in health and could therefore potentially be an answer to Maurice Glasman’s calls for a more responsive, pluralist and less standardised mode of public health provision to be part of the Blue/One Nation Labour approach, I’d like to hear more about how the corporatist ideas for public services Ed Miliband has spoken about will be integrated into our health platform. In the recent Cruddas-Labourlist One Nation pamphlet, Steve Griffiths and Sue Marsh also put forward some interesting insights, some of which will hopefully become part of our thinking. 

In any case, while The King’s Fund may have correctly described our policy review as “incomplete”, that’s a given when the review itself has only just been announced. What’s important is that they were certainly on the money when they called it ambitious.