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I watched Andy Burnham at the despatch box, Tuesday…
... he was as at-home leaning on the box as leaning on the bar at the local.
Power, he said, has become too centralised. People and places have lost control over the services that shape their lives.
The answer?
Devolution. Mayors. Neighbourhoods. Decisions made closer to the people affected by them…
… fair enough, but sitting in Parliament is a big fat Health Bill, dragging the NHS in the opposite direction.
It abolishes NHSE and antithetical to Burnhamism, transfers extensive powers back to the DH++.
The Secretary of State would be able to direct ICBs, determine financial objectives, appoint trust chairs and control resources...
... and be in the firing line when things go wrong. Mmmm....
Foundation-trust governors disappear. Healthwatch disappears. Local freedom... subject to whatever Whitehall decides…. disappears.
The Bill returns to the Commons next week. Cocidius cannot promise to disperse political power and then wave through legislation concentrating NHS power in ministers.
He should stop the Bill...
... not to save NHSE. The danger is that it disappears, only for its bureaucracy, habits and command-and-control culture to be rebuilt inside the DH++(+).
Same machine. Different headed paper. However, there’s a simpler alternative that can be achieved with some even simpler redrafting.
The NHS already has seven regions overseeing quality, finance and operational performance. Develop them.
Ministers should set the budget, uphold national standards and specify a handful of outcomes.
Regions should be accountable for delivery.
And then, what about ICBs? For a time I could see them disappearing. Now, maybe not? They could be useful.
They could become the linchpin of their communities. Change their name, change their purpose. Rebrand them...
Integrated Community Boards. The place where the NHS meets…
- mayors,
- councils,
- social care,
- public health,
- primary care,
- hospitals,
- voluntary organisations,
- patients and the public.
A table big enough for everyone interested in wellness, to sit around and have a say.
There's an old rule. The golden rule…
'... whoever has the gold makes the rules.'
Could we let ICBs make the rules, the principles and the guard rails?
Yes, but…
… the government proposes that the best Foundation Trusts could become Integrated Health Organisations, holding the whole health budget for a population, providing some services and subcontracting others.
If the Trust holds the gold, the Trust runs the local health economy. The ICB becomes the strategic commissioner (whatever that is) of a budget it no longer controls.
That ain’t gonna work.
Trusts should deliver services. Integrated Community Boards should decide what their population needs. This is a tricky balancing act but I think there is a way to make it work. Let's invent...
Alliance Contracts.
The ICB would contract with an alliance of primary care, acute, community and mental-health services, social care, voluntary organisations, and…
… and local authorities to contribute their resource to alliance contracting.
Right now we call it the Better Care Fund… an Alliance Contract is the big brother.
Instead of rewarding every organisation principally for its own activity, the AC would establish a budget for the whole pathway, shared outcomes and shared responsibility for spending.
If investment in general practice, community nursing, social care and rapid response, safely prevents admissions the benefit should flow back into those services.
The tariff becomes an alliance health policy, expressed in money.
At present, almost all elective activity is paid at 100% of the national unit price. More hospital activity generates more hospital income.
A GP who prevents an admission may save the NHS money, but the saving appears in someone else’s budget.
We keep shouting about 'care to move-left' while the money quietly flows-right. An alliance contract could reverse the current.
There might have to be upfront investment, even a period of double-running. Hospital costs don't disappear because a handful of admissions have been prevented.
The savings must be genuine, independently verified by the Regions, and reinvested by the Integrated Community Board… not trousered by the dominant Trust.
Burnham inherited the Bill. He does not have to inherit its thinking.
Preserve the bits of the Bill needed for a single-patient-record, patient safety, and all the other good stuff, but…
… abandon the cack-handed structural upheaval.
Put the effort into the golden rule.
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