Sir Stephen Bubb’s report exposing the failure of the NHS to reform the care of people with learning disabilities highlights the health service’s extraordinary ability to resist pressures to change.
While clinical and technological innovations are commonplace, the Bubb report exemplifies the way the NHS often seems impervious to system reform.
After Panorama broadcast videos revealing the cruelty of staff at Winterbourne View, the government pledged to move all people with learning disabilities or autism inappropriately placed in institutions into community care. Three years later, more people are institutionalised than ever.
Everyone agreed what needed to be done. There were plenty of reports outlining what good services look like and how to commission them. A concordat was signed by more than 50 organisations – from the Department of Health to the NHS Confederation to social care bodies. Collectively they achieved virtually nothing. Government policy failed. Public outrage failed. Commissioning failed. Organisations promising to change failed.
Bubb concludes that “we made it too hard … to make change happen, and too easy to continue with the status quo”.
Speaking to the BBC on Wednesday, Norman Lamb’s frustration was palpable; the care minister had even been driven to intervening personally in some cases by bringing families and care managers together to try to find a way through the impasse.
So what will secure NHS reform? Not patient choice; in an interview with HSJ this week the health secretary, Jeremy Hunt, conceded that giving patients choice would not improve performance. No doubt some will rejoice at this defeat for market principles; refusing to respond to the wishes of patients seems an odd thing to celebrate.
After a quarter of a century, commissioning has made too little difference. There are many small-scale successes but attempts at large-scale change invariably meet massive, and usually overwhelming, resistance.
Empowering patients produces dramatic results where it is allowed to happen, but despite the fine words of the NHS Constitution, it is a minority NHS sport.
National clinical programmes have their place but can only secure change in a narrow field.
Closure is a guaranteed way to change services. Bubb recommends a closure programme for the worst units. In time this might do for learning disabilities what the closure of the Victorian asylums delivered for mental health care. But in the acute sector failure is more often met with more money than closure. As the health economy tightens, will the time come when commissioners and ministers stop propping up the weakest hospitals and plough that funding into new care models instead?
In the US Obamacare – the Affordable Care Act – is having success in incentivising hospitals, doctors and other services to collaborate in accountable care organisations (ACOs) to keep a population healthy while getting a grip on healthcare costs. The providers have a vested interest in avoiding duplication and sharing patient information. Funding is through a capitation payment – a fixed fee for each person for a month or year. Performance measures have to be met.
It is not a panacea, but it is indicative of how carefully aligning financial incentives with performance measures can quickly change a healthcare system. In 2010 there were around 40 ACOs; now there are hundreds all over the country, supporting one in seven of the population.
The NHS will change when the flow of cash forces it to do so. As former Labour health minister Lord Warner said at a recent debate, the pattern of care will ultimately have to “follow the money”. Every time more cash is given to hospitals simply for activity, reform becomes more distant.
After the general election, NHS England should be bold in its reforms to the payment system. It needs to make a decisive change in how providers are rewarded while giving more money to primary care and less to the acute sector. The government could start now – every penny of the extra money heading towards the NHS in the autumn statement should be spent outside hospitals.
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