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Place-based health - some critical questions

Steve Iliffe

29 July 2016

Jessica Studdert makes a good case for transferring responsibility for the NHS from central to local government.1 Such a transfer would correct the democratic deficit that was built into the NHS in 1948 and that has never been addressed by any government. As Jessica argues, it might also tilt the NHS’s emphasis from hospital-based ‘cure’ to prevention and community-based care, if only a little. These look like worthy objectives for a future Labour government, but are they realistic?

We need to avoid conflating the impact of demographic change (essentially, population ageing) and the effects of government funding policies on strains in the hospital sector. Likewise, the possible benefits of local programmes of preventive work and the potential for community-based services to provide better quality care need to be separated.

The cost consequences of an ageing population are surprisingly small; most of the rising costs in health services are due to technological innovation (including new medicines) plus the expansion of clinical activity to new conditions.2 The two clear examples of the latter are the NHS’ responses to age-related disorders like dementia and frailty. Both conditions are poorly understood and there are no cures for either. Nevertheless services are evolving to identify people with either or both condition, even though we have limited options to help people with them. At the same time hospital services designed to deal with single conditions (heart attacks, infections, strokes) are struggling to manage individuals with long-lasting multiple problems for whom community-based care would be more appropriate and safer, if it were available. Part of this clinical miss-match is due to the way the NHS medical workforce has over-specialised. Over-specialisation has left a generalist-shaped hole in NHS hospital staffing and there are not yet enough geriatricians to fill it.3

All these trends have increased the strain experienced by NHS hospitals, but the government’s austerity policy towards the NHS has added to them enormously. By holding funding increases down to 1.8% per year instead of meeting the NHS’s inflation rate of around 4% (due again to innovative technologies and expanding medical activities), the current government has generated a financial crisis, particularly in the hospitals. It is this deliberate policy of under-funding (and expecting shortfalls to be made up by implausibly high levels of improved productivity) that is causing NHS finances to deteriorate, not unprecedented levels of demand. No change in management of the NHS looks fit to correct the accounting deficits, certainly not transfer of responsibility to cash-strapped local government.

Nevertheless, drifting towards local control of the NHS would be a good policy option, especially because it could end a long period of centralisation and strengthen local government. Public health was restored to local government by the 2013 Health & Social Care Act, having been annexed by the NHS in 1974. Within local government public health expertise could be fruitfully reunited with expertise about housing, environment, leisure services, the voluntary sector and education, if its budgets were not being cut centrally to support hospital services in financial crisis. Programmes for prevention of ill health that are effective – for example, exercise promotion – need long-term investment. Even then, their impact on NHS service use may be limited compared to their effect on individual and social wellbeing.

The next to follow could be community-based nursing services, which rely on the work of (largely) unpaid family carers and the patchwork of commercial home care resources  to be able to support people in their homes. We could use the existing home care resources – in effect bringing them into the public domain – to grow a robust hospital-at-home system that could provide an alternative to hospital care, using the French and Australian models as examples. Hospital at home not only requires a stable nursing workforce, but also a ring-fenced budget to prevent other parts of the NHS from robbing it. This cannot be dependent on short-term financial gains to the NHS or local government, which are by no means guaranteed; for example, hospital admissions of frail older people may not decline but they may get shorter, reducing the risks of hospital care to the frail individual, like injurious falls and resistant infections.

And then there are the hospitals. Do local governments really want control of hospitals? After all, local government (and the NHS) struggle to engage commercial care home chains in health service initiatives, and they are less complex than hospitals. Would they be any better placed to prevent all resources from being tipped into maintaining them? Could local authorities close redundant hospital services any easier than the centralised NHS does, or would they be too much influenced by local political passions?  We may not be able to answer these questions without some trials of new management arrangements for the NHS, but if we favour a drift towards local government control, these trials may be needed to clarify the problems and their solutions, empirically. Local variations in how the NHS works would then increase, but as Studdert argues, we cannot allow fears about ‘postcode lotteries’ in services to stifle experimentation.

Steve Iliffe is Emeritus Professor of Primary Care for Older People, University College London.

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Notes

1 Studdert, 'Place-based health: why local accountability would lead to better quality and outcomes', Renewal, 24 (2016).

2 R.G.Evans, K.M.McGrail, S.G.Morgan, M.L.Barer & C.Hertzman, 'APOCALYPSE NO: Population Aging and The Future of Health Care Systems', Canadian Journal on Aging, 20 (2001).

3 RCP, Debated in the consultation about the Royal College of Physicians’ Future Hospital Commission, 2013, www.rcplondon.ac.uk/projects/outputs/future-hospital-commission.

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