The healthmatters blog; commentary, observation and review
The team of researchers has successfully ‘trained’ a respiratory virus to recognise ovarian cancer and completely destroy it without infecting other cells.
The reprogrammed virus could also be used to treat other cancers such as breast, pancreatic, lung and oral.
Dr Alan Parker from Cardiff University’s School of Medicine said: “Reprogrammed viruses are already being used in gene therapy procedures to treat a range of diseases, demonstrating they can be trained from being life-threatening into potentially lifesaving agents.
“In cancer treatment, up until now, reprogramed viruses have not been able to selectively recognise only the cancer cells and would also infect healthy cells, resulting in unwanted side effects.
“We’ve taken a common, well-studied virus and completely redesigned it so that it can no longer attach to non-cancerous cells but instead seeks out a specific marker protein called αvβ6 integrin, which is unique to certain cancer cells, allowing it to invade them.
“In this case we introduced the reprogrammed virus to ovarian cancer which it successfully identified and destroyed.
“This is an exciting advance, offering real potential for patients with a variety of cancers.”
Once the virus enters the cancer cell it uses the cell’s machinery to replicate, producing many thousands of copies of itself, prior to bursting the cell and thereby destroying it in the process. The newly released viral copies can then bind and infect neighbouring cancer cells and repeat the same cycle, eventually removing the tumour mass altogether. The virus also activates the body’s natural immune system, helping it to recognise and destroy the malignant cells.
The reprogrammed virus is from a group of respiratory viruses called adenoviruses. The advantage of using these viruses is that they are relatively easy to manipulate and have already been safely used in cancer treatment.
The technique used to reprogramme the virus to identify the protein common to ovarian, breast, pancreatic, lung and oral cancers could also be used to manipulate it so that it would recognise proteins common to other groups of cancers.
Additional refinement to the viral DNA could also allow the virus to produce anticancer drugs, such as antibodies, during the process of infecting cancer cells. This effectively turns the cancer into a factory producing drugs that will cause its own destruction.
The research was carried out in a laboratory, using mice with ovarian cancer, and has not yet reached clinical trials. The next step is to test the technique with other cancers, with a view to starting clinical trials in five years’ time.
Dr Catherine Pickworth from Cancer Research UK said: “It’s encouraging to see that this virus, which has been modified to recognise markers on cancer cells, has the ability to infect and kill ovarian cancer cells in the lab. Viruses are nature’s nanotechnology and harnessing their ability to hijack cells is an area of growing interest in cancer research. The next step will be more research to see if this could be a safe and effective strategy to use in people.”
The team includes researchers from Cardiff University; the Mayo Clinic in Rochester, USA; Glasgow University; the South West Wales Cancer Institute; and Velindre Cancer Centre.
The research was funded by Cancer Research UK, Tenovus Cancer Care and Cancer Research Wales.
The paper ‘Ad5NULL-A20 – a tropism-modified, αvβ6 integrin-selective oncolytic adenovirus for epithelial ovarian cancer therapies’ is published in Clinical Cancer Research.
Today the NHS Confederation responded to Securing The Future: Funding health and social care to the 2030s, the report it commissioned with the Health Foundation and the Institute for Fiscal Studies. The aim was to produce an objective study that looked at trends in health and disease, the potential of these services to become more productive and, as far as possible, consider health and social care funding together.
Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the healthcare sector, said:
“This report is a wake-up call. And its message is simple – if we want good, effective and safe services, we will have to find the resources to pay for them.
“The scale of what we face is not widely understood. Over the next 15 years in the UK, there will be four million more people over 65 and the prospect of a 40 per cent increase in hospital admissions and further large increases in the number of people with numerous long-term conditions.
“It is now undeniable that the current system and funding levels are not sustainable. Without new ways of delivering services and sustained investment, NHS and care services will not cope, and we will face a decade of misery in which the old, the sick and the vulnerable will be let down.
“The findings suggest that even with modest real terms increases every year we could still be doing little more than managing decline. Such is the challenge of an ageing population with more people living with chronic conditions.
“It is time for honesty and a wider public debate about what sort of services we want and how much they will cost. The Prime Minister and the Health Secretary deserve great credit for recognising that we need a significant and a longer-term settlement and that both health and care need to be tackled.
“The report suggests this can be paid for through additional taxation. But we hope the Government will not rush into decisions or promises without consulting those who work in and use these services.
“The danger is that quick centrally imposed solutions will fail to address the enormity of the challenge and the need to secure widespread support. Instead we need to develop a new compact or agreement between government, the NHS and its staff, and the public.
“It should be agreed following a national conversation with a clear investment and workforce strategy, alongside commitments from the NHS and care services about what will be delivered in return.
“There is a growing realisation across the political parties that something needs to be done. This should not be a counsel of despair – we have perhaps the fairest healthcare system in the world, a world beating life sciences industry and a public that says it is prepared to pay more in taxes in return for better services. It is the major social issue that confronts us, but it is solvable.”
Alzheimer’s Research UK, the UK’s leading dementia research charity, is backing a call for governments worldwide to develop and implement action plans for tackling dementia. The recommendation, which comes during Dementia Action Week, is made in a report from Alzheimer’s Disease International that examines progress towards the World Health Organisation’s global action plan for dementia. The plan, published last year, includes a global target to double the output of dementia research by 2025.
The report finds that 27 WHO Member States have a national plan for dementia in place, with 28 in development – against a target for 75% of the 194 Member States to have a plan in place by 2025.
Dr Matthew Norton, Director of Policy and Strategy at Alzheimer’s Research UK, said:
“Today’s report underlines the gravity of the global challenge posed by dementia and the urgent action needed to tackle this devastating condition. It’s nearly five years since the world’s health leaders set an ambition to find a new treatment by 2025, and in that time, dementia has become the leading cause of death in the UK. While there have been welcome increases in funding, investment in dementia research still lags behind other health conditions in the UK and globally. We now understand more than ever about the diseases that cause dementia, but to translate that understanding into life-changing treatments, our scientists need the backing of governments across the world.
“The UK is leading the way in this effort, and initiatives like the UK Dementia Research Institute are prime examples of the collaborative approach that’s needed to defeat dementia. But with just one dementia researcher for every four working on cancer, we cannot be complacent. Dementia must be a priority for governments worldwide if we’re to bring about the treatments, preventions and improved diagnosis that will transform the lives of millions.”
New research among more than 2,000 adults has examined the UK’s eating habits, revealing how different parts of the country compare when it comes to fast food consumption, takeaway deliveries, restaurant visits and ‘food porn’ selfies. The survey found:
- London is home to the worst eating habits – the capital ranked topped for the number of people who at least once a week would eat fast food (39%), ready meals (48%) and takeaways (32%)
- Londoners were also the most likely to eat in restaurants on a weekly basis (30%), consume leftovers (31%) and take photos of their food to share on social media (20%)
- Just 13% of people in Northern Ireland say they typically eat five portions of fruit and veg a day, the lowest proportion of all 11 regions
- Wales was also high on the list when it came to ready meal consumption (2nd), failure to eat five fruit and veg each day (2nd) and fast food intake (3rd)
- 11% of UK adults said they eat reheated leftovers from a takeaway or restaurant visit at least once a week
- The figure jumps to a massive 30% in London, and 22% in the Midlands
When it comes to explaining why the UK eats so many ready meals and takeaways, PharmacyOutlet.co.uk’s survey also revealed that:
- 26% of UK adults opt for these food options because they are too busy to cook
- Meanwhile, 13% (6.7 million) say they actually do not know how to cook
- Only 27% of people monitor their daily food intake – such as calories, fats and salt levels
The UK’s high streets are filled with restaurants, takeaways and convenience stores selling ready meals, but just how often do consumers visit these places? PharmacyOutlet.co.uk
The independent, nationally representative survey of more than 2,000 UK adults reveals which regions eat the most fast food, ready meals, takeaways, restaurant grub and reheated leftovers. It also explored the parts of the country that are the worst offenders when it comes to not getting their five portions of fruit and veg each day, and who is the most likely to put a pictures of their dinner up on social media.
Here are the results:
Hitesh Dodhia, Superintendent Pharmacist at PharmacyOutlet.co.uk, commented on the research: “From curries to Chinese, fish and chips to pizza, the UK loves its fast food and takeaways. But this research illustrates just how often busy Brits resort to takeaways, ready meals, restaurants and leftovers to satisfy their appetite.
“While there is nothing wrong with eating out or having food delivered from time to time, it must form part of a balanced diet, and it’s concerning to see how few people – just 26% – actually consume five portions of fruit and veg a day. The public must be wary of the fat and salt content of restaurant food and takeaway meals; failure to do so can cause serious health concerns, as well as generally effecting energy levels and the way both the body and mind perform,” he said.
Many say they lack the confidence to offer the best support to patients
Brussels, 17 May 2018: European General Practitioners (GPs) are calling for more and better training on obesity in order to improve treatment and care for patients.
A survey of more than 700 GPs from seven European countries has shown that almost a third are not confident enough about the complexities of obesity to offer the best support to patients, and less than half think that GPs generally provide effective advice on losing weight and overcoming obesity.
According to the survey, conducted for the European Association for the Study of Obesity (EASO), 83% of GPs feel they should have more training on its causes, consequences and treatment. Approaching half of them (43%) reported having received less than four hours of such tuition during their entire medical training, which typically takes around 10 years.
This is despite the fact that almost 95% of the GPs view obesity to be a serious danger to health in their country and 38% recognise it to be very dangerous.
The figures support the view of the World Health Organization that obesity is one of the greatest public health challenges of the 21st century as its prevalence has tripled in many countries in Europe since the 1980s.
A serious danger to health
Overall, GPs ranked obesity fifth in a list of serious dangers to health. However, three of the top four – cancer, cardiovascular disease, and type 2 diabetes – commonly result from obesity.
The GPs agree that more effective treatment of obesity would significantly reduce the burden on the healthcare systems from the many other diseases and conditions on which it impacts.
Furthermore, there is wide agreement among GPs (83% of those interviewed) that obesity is a disease and should be more widely recognised and treated as such. Almost three quarters of them (74%) agreed that it would result in better patient care.
Only three countries in Europe (the Netherlands, Portugal and Spain) currently recognise obesity a disease.
Among other key findings are:
- Nearly six out of ten of the GPs’ patients are overweight or have obesity (58% in total: 35% overweight and 23% with obesity). The highest reported number of patients with obesity was in Germany (29%). The lowest in the Netherlands (15%).
- More than a quarter (28%) of GPs rarely or only occasionally initiate discussions on weight with their patients with obesity. In the UK it is 34%.
- Lack of exercise is seen by GPs as the most common cause of obesity (72%)
- Bariatric surgery is an effective treatment in helping patients with obesity to lose weight (according to 91% of GPs) and is considered a positive way of treating other diseases and conditions caused by obesity.
European Obesity Day
“Despite the growing epidemic and the burden it places on healthcare systems, it is clear that GP’s are given very little training on obesity,” says EASO President, Professor Hermann Toplak.
“This is a major barrier to obesity treatment. More effort needs to be made to improve healthcare professionals’ understanding of obesity and comprehensive treatment approaches that can be delivered as part of patient care,” he said.
- NHS trusts spend £1.46 billion a year on temporary staffing to plug the nursing gap – the equivalent of salaries for 66,000 newly qualified registered nurses
- If existing gaps were permanently filled, trusts could save as much as £560 million a year
- Poor retention is highlighted as a significant factor driving the shortage, with 70 per cent of registered nurses leaving their NHS trust within 12 months of qualification
NHS trusts in England are being forced to turn to expensive temporary staffing arrangements to plug gaps in nursing rotas – at a cost of £1.46 billion last year.
Data secured under the Freedom of Information Act as part of The Open University’s new report Tackling the Nursing Shortage quantifies the financial impact of the national shortage – £1.46 billion. This bill for temporary staff would be enough to pay the salaries of 66,000 newly qualified registered nurses – more than filling the 38,000 existing vacancies.
In 2017, NHS trusts paid for an additional 79 million hours of registered nurses’ time at a premium rate – 61 per cent above the hourly rate of a newly qualified registered nurse in full-time employment. Based on the difference in cost, if current vacancies were filled permanently, the NHS could save as much as £560 million a year.
However, a new UK survey of 500 registered nurses and healthcare support workers commissioned by The Open University reveals that three quarters (76%) of registered nurses expect the shortage to worsen in the next 12 months and three in five (61%) believe even more temporary staff will be needed.
Poor retention is a problem in the NHS. Issues around pay, workload, organisational culture and access to continued professional development is driving nurses on to other trusts and the private sector, or to leave the profession altogether. Brexit has also seen a 28 per cent rise in EU nurses quitting Britain, which could further exacerbate the problem.
The study found one in three (34%) registered nurses are unhappy in their current role – and a similar number (35%) are thinking of leaving their job if things do not improve.
Retention is particularly problematic at the beginning of nurses’ careers, with seven in 10 (70%) newly qualified nurses quitting their NHS trust within a year of qualification, leaving gaps that can be hard to fill. Many nurses have to complete their pre-registration training away from home, particularly in rural areas, but it means significant numbers are moving back when they qualify, with 16 per cent giving this as their main reason for moving between trusts.
Attracting new recruits is the other challenge. The introduction of student loans for nursing degrees has seen the number of applications to study nursing at university fall by around a third, and overseas applications have fallen 87 per cent in the last year as a result of the EU referendum. For this reason, creating new or alternative routes into the nursing profession is essential.
Providing alternative ways to study to become a registered nurse is one suggestion for tackling the shortage. In this survey, nearly two thirds (63%) of registered nurses believe offering flexible distance learning would help to recruit nursing students from more remote areas and keep nurses in these areas after they qualify. 71% believe apprenticeships could help to attract new student nurses to the profession and 60% believe that they offer a good alternative to recently removed bursaries.
Offering trusts the opportunity to develop their existing health care support workers and new recruits via on-the-job training makes the concept of a Registered Nurse Degree Apprenticeship appealing. The NHS is the biggest contributor to the apprenticeship levy, so this approach would ensure they are making the most of their investment. The report concludes that an increased focus on work-based training and apprenticeships could therefore offer a more stable long-term approach.
Jan Draper, Professor of Nursing at The Open University
The full report can be accessed here: http://www.open.ac.uk/business/apprenticeships/blog/tackling-the-nursing-shortage-May-2018
A “Vision” might be an overstatement but there has to be a clear statement of aims – to improve care for all – to develop (over 2 terms) into a care system designed to increase population wellbeing through prevention, early intervention, excellent primary, secondary and tertiary planned and emergency care and long term support. The system should be delivering outcomes comparable with the best in the world, reducing inequalities and being active in redistribution through public services provision.
The design should build on:-
- Berwick’s 9 principles for a more moral system (Era 3)
- Wanless’s 2002 fully engaged scenario ( the NHS will remain viable if the population engages fully with it)
- Care Act 2014 “I” statements (or the Patient Voices equivalent)
Core principles for healthcare need to be reinforced – comprehensive, universal, free at the time of need and tax funded. These principles can be extended to social care (and housing) over time. We can add new principles around accountability and quality. A strengthened Constitution will cover health and social care.
Health care will be fully integrated into the rest of the public sector within an overall system giving all the right to appropriate care and support – including public health, social care, housing and monetary support (through, for example, incapacity allowance, pensions and universal credit).
Care services will be planned and delivered based on a population approach with areas made up of one or more local authority areas. (not all STPs are coterminous now.) There will be local autonomy over the organisation of services within national frameworks.
There will be democratic accountability of the planning of services and resource allocation. Various permutations of health boards, care boards, joint integration boards and local authorities are all possible but will lead eventually to a single accountable body for each area (local authority).
Operational delivery of services will be accountable through public bodies with boards with NEDs including public, patient, staff and Local Authority representatives. Such bodies must be exemplars in terms of ethical behaviour, staff terms conditions and relations, and environmental impact.
Service design will be accountable through coproduction approaches. Service delivery will be through shared decision making (unless clinically inappropriate). Patients and communities will be increasingly involved in their care.
This is a “public” system; or rather a series of public systems. Services will not be delivered through legally binding contracts although SLAs and “NHS” contracts may be part of performance management. No part of the system will be “autonomous”. All parts of the health and social care system will be open and transparent and “commercial confidentiality” will not be recognised in respect of anybody getting public funds.
Entitlement will be National (social care isn’t now); service frameworks will be National; standards (targets) will be National; terms and conditions for staff will be National.
Making the Change
In our view essential structural requirements for change will include:-
- greater levels of sustained revenue funding
- new sources for capital funding
- social care free at point of need, or cost-capped
- new funding allocation models, and fund – pooling permissions
- removal of markets and competition
- reversing previous privatisation (and developing new models for ownership)
- restoring powers to Secretary of State (ending autonomy)
There will be significant ongoing investment in:-
- rebuilding the management skills and expertise to make a publicly managed system effective
- developing the skills and expertise within local councils to take on new planning and oversight roles for the NHS
- having NEDs, staff representatives and other system managers drawn from a more diverse and inclusive background, supported by training, development and peer support
- increasing accountability and participation
- building effective partnership working and workforce planning.
To avoid disruption and opportunity costs the changes necessary must not rely on top down reorganisation, disbanding and then creating hundreds of organisations, or changing local authority boundaries.
Existing organisations should be given some flexibility over form but any new organisation or mergers, acquisitions, takeovers would require Secretary of State approval. Secretary of State powers should be delegated to regional level.
Primary legislation should be used to remove barriers (such as market competition) to more integrated care or to widen opportunities for collaborative approaches (easier pooling of budgets).
The Care Act: ‘I’ statements
What are the ‘I’ statements?
‘I’ statements are an assertion about the feelings, beliefs and values of the person speaking. In the case of ‘Making it Real’, the ‘I’ statements are what older and disabled people, carers and citizens expect to feel and experience when it comes to personalised care and support. They are grouped around six key themes:
- Information and Advice: having the information I need, when I need it
- I have the information and support I need in order to remain as independent as possible.
- I have access to easy-to-understand information about care and support which is consistent, accurate, accessible and up to date.
- I can speak to people who know something about care and support and can make things happen.
- I have help to make informed choices if I need and want it.
- I know where to get information about what is going on in my community.
- Active and supportive communities: keeping friends, family and place
- I have access to a range of support that helps me to live the life I want and remain a contributing member of my community.
- I have a network of people who support me carers, family, friends, community and if needed paid support staff.
- I have opportunities to train, study, work or engage in activities that match my interests, skills, abilities.
- I feel welcomed and included in my local community.
- I feel valued for the contribution that I can make to my community.
- Flexible integrated care and support: my support, my own way
- I am in control of planning my care and support.
- I have care and support that is directed by me and responsive to my needs.
- My support is coordinated, co-operative and works well together and I know who to contact to get things changed.
- I have a clear line of communication, action and follow up.
- Workforce: my support staff
- I have good information and advice on the range of options for choosing my support staff.
- I have considerate support delivered by competent people.
- I have access to a pool of people, advice on how to employ them and the opportunity to get advice from my peers.
- I am supported by people who help me to make links in my local community.
- Risk enablement: feeling in control and safe
- I can plan ahead and keep control in a crisis.
- I feel safe, I can live the life I want and I am supported to manage any risks.
- I feel that my community is a safe place to live and local people look out for me and each other.
- I have systems in place so that I can get help at an early stage to avoid a crisis.
- Personal budgets and self-funding: my money
- I can decide the kind of support I need and when, where and how to receive it
- I know the amount of money available to me for care and support needs, and I can determine how this is used (whether it’s my own money, direct payment, or a council managed personal budget).
- I can get access to the money quickly without having to go through over-complicated procedures.
- I am able to get skilled advice to plan my care and support, and also be given help to understand costs and make best use of the money involved where I want and need this.
The outsourcing of public services to non-statutory providers, especially the private sector, has been the delivery model of choice in the UK for around thirty years. The budget devoted to such contracts is hard to estimate but is reckoned to be in excess of £100bn (Walker and Tizard, 2018), equivalent to about 8% of Gross Domestic Product. The model has also changed in nature over the years, moving beyond back-office functions and into front-line service delivery.
A number of high profile problems and outright failures, from Carillion to rail franchising, have brought the model into more prominent view, but much less interest has been paid to the longer-standing privatisation of adult social care (ASC). This is a large market worth in excess of £22bn and rising as the care needs of adults intensify and become more complex (King’s Fund/Nuffield Trust, 2016). This blog explores the reasons for this relative lack of interest in the issue of ownership and considers the issues involved in attempting to secure a different balance of provision that better fits the circumstances of those who need services and support.
Adult Social Care: An Intractable Privatisation?
The relative absence of policy interest in revisiting the ownership structure of ASC may be due to three related factors – market penetration, market fragmentation and market fragility. Together these make the prospect of some ‘big bang’ change in market structure seem unlikely and impractical.
Market Penetration: The longer the period over which outsourcing has taken place and the greater the penetration of the market, the more difficult it is likely to be to reverse the situation. This is the position with ASC where the process has been in train for over thirty years and the current structure is deeply embedded. In 1979, 64% of residential and nursing home beds were still provided by local authorities or the NHS; by 2012 it was 6%. In the case of domiciliary care, 95% was directly provided by local authorities as late as 1993; by 2012 it was just 11% (Centre for Health and the Public Interest, 2013).
Market Fragmentation: There is no compact ASC service that can be easily repatriated into public sector ownership. Rather the sector is characterised by a multiplicity of fragmented, competing providers. The care home sector supports around 410,000 residents across 11,300 homes from 5500 different providers ((Competition and Markets Authority, 2017). The situation in home care is even more diverse with almost 900,000 people receiving help from over 10,000 regulated providers. Nor is it any longer the case that the state is even the dominant commissioner of these services – tighter access to local-authority-funded care has resulted in a large growth of self-funding ‘customers’.
Market Fragility: The third complicating feature of the ASC market is its fragility and the politically toxic consequences of market failure. The first major casualty was Southern Cross in 2011 – a large national care home provider which had 9% of the market nationally but a much greater share in certain regional areas. Much of the Southern Cross provision was eventually taken over by another major provider, Four Seasons, which is itself now at high risk of going under. Whether through financial collapse or strategic withdrawal the market model is widely considered to be at tipping point.
This is an unenviable policy dilemma. Unlike some other services and utilities there is no simple way of shifting such a dominant and entrenched model of provision. Nor is there any reason to think that the ‘purchaser-provider split’ will be removed in the foreseeable future. Better and fairer funding is a prerequisite for improvement and has been exhaustively explored elsewhere (Barker Report, 2014), but in addition to this the local state (as the biggest commissioner of services) and national government (as policy-maker) can also act in ways that could create better care quality and reshape the provider mix. The key to this is a different approach to the way support and services are commissioned.
Currently commissioning is too often a hand-to-mouth process devoid of a wider purpose. Any sustainable alternative model has to go beyond the notion that the role of the state is to ‘fix’ or somehow forestall market failure (Hudson 2014); rather it is to act as a catalyst for innovation. One variant here is that promoted by Mazzucato (2012) with her proposal for ‘mission-oriented’ public investments where the task of the state is to determine the direction of change by ‘transforming landscapes and creating and shaping markets’. It is worth exploring what this might look like in the case of ASC. Four dimensions can be identified: commission local and small; commission holistically; commission individually; and commission ethically.
Commission Local and Small
The trend in the residential sector is for small operators to be replaced by large provider chains with more than fifty care homes. Recent building of new homes in a standard format with sixty or more en-suite beds has been dominated by chain operators, while many of the remaining smaller businesses are likely to exit the market in the next decade by selling homes which are valuable property. Industry estimates (Knight Frank, 2017) indicate that as care homes grow in size they become more profitable, with the highest margin for those with over a hundred beds. The paradox here is that while the market is moving towards large-scale provision, the evidence from the social care regulator is that smaller facilities tend to receive better ratings for quality of care (Care Quality Commission, 2017).
A focus on smaller and more local commissioning is needed to counteract this trend – a challenge for public sector commissioners who generally favour larger, less complicated organisations. This fits in with ideas around Asset-Based Community Development (King’s Fund, 2018; Coalition for Collaborative Care, 2018) – a focus on interdependence as people share skills and support – and on supporting communities to rebuild their own social infrastructure by harnessing community businesses (Power to Change, 2017).
Complementary to this level of ‘micro support’ is the concept of Local Wealth Building (DCLG/Cooperatives UK, 2017), a growing movement in Europe and the USA based on the principle that ‘places’ hold significant financial, physical and social assets of local institutions and people. The key is local ‘anchor’ institutions (public, social, academic, commercial) and their procurement role in supporting the local supply chain. This will include opening markets to local small and medium enterprises rather than looking to national and international chains. The experience of Preston, Lancashire, in the UK is seen as an exemplar (Chakrabortty, 2018). Through the Public Services (Social Value) Act, public authorities can also embed social value into the design of services and decision-making criteria rather than fixating on cost and efficiencies.
It no longer makes sense to think of social care commissioning in isolation; rather the focus is upon ‘holistic’ or ‘place-based’ commissioning. Most social care is commissioned separately from other place-based interventions. The most frequent concerns about potential intersections are those with the NHS, where accessing social care is felt to be adversely affecting transfers of care from hospital. However, market-shaping is a much broader strategic task spanning several council departments and other partners – social care, planning, transport, housing, economic development, health, education, criminal justice, community safety, training providers and more. Coordination on this scale would require significant investment in capacity, skills and structures – in effect the reinvention of robust municipal governance at several levels. Britain is the most centralised country in the Western world, and in this respect the reform of social care has to be considered as part of a much broader shift in the way decisions are made and resources are allocated.
Policies on access to social care support have created two groups of ‘personal’ commissioners’ – those who fund their own care and those whose care is funded via an ‘individual budget’. Both are in need of greater support. A market requires consumers who seek and digest information to inform their choice of product. From this perspective the care home market in particular has some characteristics of an inefficient market (National Audit Office, 2011) – entry is often unplanned, made in response to a personal crisis and with very low rates of switching to a different provider in the event of dissatisfaction.
The obstacles facing those who fund their own support have been comprehensively identified by the Competition and Markets Authority (op cit) which notes: most individuals and families are poorly informed and have done little or no planning or research; they struggle with the notion of exercising choice and rarely move between providers; there are low levels of complaints, fears of retaliation in the event of a complaint; and lack of understanding of the formal procedure. In addition there is a litany of malpractices including: lack of information about prices; demands for substantial deposits and other upfront payments; a raft of hidden extra charges and surcharges; demands for top-up payments without local authority agreement; and fees charged after death.
It is not entirely clear how this situation can be easily transformed. The CMA report raises the prospect of enforcing consumer law, but others will take the view that it is simply not possible to replicate a market in the social care sector. However one option that can work for some people is that of personal budgets (House of Commons Public Accounts Committee, 2017) and more recently personal health budgets (Jones et al, 2017), though here too there are issues to be resolved around issues like making choices and decisions; receiving Information and advice; understanding allowance and spend; budget management, monitoring and review; and risk management and contingency planning.
The imperative to commission ethically is implicit in all approaches. It could encompass the following dimensions.
Commission from ethical employers: Commissioners need to be able to distinguish between the workforce practices of different providers and prioritise those acting as ‘good employers’. This might have several components such as prioritising providers that comply with minimum standards around workforce terms and conditions, have effective training, staff development and supervision, comply with ethical care charters and encourage staff to participate in collective bargaining (Burns et al, 2016; Hendry 2014).
Commission from transparent providers: A ‘transparency test’ could stipulate that where a public body has a legal contract with a private provider that contract must ensure full openness and transparency with no ‘commercial confidentiality’ outside of the procurement process. All providers of public services should – at a minimum – publish details of the funding they receive, performance against contractual obligations, the suppliers to whom they subcontract services, the value of these contracts and their performance, and user satisfaction levels (Gash et al, 2013).
Commission from tax compliant providers: The ownership of all companies providing public services under contract to the public sector, including those with offshore or trust ownership, should be available on the public record. At the same time, a taxation test could require private companies in receipt of public services contracts to demonstrate that they are domiciled in the UK and subject to UK taxation law (Corporate Watch, 2012).
Commission from not-for-profit providers: A fresh approach to adult social care offers the opportunity to rethink the role of other sectors. Whilst wholesale renationalisation seems unlikely there is every reason to encourage local authorities to begin to build up their own in-house provision and to support all organisations with a social purpose, whether in the public, private or voluntary sector. This could include encouragement for user-led organisations, social enterprises, mutuals and others to recruit and train service users in innovative ways.
The privatisation of ASC in the UK exhibits an unusual policy narrative compared with other sectors. Devoid of any real debate or stated purpose, a thirty year process of outsourcing – predominantly to private companies – has continued unabated and unchecked. The scale of penetration and the dismantling of alternative providers have resulted in a situation that fails to meet ordinary market standards around choice and control. And now, as a result of austerity politics, there is every chance that the private sector will lose interest and leave the market with dire immediate consequences for those in need of services and support. Whilst it is not feasible to simply eliminate a model that has become so deeply embedded, a combination of better funding and smarter commissioning could, over time, reshape ownership structures, increase provider stability, focus on ethics rather than cost, connect people more fully to their local communities and enhance the quality of care.
Barker Report (2014), A new settlement for health and social care: Final report
Burns, Diane., Hyde, Paula and Killett, Anne, (2016), ‘How financial cutbacks affect job quality and care of the elderly.’ Work and Employment Relations in Healthcare. Industrial Labour Relations Review
Care Quality Commission (2017), The State of the Adult Social Care Services, 2014-17
Centre for Health and the Public Interest (2013), The future of the NHS? Lessons from the market in social care in England, pp. 10-11
Chakrabortty, A (2017), https://www.theguardian.com/commentisfree/2018/jan/31/preston-hit-rock-bottom-took-back-control
Coalition for Collaborative Care (2018), Commissioning Community Development for Health.
Competition and Markets Authority (2017), Care Homes Market Study, Final Report
Corporate Watch (2012), An unhealthy business: major healthcare companies use tax havens to avoid millions in UK tax
DCLG/Cooperatives UK (2017), Community Economic Development: Lessons from two years’ action research
Gash, T, Panchamia, N, Sims, S and Hotson, L (2013), Making public service markets work, Institute for Government
Hendry, J (2014), Reconstruction after the crisis: a manifesto for collective bargaining, Institute of Employment Rights
House of Commons Public Accounts Committee (2017), Personal Budgets in Social Care: 2nd Report of Session 2017-17
Hudson, B (2014), Dealing with market failure: a new dilemma in UK health and social care policy, Critical Social Policy, 35(2) pp281-292
Jones, K et al (2017), Personal Health Budgets: Process and context following the national pilot programme (PSSRU, University of Kent)
King’s Fund/Nuffield Trust (2016), Social Care for Older People: Home Truths
King’s Fund (2018), Reimagining Community Services: Making the most of our assets
Knight Frank (2017), Care Homes Trading Performance Review, 2015-16
Mazzucato, M (2012), The entrepreneurial state: debunking private v public sector myths. London: Anthem
National Audit Office (2011), Oversight of User Choice and Provider Competition on Care Markets.
Power to Change (2017), http://www.powertochange.org.uk/what-is-community-business/
Walker D and Tizard, J (2018), Out of Control (London: Smith Institute)
Professor Bob Hudson,
Centre for Health Services Studies,
University of Kent,
The NHS Confederation has launched a petition calling on the government to commit to a funding plan for health and social care to 2035 in recognition of the crippling effects of rising demand, underfunding and workforce shortages.
Following repeated warnings of services on the brink and an NHS gradually becoming unsustainable, the organisation has launched a public petition to secure a debate on the issue in Parliament.
The petition, available on Parliament’s website, urges the government to commit to a long-term funding plan that covers both health and social care to the year 2035.
“The NHS is facing a funding and workforce crisis which means the next decade must be very different from the last,” said NHS Confederation chief executive Niall Dickson.
“Any long-term funding settlement must bring health and care together and move away from short-term cash injections that do not enable transformation.”
The petition is entitled “Commit to a long-term funding plan for health & social care to the year 2035.”
It comes after the Prime Minister in March announced plans to come forward with a multi-year settlement and long-term plan for the NHS.
But the announcement lacked detail on what period the settlement would cover and whether it would include social care – 85 per cent of healthcare leaders in England believe it should.
“Without action, our health and care system will continue to deteriorate; millions will wait, more will suffer and some will die. It is now clear that the cries for more funding are unequivocal,” Dickson warned.
The organisation aims to gather over 100,000 signatures, surpassing the threshold needed for the petition to be considered for debate in Parliament.
The Confederation, which represents healthcare providers and commissioners in England, Wales and Northern Ireland, has teamed up with the Institute for Fiscal Studies and the Health Foundation to conduct a comprehensive study into the funding needs of the UK’s health and care systems over the next 15 years.
The study will be out in the next coming weeks.
To promote the petition and the upcoming study, the NHS Confederation this week also released an animation entitled “Securing the future: Funding Health and Social Care until the 2030s.”