Now the Labour Party’s objectives for the NHS are clearer, the real politics begins. If May’s government collapses, as looks increasingly possible, Labour will need to project its tactical policies for the NHS forcefully, both to rise above the din of Brexit and to see off Tory claims to be the party of the NHS. As always, the devil will be in the detail. The plausibility of how it plans to cope with the winter bed crisis will matter – what will the promised £500 million actually be spent on? How will a Labour Secretary of State for Health manage delayed transfers of care? If market mechanisms in the NHS are to be rolled back, how will this happen and how far will it go?
Of course Labour may not win an election, snap or planned. As Compass has warned, the Labour coalition is fragile. If May’s government survives Labour will have to live with Hunt Supremacy for a while longer, and because political rhetoric has limited value, will need some practical ideas about effective Opposition. Two events in the last week offer some possibilities; the King’s Fund report and webinar on the development of an accountable care organisation in the Canterbury region of New Zealand, and John Appleby’s review of PFI in the NHS, published by the Nuffield Foundation. The former has much to teach about integrating health and social care, and the latter offers new – and rational – thinking about PFI arrangements.
The Canterbury story was explained in the webinar by two leaders from the District Health Board and a large GP federation. They described the situation a decade ago in terms familiar to anyone in the NHS; clinicians trying to integrate a fragmented system but often inadvertently working against each other; hospital gridlock; and a common feeling that if only other people would sort themselves out, all would be well.
Creating an integrated local health service required investment in general practice, starting with the organisation of out of hours services, and growing collaboration around care pathway developments, not structural changes. Resources were created for GPs to support their patients in the community more easily, and hospital admissions declined. Effort went into relationship building, influencing the private provider organisations (the majority) and letting go of history in which grievances were prized possessions. Making the process of change clinician-led and management- enabled stabilised the primary care workforce, avoiding the problems we currently have. The leadership of the changes avoided consultation, with its undertones of decisions already made elsewhere, and sought dialogues instead. Likewise, debates about funding and contracts were postponed because early exposure to them demonstrated that nothing could change. Realistic timescales were sought – none of the quick fixes that plague the NHS. The integrated system works on the basis of not wasting people’s time (patients and professionals) and stressing its operational principles of “no wait, no harm, no waste”. The cancellation of a single elective procedure because of emergency care counts as failure. These might be principles that Labour could bring to the NHS.
Of course this may be too good to be true. The King’s Fund regularly leads its followers on visits to the collective farm that worked. Canterbury may well be the new Torbay, full of experience of positive change but hard to replicate once off home turf. The New Zealand speakers in the seminar mentioned that the earthquakes of 2010 and 2011 exposed the local health services’ fragility, and this realisation made change essential not optional. We are unlikely to have this kind of social and economic stimulus to change.
John Appleby dissects the scale, size and costs of NHS PFI schemes, which vary enormously. He concludes that it is not necessarily the case that PFI scheme were poor value for money. Early schemes were not always good deals, but as the NHS gained more experience of PFI it negotiated better terms. For example, Tees, Esk and Wear NHS Trust, which has paid off one PFI scheme, judged that its more recent schemes were good value and has left them in place.
A Labour Government could find ways to end PFI schemes early but the question is at what cost and opportunity cost? Would such repayments be money well spent, or could they provide more benefit if spent on something else? The drive for PFI has weakened. Seventeen new PFI schemes were expected to reach final construction in the NHS between 2011 and 2018, compared with 92 in the nine years from 2002. This may change again. Trusts needing to increase their capital budgets have been encouraged to open new PFI projects rather than borrow money directly. This will create some challenges for Labour, whether in office or in Opposition.
Appleby, J (2017) “Making sense of PFI”. Nuffield Trust explainer. www.nuffieldtrust.org.uk/resource/making-sense-of-pfi
Steve Iliffe 8/10/17