The Third Era group is a small network of academics, care professionals, managers and politicians who share an interest in making our health and social care systems better.  They share the view that as the era of markets and competition ends there will be a valuable opportunity to address some of the long-term issues which face our care systems. The group’s emphasis is on solutions that a progressive government could implement.

The group is coordinated by Prof Steve Iliffe and Richard Bourne, who have published a series of articles drawing on discussions within the group.  See  http://www.healthmatters.org.uk/era-3/  We welcome further contributions; please send them to Steve Iliffe (s.iliffe@ucl.ac.uk) or Richard Bourne (richardbourne@msn.com).

What Should Labour Do?

That our care system is in crisis is regularly reported. We know a lot about what is bad.  Honest analysis suggests we also have serious long-term problems that cannot be wished away. If Labour wins the next election what should it do to make our care systems better, in the short, medium and longer terms?  The Third Era group is debating possible solutions.

“Better” for us means increasing population wellbeing; maximising happiness by dealing with the social determinants of poor health and implementing policies which disproportionately favour the most deprived, the less well-off and the least powerful.  It should be better also in ways the public actually want; shorter waits, easier to access and use, continuity in care. And it should be better in the technical sense of quality.  

Some of the ideas about enabling the development of a better care system were set out by Don Berwick, but we have anglicised these, added to them and built in the ideological context.  As with Berwick we believe the new Era will not be a return to the Bevanite bureaucracy of the 1970’s, nor to the markets and competition that followed it.

From this mix of requirements, wishes and ideology a consensus is emerging about some of the key features of a better health and social care system under Labour.  

  • Non market (mostly tax funded) –stability in funding
  • Joined up (healthcare brought into the family of public services)
  • Joined up (weakening boundaries between health and social care, physical and mental health, primary and secondary care)
  • Tackling inequalities
  • Open and transparent
  • Democratic and participative
  • Social model predominates, not the medical model.
  • Devolved (local decisions about how care is organised and provided)
  • Responsive to communities, embracing shared decision making

We are beginning to describe the gap between where we are now and where we would like to be, and as a group we are debating how the gap might be closed.

There is a lot of evidence out there that helps us.  At system level we can observe Scotland and Wales as well as many EU neighbours, all of whom have systems that provide comprehensive universal care.  There is also some evidence of what does or does not work in terms of models of care, pathways and service frameworks , more recently from the upheavals in England prompted by the 5 Year Forward View.  This set of political experiments has begun to suggest some challenges for reformers. The hardest is that context and local factors are hugely important.

What works well in semi-rural A may not work as well in urban B.  Rolling out good practice cannot be enforced. Small scale success often cannot be scaled up.  All roads appear to lead not to Rome but back to where you started. There has to be a lot of flexibility around allowing local systems to innovate, adapt and even to fail.  Reorganisation and restructuring does not achieve much; teambuilding, relationships and networks are far more important. The big isolated national NHS – top down, do what you are told, managed by shouting – is no longer an appropriate model.

Lurking behind this are the issues that are unresolved, and which are rarely even discussed.  Should NHS principles be extended, should all care be free? How are the parts of the system held to account – who deals with failures and problems?  Who controls the funding flow? Do we have local as well as national sources for funding? What is reserved for national and what is permitted to the local?  How do we build the capacity for a better managed but more accountable system? How will vested interests be overcome for the common good? How long do we wait for improvements?  Labour’s generally well received 2017 Manifesto sheds little light on these key issues.

Labour does have an absolute commitment to greater funding and to repeal of the marketisation legislation.  But the money spoken of so far is not enough and what replaces the legislation poses nasty questions. Initially Labour can increase funding and that could bring some early benefits, especially in social care.  Labour can and should remove the barriers to developing better care by legislation to remove the markets and competition. It can do many things to raise staff morale. It could target specific issues like long waits by throwing money at them.  It can kick off the necessary work to plan for change and invest in change initiatives. It can facilitate more devolution and local decision making.

In the medium term it will have to build capacity for change.  It can over time look at the requirements for more staff, scanners, ambulances, theatres – some of which have long lead times, so it should start now.  Investment in human infrastructure is needed for better management, better informed Councillors, robust planning, and strengthened communities.

The longer term may in part just be the roll out of short term measures, but must be used to shift the conversations and change expectations and beliefs.  The previous Labour government implemented many progressive changes but tried to pretend they had not because of electoral anxieties – so it never altered the national debate.  The long-term goal is an irreversible shift in opinion to favour a public, comprehensive, universal system that cares for us all