Era 3 – A Better Care System; Design Principles and Assumptions

Era 3, Health care reforn in the UK

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 well being 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:

1. 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

2. 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 opportunitie 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

3. 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 change
I have a clear line of communication, action and follow up

4. 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

5. 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

6. 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



  • 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:

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