Conference 2011

BHTA Conference 2011

He suggested that the NHS must in future be able to meet the changing needs of our society. "It has to respond to greater public awareness of healthcare that is available.”

Turning to the assistive technology sector he commented: "It has become clear that the assistive technologysector has an important and pivotal role to play in this next iteration of our health service. We provide many of the products and services necessary to ensure that people can remain in their own environments. We provide them on a cost effective basis and in a way that supports the demographic changes that we are facing. But we need to get better at showinghow we can achieve this.”

Ray added: "There are always points in history when we later know that they were important moments – when some things really changed. I believe we are at one of those points. We must now ensure that our industry adapts and changes to meet the changes and challenges that are ahead. We know that they will not be easy for us and that we have a lot of work to do to ensure that our industry really is ‘fit for purpose'. We need to be better equipped, better involved, more trained and more efficient.”

However, he said that he had always believed that we have to take a greater part in health and social care provision. "In the years to come, I hope that we do not look back and regret missing the opportunity that the new health and social care system will present to us.”

He told delegates that the Local Government Association is a trade association and is essentially a political organisation.

"What are the key implications of the changes?” he asked. "The headline implications are the creation of the Health & Wellbeing Board, the focal point for local government's engagement with both the health service and the plans to bring other services to the party. This is a welcome recognition that health and other services need to come together to address the major challenges. Councils will have a statuary responsibility with partner organisations to produce an assessment of local need, which we have had for some time, but with varying degrees of success, but this will need to be converted into a strategy that all the relevant players locally will be comfortable with.”

He said that the second major implication is the transfer of health improvement and some aspects of health protection to local government from the Primary Care Trusts (PCTs) and the third dimension is the extension of the health scrutiny function that councils have. "Local government will also have a responsibility for commissioning the replacement of the local information network links. Health Watch will have a much wider brief than Links and will have to be a formal organisation whereas Links has a much stronger voluntary aspect. Health Watch will extend into social care as well as health and so it will be looking at the boundaries across the two and councils will be able to use Health Watch to look at the independent complaints aspect of social care and related activities.”

"The Bill has been developed considerably since the pause” he explained. "This is, of course, the Health & Social Care Bill, but there isn't much about social care in it at all. In fact, most of the social care bits relate to technicalities around the transfer of the general social care councils. There will be a social care and health bill next year which will address the important issues for social care and sustainable funding.”

And he questioned whether legislation had been necessary. "Our view in local government, to be honest, is that much of what the Secretary of State is looking to achieve through the legislation could actually have been achieved without the legislation. It would be possible to have fewer PCTs, it would be possible to split the acute commissioning functions of PCTs and develop closer links with local government, community and other related services. It would certainly have been possible to have much more clinical engagement in commissioning and to have a stronger role in primary care without legislation and it would have been entirely possible to step up prevention and intervention and develop the market within the framework of the NHS, but we are where we are and we have a Bill that is, in itself, substantially larger than the Bill that set up the health service originally and a Bill that has required 1000 amendments after the ‘pause'. It is a Bill that is, from our perspective, increasingly out of control. It is interesting that the man chosen by the Secretary of State to chair the national Commissioning Board has himself described the Bill as ‘unintelligible' and I think that is putting it mildly.”

"We welcome many aspects of the Bill” he said. "We welcome the much stronger role for GP's and primary care in commissioning. All our experience is that GPs share with councils a sense of locally and the complexity of people's lives and they very much get the need to think about people's lives in the round and not just as a series of conditions that need to be treated. We also welcome those aspects of public health that are coming back to local government and we welcome the sense of the NHS becoming a more flexible organisation but some of my reservations are about how much that will actually prove to be the case, at least in the short term. And we are very enthusiastic about the potential of Health & Wellbeing Boards. Councils are very enthusiastic about them and some 95% have already begun the process to set them up.”

He said that there were reservations though. "There's no greater expression of that in my view than the incoherence in responding to the challenge of an ageing population with people being inappropriately in hospital, either because they don't need to be there or that they are staying there too long. We also have some worries about the weight in the Bill that is given to the concept of integration. I think that when the Prime Minister talked about integration after the Future Forum, the body of experts that looked at the Bill during the ‘pause' in the parliamentary process, I think he talked more about integration of the different bits of the health service.”

He told delegates that Clinical Commissioning Groups will have to be authorised to be fully fledged. "It is estimated that 50% of them may not be authorised in time the process starts and so what will the commissioning process be like in a place where there is an unauthorised body?” He asked.”I understand why, but I think that it confuses the commissioning dynamic to have provider representatives on clinical commissioning groups. I think it's possible that the changes to the bill, that have tended to calm down fears about competition in the NHS may have actually set back opportunities for new providers with clinical commissioning groups to develop new types of provision.”

"To be honest” he added, "our biggest concern is not the bill itself, but the context in which it is dropping. The impact of what the Health Secretary calls the ‘Nicholson challenge', for the NHS to recycle £20 billion in order to meet the challenges of running the NHS and that £20 billion challenge will potentially dominate much of the discussions locally. We are seeing a degree of pre-organisation with clusters of PCTs, we're seeing the loss of relationships locally with NHS organisations and we are seeing the re-opening, in some places, of disputes about jointly funded activity.”

He talked about a recent joint statement, which he said was unprecedented, with organisations such as the Directors of Public Health, BMA and the NHS Confederation. "The statement was about our shared concerns about some of the proposals and at the heart of these was the need for the design of a public health system in which local government has its place, rather than the design of public health England and then somehow the crumbs from the table actually being used to fund public health locally. We feel that we need to see a system that carries all three domains of public health, health protection, health improvement and improving health services and to be clear about the role and contribution of all levels of activity before we can make judgements about whether the right amount of resources are coming into local communities to support public health and we've used the phrase ‘cuckoo in the nest' as we fear Public Health England, to meet the national expectation of the system could suck even the limited amount of money spent by PCTs on a very variable basis out of the system.”

And he is looking for more changes to the Bill. "In the Lords process we are seeking further changes to the Bill to reinforce the need for a ‘whole population' commissioning approach to certain sorts of services. We feel that, at the moment, the Bill effectively initially said that the commissioning services should have regard to the views of the health and wellbeing board. We think that the Bill should go one stage further and that the health and wellbeing board should sign off the fact that the agreed local priorities are reflected in those plans.”

As for children's services, he said: "We are particularly annoyed at the continuing split in children's services with 0-5's being the responsibility of the National Commissioning Board and 5-20 being the responsibility of Health & Wellbeing Boards. We think that's largely for political reasons because of the commitment to find Health Visitors, but we think that Health & Wellbeing Boards and everyone locally should be working on children's issues from 0-18.”

"So, what do we bring to the party?” he asked. "Nobody can argue that we have not substantially diversified the social care market. We bring a local focus through Health & Wellbeing Boards and a strong commitment to integrate services, not just organisationally, where there are limitations to how far we can go, but with our experience of individual budgets and personal budgets in social care which a third of social care user now have. We also have, through our broad experience, the ability to join up with those aspects of the NHS around those issues that essential to addressing health inequalities.”

"We welcome much of the NHS reforms and much of my concerns are marginal and probably operational, but it is very clear to us that we do need a parallel reform of the social care system as it's no good the NHS being more flexible and local if social care is about helping fewer and fewer people with greater and greater need because the resources aren't in the system.”

Finally, he told delegates: "I think that the legislation is a distraction. Actually, people are cracking on with this and 95% of councils have already set up Health & Wellbeing Boards and it really is a case of getting on with the practicalities and addressing the major issues of better health and health inequalities that we should be focussing on.”

A question from a delegate related to the lack of detail and references in the Bill regarding children's services and the impression that the Government is leaving children out of any plans. It was also mentioned that only 30% of the country actually has a budget for children's equipment and that the rest had to take the money from adult budgets. It was also mentioned that children represent 17% of the disability marketplace but that the funding is nothing like that in percentage terms.

Andrew replied saying that The Local Government Association has made similar points in regard of the government being largely silent on children's services. In the list of issues that we feel that should be planned for at a ‘whole population level' children feature very strongly in that and we have lobbied both the Secretary of State for Health but also Michael Gove (Secretary of State for Education) around the need for coherence in relation to children's health services and we don't believe that it is fair. We will continue to lobby around that as it is a gap in the process.

He talked about practice based commissioning. "Each Practice was given a budget to manage. In a small Practice that is quite difficult and I run a Practice with 3,500 patients and I had a couple of patients who were very ill and ended up costing us around £50,000 in treatment costs each and that blew the budget somewhat. We started to form a commissioning group where you can share the budget and that helps to smooth out some of the fluctuations of costs.”

He mentioned that he had been warned in 2008 that budgets may well be under pressure in the future and that there wouldn't be any extra money around for the next five years although they were having to live with an inflation rate in healthcare of around 10%. "We suggested that they would have to engineer some changes in the way that people operate and we have to change as we couldn't carry on doing what we were doing with ever increasing costs and ever decreasing resources and so we suggested that groups of between 6-10 Practices were formed with somewhere between 50-100,000 patients who would work out ways of addressing the local health problems and we called it a new commissioning model. We believe that this was seen from ‘on high' and so we may be personally responsible for what has happened.”

And he had strong views on the Health Bill. "I have to agree that the legislation is probably the worse written piece of legislation ever. It is also the longest ever Bill to be put through Parliament.”

He added: "In November last year we decided that we needed a group of GP's who would lead the process, both in terms of making decisions and also engaging with all the stakeholders that we have and have an interest. We have been working together for a year now and we have been on a very steep learning curve and we have tried to solve the really difficult question of how large a Commissioning Care Group should be. That hasn't been easy as the DoH and the emerging healthcare commissioning board keep moving the goalposts. We recognised in the beginning that small groups of GPs could work closely together in a co-operative way and would be a coherent group and powerful player but our final configuration that we are going to work to is a CCG that is extremely large, serving some 850,000 patients. However, underneath that will be a very strong locality focus to address the local problems. I am a GP is a rural area and we have a unique set of problems in our area which are very different from the problems that are faced by GPs in the centre of towns and cities and so we need to focus on local. The high level Health & Wellbeing board would set the direction and then working with District Councils and even Parish Councils there would be the delivery of local projects and we think that's really important.”

"We could have done all of that without a change in the law and we would have made life a lot simpler. Having said that, the PCTs are going to disappear. The Strategic Health Authorities were supposed to disappear, but they have morphed into something bigger and probably worse. How they will get a grip on local issues, I'm not entirely sure.”

Highlighting the changes, he said: "I think the question is, what is going to be different? Well there's a different philosophy and how we go about our business. GPs are very focussed on patient needs and I think that is one of the keys and I stress the word ‘needs' and not ‘wants'. I think that GPs inherently are not very good at partnership working and are going to have to learn how to do it. We are, by our nature, rather isolated and independent and it is amazing how little some GPs work together in partnerships.”

Simon talked about some of the frustrations of wasting money when it takes too long to get people out of hospital and back into their own home, saying that the cost is something like £240 a day to keep a patient on a ward. "We spend about 60% of our budgets on people over the age of 65 which, in Cambridgeshire, equates to about £240 million a year. I think, personally, that we do that very badly.”

And he is keen to change the emphasis. "I have talked to a lot of colleagues about bring a commercial edge to our business. Our CCG is going to have around £25 million to run its own organisation and so it is a relatively small organisation, but it will have around £1 billion to spend on our population which is a large sum and we will want to make sure that it is spent most appropriately.”

He told delegates that people working in the healthcare environment don't think in a commercial way and compared the experience of buying a car and all the steps that you would go through to make sure you had the best deal. He suggested that some colleagues consider the commercial approach ‘aggressive'. "I would say that it's sensible rather than aggressive and essentially all we are doing is buying services and equipment for our patients, which is a very simple commercial transaction. Those who come up with the best package, we'll do business with you. If you come up with something we can't afford, we'll tell you and that's the change of philosophy that we are going to bring to this.”

He told delegates: "We're changing and we're putting together a new organisation. I think that from a business person's point of view, you will find it a much easier organisation to deal with.”

In response to a question about the management of budgets, Simon replied: "I think that part of the change we are trying to engineer within primary care is to get each GP and indeed District Nurse and other health professionals to actually think like commissioners and to think about what things cost and what is actually cost-effective.

He told delegates that he was responsible for the £20 billion efficiency savings in the NHS and quality improvement.

He opened by saying: "We are in this paradoxical position with the NHS of having both a settlement for the future which is generous by comparison with virtually all other parts of public expenditure, but at the same time is the most financially challenging settlement. I believe that the thing about the challenge is that it has been caused by an acute exacerbation problem facing all healthcare systems. In essence, over the last fifty years, healthcare costs have grown in every developed country faster than the GDP of those countries and that is unsustainable.”

"Although the economic framework is very tough” he added, "it is potentially a fantastic opportunity as to how we work together to create sustainable healthcare and we already have a lot of solutions, they just aren't properly distributed and there is a huge amount of innovation in both products and services and if we apply those, encourage them and support them to develop then we will be a long way along the way to getting, in the next five to ten years, the change that we need.”

He said that he was positive about the future: "I don't feel downhearted about it. I feel that it is a fantastic opportunity to together create new kinds of ways of working that can sustain what to me is the most important public service in the country. Having worked with Ministers of all parties over the past few years, their basic instinct is to ask how we adapt to make that kind of change. There's no real argument about markets themselves, the issue is how do we encourage more innovation? The reforms are trying to develop more local innovation and more independence of action within a national framework and I think that there is more continuity here than discontinuity.”

He said that he would give a personal description of what he felt the landscape was like at present. "Perhaps the key feature is locally led GP Commissioning. It's been a bit of a disaster in policy terms as the engagement in the process of management change has included poorly the drivers of the healthcare system in this country, which are GPs who have the majority of contact with patients. You will see the emergence of Consortia as powerful bodies making real decisions about significant change. I think that we may see the emergence of scaled up Consortia and one of the concerns of industry, which I understand, is that it's almost impossible to market to some 150 PCTs across the country and some 300 Consortia would make it worse but I think that there will be the emergence of scale in the way that some of those do their business and they will group together to provide services. I would encourage you to watch very carefully how that might emerge.”

He emphasised the importance of the National Commissioning Board. "Of you course, you do have a National Commissioning Board (NCB) that has been described as the ‘mother of all Quango's. It will be empowering and authorising CCG's to get working and also setting itself up as a commissioning body. For those of you who are working in the more specialist end of the business it is important for you to remember that the NCB will itself be a £20 billion commissioner of services and so will be a powerful voice for commissioning. It will also be bringing the whole commissioning system together and will be involved with standards and, where necessary, setting clear national objectives.”

"There is a great human tendency to have this debate in entirely cartoon terms” he said. "Is it about top down grip or control or local freedom and autonomy? Which is it? My answer to the question is yes. You don't run your companies by choosing to have grip and control or freedom and autonomy, you want your front line people to be thinking, creating and making change happen and you have standards and systems that people need to comply with. We are the same, although our scale is slightly challenging. We need to have discussions about the balance between fantastic local clinical leaders innovating to make change happen and joining up together and also living within standards enabling to account for £80 billion worth of expenditure. We need grown up discussions about striking a balance. It's going to take some time to work out and it will be different in different places and there will be people in the new system who use innovation to create change, at a pace far faster than we ever did in the old system, there will be people who make progress and there will be people who fail and failure is a high profile issue here. I am very optimistic that we will find a way of sealing the new deal in a way that works.”

He mentioned what he described as the ‘interplay and relationships. "I am also aware that for many people at the conference, your business isn't a health business but a care business and I think that one of the things hard to understand is the interplay and relationships between local commissioners, local authorities and health and wellbeing boards. My own sense of it is that what will be created in structural terms will be a pretty loose template and very dependent on leadership locally to make that either fantastic co-operative or potentially sterile and there will need to be a lot of work for that to happen. There is a lot of development work to do to be able to bring that to market in the most productive way.”

And he added: "There will be a continuation of the path of the NHS not seeking directly to micro-manage its providers, but to give them autonomy and freedom. In one sense the commissioning provision changes are the hardware of the new system and the empowering patients and new relationships is the software. It's much easier to say than to do and they are things that we have talked about for a long time, but there is a serious desire to do it and don't underestimate the efforts that will be made to try and drive that change. It's a bold and ambitious programme.”

And he emphasised the importance of innovation. "I know that there are people who struggle with this it going to be locally free or is it going to be top down. The job of the centre will be to empower the new system, create and develop the support for it and encourage as much autonomy as we can to innovate. There needs to be a way that the system comes together, not top down, but to drive innovation. The NHS remains, as do many healthcare systems internationally, a slow adapter and we want to see if we can find ways of driving with the system and not to it and some innovations, including technological service innovations, more quickly.”

And of the responsibility of Government, he said: "No-one really believes in the centre that you can ultimately disconnect the Secretary of State from his responsibility of what happens in healthcare and what you want to disconnect is the idea that the Secretary of State is responsible for the minutia of what happens locally. Those people who call for a complete disconnection, whilst I understand that, should be very careful about what they wish for as the NHS has a role at the heart of the political discourse in this country.”

He spoke again about the opportunities that exist. "Potentially this is moment of great opportunity for a number of companies. All the analysis that we have done makes it clear that in order to square the circle of cost and quality over the next five to ten years, there has to be a basic change in the direction of care, particularly the care of long term conditions. To do that really well, we don't just need what we call a new pathway, but we need new technologies, new ways of supporting the model, monitoring systems and so on that stuff exists now, but we implement it in an incredibly piecemeal and timid way.”

And he spoke about how he sees the future. "I would like to be involved over the next ten years in the leadership of change in the provision of care as the same scale as change in the mental healthcare in the 70's, 80's and 90's and that we would look back at the number of beds involved in those people's care in the same way that we now look back quite critically at the hundreds of psychiatric beds that we had in the 70's and wondered why we ever thought it right to run care like that. When we are older, we will not want our care like that. We will want to manage our care, know where we are, be experts and we can start that revolution now.”

"The Bill does not seek to change the NHS deal” he added "and neither does my work on the economics. The aspiration is to maintain the deal in what we provide free at the point of delivery, not to start eroding it. We are not trying to change the deal we do with our society. This is not the disintegration of something called the National Health Service.”

On the subject of ‘any qualified provider' Jim said: "You hear that either the NHS is being thrown to the wolves or its being kept the same as some terrible national monopoly. What's happening in any qualified provider is that we are trying to indentify those areas of innovation and expertise of new fresh thinking, often with new organisations, within the NHS but also often from outside.”

And he admitted that, in some areas, things could be better. "Taking the example of wheelchairs for example, I know that the NHS is full of wonderful people but frankly, I could not stand on the platform and defend the services that we provide to many wheelchair users. With any qualified provider, we are trying to identify the areas were we know that we don't do well.”

In conclusion he told delegates. "It's an amazing time politically, with a new system being born with all the opportunities that brings and it's amazing time economically and I think it's correct to say without innovation and with adoption of some of the nest things that you (industry) have got, it's very difficult to see how the NHS will survive in its current form but, because we are seeking to drive the changes I am incredibly optimistic that we will see an acceleration of pace of innovation and I hope that you find a place in that for a positive, strong and sometimes challenging set of discussions about the role you can play in the future of the most important public service in the country.”

In answer to a question that asked ‘What would you need to see in order to believe that he changes had been successful', he replied: "We are effectively trying to measure three things. One is whether the quality of service is being sustained or improved across the service and wrapped up in that is a whole load of things such as waiting times and outcomes. We are also trying to measure our financial stability and thirdly we are trying to measure the opinions and experiences of the people we serve. We have those measures and we are very public about them. We are seeing some people making good progress and doing the right things to drive value and reverting to proven methods which definitely will save them money and we need to provide more support for those. Saving £20 billion is an easy thing to do if you don't care about quality.”

Peter told delegates that he wanted to communicate three messages. The first was that the third sector and SME private sector have more in common when it comes to provision of healthcare services than people might expect. The second was that the third sector has some unique strengths in the way it provides services and so logic dictates we should be looking more closely at partnerships between private and third sector organizations and finally that NHS reform will be driven increasingly by changes in broader society which will recognise and reward providers who achieve preventative outcomes as opposed to today's arrangement which is tragically remedial.

He suggested that many people are surprised at the extent of third sector integration in the NHS. "It is estimated that £4.7bn worth of services are commissioned from the charitable sector each year” he explained, "and research published by the NCVO shows that 57% of the sector's workforce is in health and social care, that's 437,000 people. The number of people working in the voluntary sector doubled in the years between 2001 - 2010, as did the sector's turnover.”

Peter suggested that it would be easy to put this success down to a lot of charities being good at fund raising, or the general growth in national prosperity during much of this period. "By the truth is rather different” he said. "In this time government became the largest source of income into the sector, even though grant funding remained broadly static.”

And he told the conference that performance levels are high. "When services are opened to competitive tender, providing the commissioning body is doing its job and judging potential providers on more than just economic efficiency, then the third sector performs well. This is even more so when patients take control of their own budgets, when almost 80% of them subsequently choose non-statutory providers which tend to come from local communities.”

He added: "Some people wrongly assume that because a number of charities have been around for a long time, and their branding exploits their history, that the absence of change lies behind their success. I disagree. Look closely at the work of the Salvation Army, The Scouts, and the WRVS, for example, and you will see professionalism and social innovation that would set standards in any sector.”

He revealed what he thought were the core strengths in third sector provision. "There is evidence that the third sector is able to reach down deep into the most vulnerable groups in society in health it means getting people with very chaotic lifestyles onto a stable pathway that avoids regular visits to A&E. It goes without saying that these types of interventions save the taxpayer a fortune. One bonus about not representing the state or a profit-making organisation is that many vulnerable people are open to establishing strong bonds with the staff of charities. Another reason for this is that third sector organisations tend to have a higher percentage of former service users on their payroll. But whatever the reason, having this relationship translates into positive outcomes. The representative role of the sector is seen as core to our existence. From big noisy campaigns such as anti-smoking or gay-rights down to representing the needs of an elderly lady to her doctor or benefits officer, the third sector sees the role of campaigning as a vital to achieving social outcomes.”

And he said that, it's a surprise to him that partnerships between the sectors are not more common. "I know enough people who choose to work in the private sector because they care about the plight of vulnerable people to know that we in the third sector do not have any monopoly on ‘values'. I also know people who chose a career in the voluntary sector because they like competing - and winning - to know that we have examples of competitive spirit that would singe the eyebrows of the most ardent capitalist.”

He suggested that there is the demand for more innovative partnerships. "Funders of healthcare, primarily the NHS, are increasingly looking for both innovation and scale - two features which don't always go hand in hand. So why not look to the style of partnership itself as a tool to deliver both simultaneously.”

He talked about where the demand for new partnerships was coming from. "It is easy to blame the politicians for creating the demand for reform, but the truth is it's the public, even if they don't know it, who are the cause. Many are knowingly driving this process by insisting on better value for money, and transparency, in the way their taxes are being spent. This is also seen by donors to charities who increasingly ask for evidence of effectiveness before donating money. 75% of NHS spending goes on long term conditions and this also happens to be the biggest growth area in health provision. Coupled with the real-terms cuts to NHS funding, the only way our health system will cope is by doing things differently. Partly it will be our responsibility to come up with solutions to this problem. And partly it is the responsibility of government to create the environment for us to be able to do so, and have success recognised and rewarded accordingly. And I'm not talking only about money.”

But Peter did see one fly in the ointment. "The government has committed via an amendment to the Health and Social Care Bill that the Secretary of State, Monitor, and National Health Service Commissioning Board will not act with the intention of increasing the market share of one sector. This, to me, seems a very odd way of telling the public and NHS that they want change, and for people to think differently about the future of service provision. In most walks of life this amendment would not deter change, but the NHS is not an organisation that conforms to the norms we experience in ‘most walks of life'. It is huge. It is conservative. And it has a plethora of vested interests. I truly fear that this amendment will constrain real-life change from happening on the ground as commissioners are targeted with different advice from different stakeholders and end up plumping for the safe choice.”