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The NHS needs to change - but how?

When the NHS was founded, chronic illnesses and long-term care were non-issues. Adapting to the new reality means big changes are needed.

The backlash from NHS staff culminating #ImInWorkJeremy shows how carefully politicians need to tread when advocating reform of the NHS. But the pressing and urgent need for reform is going to intensify as this Parliament wears on.

Even with the extra £8bn of funding announced in George Osborne’s Budget earlier this month, the task facing Simon Stevens, Chief Executive of the NHS, is huge. The health service must find £22bn of efficiency savings over the next five years, an unprecedented target not just in terms of the NHS, but for any western health service.

Reform will have to sit at the heart of any plan to achieve this. Indeed, Stevens’ NHS Five Year Forward View sets out a range of reforms which will help us get there including the integration of health and social care and better use of new technologies. But crucial to the success of the Forward View will be the NHS’s ability to empower patients.

Patient empowerment has been an aim of the system for over fifteen years. But as more and more people suffer from complex long-term conditions the majority of care will occur not in the hospital or GP‘s surgery, but at home. By 2025 the number of people with complex long-term conditions will be more than 18 million. Patients and their family taking on the carers role will be the ones making the difficult decisions. If these decisions are good ones, demand on the service will go down. Get them wrong and it will increase. Indeed, the evidence suggests that around one in five emergency admissions to hospital are potentially preventable.

Existing empowerment initiatives – which Stevens’ NHS Five Year Forward View focus on – such as ‘voice’ and ‘choice’ won’t change this. They empower people only after or as they are entering the health service. New empowerment models being pioneered across the country create good health, rather than respond to ill health. These initiatives include giving doctors the ability to prescribe social rather than just medical treatments (cooking classes, gym memberships and community social groups), creating peer networks among those with similar chronic conditions, and working with patients to set technology enabled care plans, which help patients make decisions remotely and allow more flexible contact with healthcare professionals.  

The challenge now for the NHS is how to ensure that every patient who could benefit from these empowerment initiatives can have access to them. IPPR is recommending a transformation fund for the NHS – something backed up by recent work by the Health Foundation and the Kings Fund. This would help spread reform and prevent extra funding being used for steady-state or business as usual.

More money should also be passed over to patients directly in the form of personalised budgets, with patients holding the purse strings. At the moment, less than half a million people benefit from personal budgets but by 2020, IPPR argues that all patients with a long-term condition should be offered one.

And finally, more money and finance should be devolved to the local level. ‘Devo-Manc’ is a good start, but the government promised ‘devolution on demand’ and demand there is. Notably, the ten core cities - Birmingham, Bristol, Liverpool, Leeds, Manchester, Newcastle, Nottingham and Sheffield, Cardiff and Glasgow – recently published ‘A Modern Charter for Local Freedom’ which expressed an interest in following suit. NHS England should start thinking about when and how it will meet this demand now: devolution of this kind can make care more responsive to local populations and should galvanise empowerment focussed reform.

These changes won’t be easy; but they are absolutely necessary. As Alan Milburn’s argues: “Tinkering with change will not save the NHS. It must stop treating patients as passive by-standers and instead enlist them as active agents of change.”

 

Harry Quilter-Pinner, co-author of Powerful Patients published by IPPR.

 

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Justin Trudeau points the way forward for European politics

Is the charismatic Canadian Prime Minister modelling the party of the future?

Six months after Canadian election day, Justin Trudeau’s Liberal party continues to bask in the glow of victory. With 44 per cent of support in the polls, the Liberals are the most popular party amongst every single demographic – men and women, young and old, and people of all educational backgrounds. 

While most European mainstream parties only dream of such approval, this is actually a small dip for the Liberals. They were enjoying almost 50 per cent support in the polls up until budget day on 21 March. Even after announcing $29.4 billion in deficit spending, Canadians overall viewed the budget favourably – only 34 per cent said they would vote to defeat it.

Progressives around the world are suddenly intrigued by Canadian politics. Why is Justin Trudeau so successful?

Of course it helps that the new Prime Minister is young, handsome and loves pandas (who doesn’t?) But it’s also true that he was leader of the Liberals for a year and half before the election. He brought with him an initial surge in support for the party. But he also oversaw its steady decline in the lead up to last year’s election – leadership is important, but clearly it isn’t the only factor behind the Liberals’ success today.

Context matters

As disappointing as it is for Europeans seeking to unpack Canadian secrets, the truth is that a large part of the Liberals’ success was also down to the former Prime Minister Stephen Harper’s extreme unpopularity by election time.

Throughout almost ten years in power, Harper shifted Canada markedly to the right. His Conservative government did not just alter policies; it started changing the rules of the democratic game. While centre-right governments in Europe may be implementing policies that progressives dislike, they are nonetheless operating within the constraints of democratic systems (for the most part; Hungary and Poland are exceptions).

Which is why the first weeks of the election campaign were dominated by an ‘Anybody But Harper’ sentiment, benefitting both the Liberals and the left-wing New Democratic Party (NDP). The NDP was even leading the polls for a while, inviting pundits to consider the possibility of a hung parliament.

But eight days before election day, the Liberals began to pull ahead.

The most important reason – and why they continue to be so popular today – is that they were able to own the mantle of ‘change’. They were the only party to promise running a (small) deficit and invest heavily in infrastructure. Notably absent was abstract discourse about tackling inequality. Trudeau’s plan was about fairness for the middle class, promoting social justice and economic growth.

Democratic reform was also a core feature of the Liberal campaign, which the party has maintained in government – Trudeau appointed a new Minister of Democratic Institutions and promised a change in the voting system before the next election.

The change has also been in style, however. Justin Trudeau is rebranding Canada as an open, progressive, plural society. Even though this was Canada’s reputation pre-Harper, it is not as simple as turning back the clock.

In a world increasingly taken by populist rhetoric on immigration – not just by politicians like Donald Trump, Nigel Farage, Marine Le Pen and other right-wingers, but also increasingly by mainstream politicians of right and left – Justin Trudeau has been unashamedly proclaiming the benefits of living in a diverse, plural society. He repeatedly calls himself a feminist, in the hope that one day “it is met with a shrug” rather than a social media explosion. Live-streamed Global Town Halls are one part of a renewed openness with the media. Progressive politicians in Europe would do well to take note.

Questioning the role of political parties today

Another interesting development is that the Liberal party is implicitly questioning the point of parties today. It recently abolished fee-paying, card-carrying party members. While this has been met with some criticism regarding the party’s structure and integrity, with commentators worried that “it’s the equivalent of turning your party into one giant Facebook page: Click ‘Like’ and you’re in the club,” it seems this is the point.

Colin Horgan, one of Trudeau’s former speechwriters, explains that Facebook is “literally a treasure trove for political parties”. All kinds of information becomes available – for free; supporters become easier to contact.

It was something the Liberals were already hinting at two years ago when they introduced a ‘supporters’ category to make the party appear more open. Liberal president Anna Gainey also used the word “movement” to describe what the Liberals hope to be.

And yes, they are trying to win over millennials. Which proved to be a good strategy, as a new study shows that Canadians aged 18-25 were a key reason why the Liberals won a majority. Young voter turnout was up by 12 per cent from the last election in 2011; among this age group, 45 per cent voted for the Liberals.

Some interesting questions for European progressives to consider. Of course, some of the newer political parties in Europe have already been experimenting with looser membership structures and less hierarchical ways of engaging, like Podemos’ ‘circles’ in Spain and the Five Star Movement’s ‘liquid democracy’ in Italy.

The British centre-left may be hesitant after its recent fiasco. Labour opened up its leadership primary to ‘supporters’ and ended up with a polarising leader who is extremely popular amongst members, but unpopular amongst the British public. But it would be wrong to assume that the process was to blame.

The better comparison is perhaps to Emmanuel Macron, France’s young economy minister who recently launched his own movement ‘En Marche !’ Moving beyond the traditional party structure, he is attempting to unite ‘right’ and ‘left’ by inspiring French people with an optimistic vision of the future. Time will tell whether this works to engage people in the longer term, or at least until next year’s presidential election.

In any case, European parties could start by asking themselves: What kind of political parties are they? What is the point of them?

Most importantly: What do they want people to think is the point of them?

Ultimately, the Canadian Liberals’ model of success rests on three main pillars:

  1. They unambiguously promote and defend a progressive, open, plural vision of society.
  2. They have a coherent economic plan focused on social justice and economic growth which, most importantly, they are trusted to deliver.
  3. They understand that society has changed – people are more interconnected than ever, relationships are less hierarchical and networks exist online – and they are adapting a once rigid party structure into a looser, open movement to reflect that.

*And as a bonus, a young, charismatic leader doesn’t hurt either.

Claudia Chwalisz is a Senior Policy Researcher at Policy Network, a Crook Public Service Fellow at the University of Sheffield and author of The Populist Signal: Why Politics and Democracy Need to Change