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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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Is defeat in Stoke the beginning of the end for Paul Nuttall?

The Ukip leader was his party's unity candidate. But after his defeat in Stoke, the old divisions are beginning to show again

In a speech to Ukip’s spring conference in Bolton on February 17, the party’s once and probably future leader Nigel Farage laid down the gauntlet for his successor, Paul Nuttall. Stoke’s by-election was “fundamental” to the future of the party – and Nuttall had to win.
 
One week on, Nuttall has failed that test miserably and thrown the fundamental questions hanging over Ukip’s future into harsh relief. 

For all his bullish talk of supplanting Labour in its industrial heartlands, the Ukip leader only managed to increase the party’s vote share by 2.2 percentage points on 2015. This paltry increase came despite Stoke’s 70 per cent Brexit majority, and a media narrative that was, until the revelations around Nuttall and Hillsborough, talking the party’s chances up.
 
So what now for Nuttall? There is, for the time being, little chance of him resigning – and, in truth, few inside Ukip expected him to win. Nuttall was relying on two well-rehearsed lines as get-out-of-jail free cards very early on in the campaign. 

The first was that the seat was a lowly 72 on Ukip’s target list. The second was that he had been leader of party whose image had been tarnished by infighting both figurative and literal for all of 12 weeks – the real work of his project had yet to begin. 

The chances of that project ever succeeding were modest at the very best. After yesterday’s defeat, it looks even more unlikely. Nuttall had originally stated his intention to run in the likely by-election in Leigh, Greater Manchester, when Andy Burnham wins the Greater Manchester metro mayoralty as is expected in May (Wigan, the borough of which Leigh is part, voted 64 per cent for Brexit).

If he goes ahead and stands – which he may well do – he will have to overturn a Labour majority of over 14,000. That, even before the unedifying row over the veracity of his Hillsborough recollections, was always going to be a big challenge. If he goes for it and loses, his leadership – predicated as it is on his supposed ability to win votes in the north - will be dead in the water. 

Nuttall is not entirely to blame, but he is a big part of Ukip’s problem. I visited Stoke the day before The Guardian published its initial report on Nuttall’s Hillsborough claims, and even then Nuttall’s campaign manager admitted that he was unlikely to convince the “hard core” of Conservative voters to back him. 

There are manifold reasons for this, but chief among them is that Nuttall, despite his newfound love of tweed, is no Nigel Farage. Not only does he lack his name recognition and box office appeal, but the sad truth is that the Tory voters Ukip need to attract are much less likely to vote for a party led by a Scouser whose platform consists of reassuring working-class voters their NHS and benefits are safe.
 
It is Farage and his allies – most notably the party’s main donor Arron Banks – who hold the most power over Nuttall’s future. Banks, who Nuttall publicly disowned as a non-member after he said he was “sick to death” of people “milking” the Hillsborough disaster, said on the eve of the Stoke poll that Ukip had to “remain radical” if it wanted to keep receiving his money. Farage himself has said the party’s campaign ought to have been “clearer” on immigration. 

Senior party figures are already briefing against Nuttall and his team in the Telegraph, whose proprietors are chummy with the beer-swilling Farage-Banks axis. They deride him for his efforts to turn Ukip into “NiceKip” or “Nukip” in order to appeal to more women voters, and for the heavy-handedness of his pitch to Labour voters (“There were times when I wondered whether I’ve got a purple rosette or a red one on”, one told the paper). 

It is Nuttall’s policy advisers - the anti-Farage awkward squad of Suzanne Evans, MEP Patrick O’Flynn (who famously branded Farage "snarling, thin-skinned and aggressive") and former leadership candidate Lisa Duffy – come in for the harshest criticism. Herein lies the leader's almost impossible task. Despite having pitched to members as a unity candidate, the two sides’ visions for Ukip are irreconcilable – one urges him to emulate Trump (who Nuttall says he would not have voted for), and the other urges a more moderate tack. 

Endorsing his leader on Question Time last night, Ukip’s sole MP Douglas Carswell blamed the legacy of the party’s Tea Party-inspired 2015 general election campaign, which saw Farage complain about foreigners with HIV using the NHS in ITV’s leaders debate, for the party’s poor performance in Stoke. Others, such as MEP Bill Etheridge, say precisely the opposite – that Nuttall must be more like Farage. 

Neither side has yet called for Nuttall’s head. He insists he is “not going anywhere”. With his febrile party no stranger to abortive coup and counter-coup, he is unlikely to be the one who has the final say.