As much as many of us would like to ignore the fact, our National Health Service is at the most critical juncture in its long history. An ever-ageing population, together with the stark rise in prevalence of those suffering from lifestyle diseases, both place our healthcare system on a financially unsustainable footing. Indeed, long-term conditions, such as obesity and diabetes, will alone bankrupt the NHS within a decade, with a £19bn funding gap expected if these conditions are not managed properly.
Yet from government there seems to be a lack of good ideas on how to ensure that NHS remains viable as an institution free at the point of use. Many of the arguments surrounding health reform suggest that the solution to this financial crisis is a laughably simple one – more liberalisation. The trend towards NHS liberalisation, which started with Margaret Thatcher and continued with the Health and Social Care Bill, has been at the heart of health reform over recent decades. This trend is based upon the proposition that is all that is needed to improve NHS services is to open up the system to private sector providers. Then competitive forces will, as if by magic, improve patient quality whilst making the necessary savings.
But although competition in certain cases is to be welcomed, it is alone insufficient to tackle the health systems incoming problems. The complex conditions of the future will require a different type of healthcare, delivered by a different healthcare system. The NHS of the past, which was designed to combat acute diseases like polio and tuberculosis, is simply not configured to treat the chronic diseases associated with ageing and flawed lifestyle choices. These conditions require more integrated forms of service delivery that provide holistic, whole-person care.
It has long been known that integrated care is the holy grail of NHS reform. Yet the coalition government has failed to make this a top priority, and the cancellation of the £3.8bn Better Care Fund is clear evidence of this. In fact, instead of choosing the harder path towards better healthcare integration, the government has opted for and prioritised yet more liberalisation in the form of the Any Qualified Provider programme.
This initiative is intended to open up services and improve patient choice. Under this scheme, private providers are allowed to deliver basic NHS services. At a first glance, by the government’s standards the programme seems to have been a success, with 105 firms singed up to the scheme. But instead of opening up the service to smaller providers, as was first intended, the process has been criticised for prioritising the larger providers. A study of AQP found that 24 of the 105 firms were large companies with at least 250 members of full-time staff.
AQP is not the answer to integrated care, as it merely atomises and fragments care by multiplying the number of bodies delivering healthcare. In this way, it simply destabilises existing services and damages care pathways. It cannot, therefore, deliver the whole-person care we need. Because of this, we at ResPublica ask that the government seriously consider scrapping the Any Qualified Provider scheme. Competition and choice are to be welcomed, but they should not come at the price of collaboration and holistic care. We would instead argue for a different approach.
In our latest report, Power to the People: The mutual future of our National Health Service, we argue that mutuals are best placed to initiate a system of healthcare that delivers personalised, holistic care in a cost-effective manner. Mutual organisations are, by their very nature, democratic and benevolent institutions. As such, they are perfectly placed to integrate the needs of patients with the capabilities of clinicians in an inclusive fashion.
Such a proposal is not an odd suggestion. Mutuals already have a firm foothold in the NHS. Foundation Trusts, which operate on a mutual model, are now the standard composition for hospitals, and mutual NHS spin-outs are raising standards across the sector. One type of mutual organisation that has often been ignored, but could perhaps perform such a vital role, is the friendly society.
Before the advent of the NHS, most healthcare was provided through friendly societies. Just before the onset of the Great War, there were 26,877 friendly societies operating in England and six million members. The democratic and inclusive characteristics of these organisations would make them ideal candidates for performing an integrator role that would connect disparate elements of the NHS to deliver the holistic care our older people need.
As the report makes clear, the financial benefits of this model could be vast. By integrating care, we estimate that the NHS could save £4.5bn by 2020. Embracing mutualism would not only integrate care and deliver better outcomes, it would have significant financial benefits as well. Clearly, if we are to have the integrated care that so many of us need, then policy makers will have to ditch their fixation with ever increasing liberalisation and assess the benefits more mutualism could bring to the NHS.
Adam Wildman is research manager at ResPublica