I recently contributed an essay to a collection produced by the New Local Government Network (NLGN), in partnership with the Fabian Society, entitled ‘Labour’s Local Offer: Ideas for a Radical Local Manifesto.’
My piece was specifically on Local Government and the NHS, and you can read the full text of my essay below.
Local Government and the NHS
On 29 October last year Mr Justice Silber ruled that the Secretary of State for Health did not have the power to downgrade the A&E and Maternity units at Lewisham Hopsital. Those of us who had led that campaign celebrated but we were also very aware that our core argument had been that change was needed but should be decided locally not that change could be avoided. We also knew that making those changes would be very hard to do.
We are all familiar with the negative reaction that proposing change to a valued local facility involves – libraries, swimming pools, day centres and many others will provoke campaigns calling on councils to step back from closure. Sometimes imaginative solutions emerge with the facility being transferred to a community group but often it is a case of gritted teeth and trying to explain the bigger picture.
When it is hospitals that are threatened this process is multiplied many times over. The marches to oppose the changes at Lewisham Hospital were the biggest protest our borough has seen and on those marches many of us swapped stories about how the hospital had saved members of our families or even ourselves. I was telling one of the police officers on duty at the march about how personal it felt to me having turned up at the A&E in agony one morning and being diagnosed within a very short time and sent on my way for the cancer surgery that undoubtedly is the reason I am here writing this article today. He then told me that the A&E had saved his life when he was taken there after being attacked with a knife while on patrol.
We are dealing with an emotional connection between thousands of people and their hospital and we must not fool ourselves into believing that a few well-crafted leaflets and wise words from a doctor or two will overcome this. Yet there is a failure at the heart of our health system that we have to overcome if we are to create something which will genuinely meet the needs of our communities now and in the future. The NHS is brilliant at dealing with a crisis – but has never managed to make stopping people becoming ill in the first place the top priority. Public Health has always been the Cinderella of the NHS and now that it is back with local government it is clearer than ever that we have to try to build a “Health service” not the “Illness service” we have at present.
In an age of austerity there is an added reason to do this – it costs a lot less to keep someone healthy and thus avoid the need for treatment than it does to wait until they are ill and then help them get better. But the challenges that the NHS as currently set up faces are complex. If we take finance there is no politician who thinks it wise to do anything other than promise to protect the NHS meaning by and large the acute sector, those hospitals that we are so attached to. If they have a national brief they will want to be clear that some changes will need to be made but within the broader picture the NHS is “safe in their hands” they claim.
When George Osborn introduced the outcome of the 2013 CSR he said something interesting things about health spending – not least the need to transfer some resources to Local Government so that it could do more through Social Care to keep older people out of hospital and thus reduce pressure on A&Es. This was a sensible thing to do though some within the NHS have resisted it bitterly. In March of this year Sir Bruce Keogh the NHS England Medical Director told MPs that he was concerned that councils would spend the money on pot holes!
In fairness to Sir Bruce it may well be that his remarks were at least in part prompted by something George Osborne said earlier in that speech. He told the House of Commons that “when we came to office the health budget was £96 billion. In 2015-16, it will be £110 billion.” I have no doubt that this is true and in the context of a statement which involved slashing budgets elsewhere, cutting pay and in particular asking local government to make an unprecedented level of real cuts this surely indicated that the NHS was being treated differently.
The trouble is that unlike any other public service the NHS needs to spend substantially more each year to just to stand still. In part this is because of new drugs becoming available, in part because of demographic changes but above all because the profession has got better and better at keeping people alive who a few short years ago would have died. It is something to celebrate but it comes at a cost. But there is little or no public debate about this and we now face a situation where the NHS is teetering on the brink of a serious crisis because it has been making cuts like every other public service and services are now close to collapse in some places.
The Lewisham Hospital case demonstrated how complex local health economies are – they do not neatly match up with local authority boundaries and increasing specialisation within the NHS acute sector means that not every community can have “one of everything”. Notwithstanding our emotional attachment to our local hospitals we would all want to go to the place that is best able to give us the treatment we need – it may have been Lewisham’s A&E that diagnosed my cancer but I was more than happy for the surgery to take place at Guys where the expertise lay.
What we haven’t done is come anywhere near a consensus on what should be provided locally and the NHS addiction to organisational change has not helped. Nevertheless it is possible to envisage a system where the basic assumption is that keeping people out of hospital is what we aim to do. This would require local authorities and primary care providers to work ever more closely together offering better prevention and community based care. We even have the bones of a way to do it by building on the current Health and Wellbeing boards.
The challenge however is what we do about the acute sector and how its services are to be commissioned. The sector does need to change significantly and winning over the public to support this change requires close working between all those local partnerships and those responsible for the Acute sector. For that to happen councils will need to work together, something we are getting significantly better at, but also NHS England need to accept that local government has to be at the heart of designing a fit for purpose health care system for a society that has less money but lives longer.
If we assume that can be achieved, and it would require some very different approaches to what we currently experience, how could we move from the impending crisis to a stable future system? It will require a period of “Invest to Save” which will mean that at national level politicians of all parties agreeing to increase in real terms that spending on health and social care for the duration of perhaps a whole parliament while the local partnerships prepare and implement plans that radically reduce the demands on the acute sector and together there is the a restructuring of Acute services to reflect what is being built. Thereafter we will need to see expenditure reducing to a sustainable level.
Delivering that change will require winning of the trust of local communities and the development of a consensus that goes beyond trying to win short term political advantage. It can’t be politics as usual but the prize is one that is worth putting aside our usual divisions for whether between the centre and localities, NHS and Local Government or left and right. The alternative is a slow decline of the quality of healthcare in the UK punctuated by intermittent crises with short term fixes applied.
Speaking of America’s healthcare system Walter Cronkite said “it is neither healthy, caring, nor a system”. Britain’s Health care system most certainly is caring but needs to be more about health, less about illness and to become a system that can be sustained without constant tinkering. We are right to be proud of our NHS – we just need to have the collective courage to make it something that will serve us, our children and our children’s children in the years ahead.
Sir Steve Bullock is the elected Mayor of Lewisham and a former chair of Lewisham Hospital