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Our Health, our care, our say

27th March 2006

30032006_large-crowd.jpgThe 'Our health, Our care, our say: a new direction for community services' White Paper was published in January 2006. It sets out the Government's vision of more effective health and social care services outside hospitals.

In brief it calls for more emphasis on primary and preventive care; new clinical pathways that will reduce the role of hospitals; a new drive to correct the "inverse care law" under which the most deprived areas receive the poorest health services despite their greater needs, and more support for family carers. Health checks will be offered at 50 as well as three earlier dates. Pilot programmes under which 1,200 health trainers provide advice on diets, exercise and lifestyles, promised in an earlier white paper, will begin in 2007.

It calls for a shift in the way services are delivered towards more personalised and community-based approaches; it also seeks to tackle health inequalities through funding changes and to give people a stronger voice so that they become the major drivers of service improvement.

The Context

The government says that the NHS is now halfway through its 10 year plan to provide a more modern and effective health care service, and that Our health, our care our say White paper is the next step in that process.

The emphasis has been on increasing the capacity of the NHS, shorter waiting lists and cutting deaths from cancer and coronary heart disease. This paper puts the focus on treating people more efficiently and responding to their needs and expectations.

This fits with the present emphasis on a patient-led health service. Tony Blair said that it heralded "a new era where the service is designed around the patient rather than the needs of the patient being forced to fit around the service already provided."

The government staged a number of consultation and listening exercises in preparation for the White Paper; the first consultation was about adult social care - the 'Independence, Well-being and Choice' Green Paper. This was followed by a listening exercise 'Your Health, Your Care, Your Say'.

Meetings were held in Gateshead, Leicester, London and Plymouth, followed by a national citizens' summit in Birmingham.

The messages from these consultations were that there was a need for a more personalised service, with more care closer to people's homes to support independence.

The Paper

'Our Health, our care, our say' identifies five clear areas for change: more personalised care, services closer to people's homes, better co-ordination with local councils, increased patient choice and a focus on prevention rather than cure.

It contains several key initiatives and issues for further consideration which can broadly be divided into; partnership working across health and social care; working with local General Practices to move care out of hospital; improving access to primary care and community services, infrastructure to support these changes; and new services and developments for existing services.

New measures include:

  • shifting expenditure from spending on hospitals to spending on care closer to home and on preventative services
  • new responsibilities on local councils and the NHS to work together to provide joined up care plans for those who need them
  • bringing some specialties out of the hospital nearer to people including dermatology, ENT, orthopaedics and gynaecology
  • introducing a new generation of community hospitals for diagnostics, minor surgery, outpatient facilities and access to social services in one location.
  • a new NHS "Life Check" pilot to assess people's lifestyle risks and the right steps to take and provide referrals to specialists if needed
  • a guarantee of registration onto a GP practice list in the patient’s locality
  • incentives to GP practices to offer opening times that respond to the needs of patients in their area
  • increased quantity and quality of primary care in under-served, deprived areas through nationally supported procurement of new capacity with contracts awarded by PCTs
  • supporting self care by trebling the investment in the Expert Patient Programme
  • an "information prescription" for people with long term health and social care needs and for their carers
  • professional education and skills development
  • a personal health and social care plan as part of an integrated health and social care record
  • more support for carers including improved emergency respite arrangements and a national helpline for carers
  • extension of direct payments and piloting of individual budgets for social care.

The Comments

Many sources broadly welcomed the White Paper's initiatives, whilst holding reservations on the financial, practical and structural implications;

The Royal College of Physicians (RCP) and Royal College of General Practitioners (RCGP) welcomed the proposals and looked forward to working with the Department of Health 'developing new patterns of care that will enable people to have more control over their health and well-being.'

However, they felt that 'the implications of the changes for the future of acute hospitals is not clear, particularly the workforce implications' and that the proposals to bring some of the services currently provided by hospitals into the community is sensible provided that 'this is done in a supported and structured way' making the best use of doctors, both specialists and generalists.

Dr Mayur Lakhani, Chairman of the Royal College of General Practitioners said that they welcomed the White Paper as a major step forward in improving patient care, but that delivering the White Paper presented a 'formidable' challenge to PCTs, says the Health Service Journal (HSJ).

The British Medical Association (BMA) said that an increased focus on prevention and making services more responsive to patients and closer to them are welcome, but that 'there must be the capacity and resources to make this happen'.

The Royal College of Nursing (RCN) welcomes the proposals for giving people more choice over the community care they receive, and ensuring closer working between health and social care, but warns that caution is needed.

Beverley Malone, the General Secretary of the RCN, when commenting about the competitive tendering process suggested to tackle health inequalities says 'this is an experiment with the health needs of the most deprived communities.' In fact, after consistent failure to address those needs over many years 'experiments are exactly what is needed' suggests the HSJ.

The King's Fund Chief Executive Niall Dickson said that "The White Paper offers an unprecedented opportunity to redesign community health and social care services." But he also said that "we must not underestimate the challenges ahead - we've been trying to do this for more than 30 years with limited results." The announcement, he said, has to be seen in the context of a health service that is struggling financially and finding it difficult to meet all the demands being placed on it.

The reservations around finance were echoed by Nigel Edwards, the NHS Confederation policy director, who said the shift in finance from acute to primary care would mean a 'pretty big dent' in the finances of acute hospitals, reports the HSJ.

Chris Ham, former head of strategy at the Department of Health, said that it would likely prompt the closure or severe scaling-back of larger hospitals. He added that those hospitals tied into long-term repayment contracts with the private sector could face serious problems, says the Times.

Other newspapers also had a mixed appraisal of the White Paper; the Guardian emphasised that moving health care from hospital to the community or even to patients' homes is an old dream which new technology can help deliver. But the timing of reconfiguring hospital care was a challenge, it said as 'We are now halfway through the biggest hospital building programme in the history of the NHS.'

The timing of these reforms in the context of the present state of the NHS was also picked up by Andrew Lansley, the Conservative Health spokesman. He welcomed the Governments "u-turn" on community hospitals, says the Daily Mail. But Andrew Lansley also said “Many primary care trusts are cutting back precisely the community-based services on which her care plan depends" and that the White Paper “fails to face up to the reality of the NHS today" reports the Times.

Royal College of GPs chair Dr Mayure Lakhani said that, with all the good intentions of Our health, our care, our say, "Winning the hearts and minds of doctors and nurses is the key to making this white paper happen" report the HSJ.

Anna Walker, Chief Executive of the Healthcare Commission, also cautioned that, whilst choice, and the movement of care to the community, is no doubt to be commended, none the less "patients and the public must be sure that they have the same assurances on quality and the same information to support choice, wherever care is provided."

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