Is the white paper a missed opportunity?

10 May 2021

Sir Norman Lamb has been Chair of South London and Maudsley NHS Trust since 2020. He also served as Minister of State for Care and Support in the Department of Health in the Conservative-Liberal Democrat coalition government from 2012 to 2015.

I broadly welcome the health and social care white paper, which I see as a move in the right direction. But I am frustrated that it doesn’t go further.

I spent the latter part of my time in parliament working on building a cross-party group calling for a public commission on the future of the NHS and social care. This white paper doesn’t resolve social care issues nor the relationship between social care and health. It’s much more about NHS reform with an invitation extended to social care to join the discussion.

I also chaired the Health Devolution Commission, where we were arguing for a greater devolution and focus on population health recognising that the wider determinants of health lie well beyond the NHS in housing, education, economic development, transport and so on. I know that unless we find ways of joining this up more we won’t see improvement.

A new Beveridge moment

This could have been a new Beveridge moment – a more fundamental rethink leading to a new settlement for health and care that treats social care as an equal partner and shows it the respect it deserves.

It could have addressed awkward issues such as the juxtaposition of free health services with means-tested social care services, which cause lots of tension on the boundaries between the two. People feel they need to fight to stay on the right side of these boundaries and that sort of fighting can bring out the worst in anyone.

We should have taken the chance to slow down a bit and take stock, working out what we want to do with social care – even if it can’t all be done we can at least start to build a roadmap.

The risk is that this could one day be seen as just another NHS reform. I really hope that’s not the case because it clearly moves us in the right direction – and it does give us the opportunity to build on permissive arrangements.

However, it doesn’t confront at all how we’re going to continue to pay for health and social care in a sustainable way. These areas are going to demand more and more of our national income but we’re not thinking through the implications of growing demand. Of course the danger is that if you give health and social care everything it needs, other key services such as education could miss out.

Power to the people…

These proposals represent a significant move away from the dominant thinking of competition. There’s a tendency for people to say ‘competition is bad; collaboration is good’ but of course the truth is that all approaches have their advantages and disadvantages.

Competition does create challenge in the system. If there’s a state provider thinking ‘we could lose this contract’, it sharpens people’s minds…there’s less complacency. The downside is that you end up with fragmentation and the patient’s experience gets worse. For that reason, I support the change of direction.

As we abandon competition as an organising principle we have to guard against the dangers of the big NHS battalions closing ranks and keeping out other providers – such as social enterprises – whose track record, particularly in providing community health services, is pretty impressive. We need a diversity of providers to encourage innovation. And we need mechanisms to ensure the NHS organisations are accountable to the people they serve.

We must find ways to give more power to people. I like the principle of personal health budgets, which are available to people receiving NHS continuing care. As Minister, I introduced the first legal right to a personal health budget. Giving people the legal right to choose where the money is spent gives them more power and I think this personalisation of health isn’t emphasised enough. We must keep pursuing that agenda.

…or power to Westminster?

The proposals clearly do strengthen the Secretary of State’s control over the NHS. I would say be careful what you wish for here as so many decisions are better taken locally, by people who have democratic accountability and who know the needs of the local area.

I understand that minsters felt constrained and that grabbing more control seems seductive. ‘If only I could just force people to do this sensible thing’, they think. I understand the temptation but it doesn’t make sense. If the secretary of state holds the power, everyone lobbies the secretary of state, attention moves away from the location and it all ends up being political.

I know that when it comes to the secretary of state deciding whether to close a hospital, factors like a marginal seat become relevant and that is never a good basis for deciding on healthcare. A secretary of state meddling in local decisions is never a good idea.

Immediate priorities

One of the anomalies buried deep in the white paper, which was identified by Andrew Corbett-Nolan, is that mental health trusts don’t currently, in the proposals, have a de facto seat at the ICS NHS Board table. I believe the mental health system needs to be making a loud noise about this. Parity of esteem must guide the make-up of critical decision-making bodies. If it doesn’t, decision making will be distorted.

The other thing we should all be doing right now is building relationships. The white paper is an opportunity to do more local level working. We can’t make the difference on our own. You do it through rich collaboration and respecting and embracing the third sector, social enterprises, charities, community organisations as well as local authorities – these are the ways we can have some impact on the wider social determinants of health. We need to be proactive on this now.

My advice to boards is to be bold and confident. The legislation might not move as far as we would like but it does present opportunities. Start thinking now about how you can take advantage of likely permissive powers to do something more radical than the bare minimum.

There will be opportunities ahead for innovation and positive initiatives to improve population health. It’s not mandated but we should use the optional powers at our disposal to make it happen.

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Prepared by GGI Development and Research LLP for the Good Governance Institute.

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