Transforming the delivery of health and social care: The case for fundamental change

I second that. Pharmaceutical drugs have a place but sadly seem to have the monopoly which is obviously driven by profit not promoting health. shouldnt we try holistic ways too. They work.

The larger is better 'solution' for the cottage industry 'problem' myth has been debunked.
ncbi.nlm.nih.gov/pmc/articles/PMC2648935/

Other assumptions that having small independent contractors providing less efficient are also not supported by evidence. The opposite, they produce better value for money.
ncbi.nlm.nih.gov/pmc/articles/PMC1927089/

Most of the variation in emergency admission rates can be explained by patient deprivation and age profile. These are not under control of the GP. Quality of care as measured under QOF has so far only shown to be a minor factor in comparison to deprivation.
journals.lww.com/ambulatorycaremanagement/Abstract/2008/07000/Quality_of_Primary_Care_and_Hospital_Admissions.7.aspx

Torbay Mencap has set up a monitoring task force to evaluate the effects of current changes and cuts to health/social care for people with learning disabilities. As part of that process I have been tasked with participating in the consultation around GP Commisioning.
In preparation for this I have been reading your recent paper - Transforming The Delivery Of Health And Social Care.
There are however two omissions and a general statement (About Care in Torbay) which mar this otherwise excellent paper.
(1) Increase in number of young people with learning disabilities (Pages 9&10) The figures given by the paper seem to take no account of the rapid increase in life expectancy of people in this catagory, or the subsequent increase in age of parents who are providing care. Problems connected with these two factors are very apparent to to a voluntary support agency such as Torbay Mencap.
(2) The approach developed in Torbay (page 21). We would recommend that before printing comments such as this you should take the advice which runs through the paper and seek
partisipent comment. The joint Health/LA Care Trust is regarded by many of its users as distinctly a "Curates Egg". The joint provision model ,excellent in theory has proved in practice to be problimatic for many people with learning disabilities and families providing care for them. The pace and scope of change has been rapid and for many uncomfortable and negative. In a short comment such as this it is not possible to give a detailed resume but Torbay Mencap would be happy to provide an accurate summary for interested parties.

I enjoyed a lot reading your comments. We need a new way to do the same things, because people really needs the same things.

A lot to be recommended in this balanced and reasonably argued report. However, in my view the analysis remains incomplete and certain assumptions are accepted unchallenged.

What appears to be lacking in the analysis is an understanding of the social context in which health care services are operating in the UK at this particular point in time. The long term conditions and the altered demographics highlighted are indeed realities, but it is also a reality that the conception of the NHS as a health service, funded through taxation, accessible to all is no longer a belief necessarily shared by all of our public and perhaps more importantly by those who may have to contribute more towards the welfare and well being of others. A socialist ideal is unlikely to be supported by an individualistic, materialistic and self interested society. Indeed one can argue that many of the 'social inequalities' are in part a product of the very choices we as a society have made, the values that we have, the financial and economic inequalities that we are prepared to tolerate. It is perhaps why inequalities are high in countries like the USA with the UK arguably falling into a similar pattern.

The second issue is perhaps more to do with the suggestions that somehow one can take out something from Sweden and transplant it in the UK without the Swedish context to make it successful. Britain is not Sweden and its society most certainly is not Swedish even remotely in its outlook. A society that believes to an extent in egalitarian principles cannot be reasonably compared to one that sees the pursuit of wealth as 'aspirational'. An example of this unchallenged assumption of decontextualised reproducibility is the British railway system arguably one of the worst in the more prosperous countries of Europe. Now many of them have private railways, which run successfully. However, in Britain the trains are overpriced and pretty rubbish in comparison.

The suggestion of the embracing of technology by Banks has to be a tongue in cheek comment and not because the situation that banks find themselves in. Some of us do remember that very ambitious ill fated project NPfIT that crumbled under its own weight. The NHS was trying to embrace new technological advances. It just didn't quite manage.

Another assumption is that armed with information people will do what they should as understood by scientists and government officials. Smoking rates went down after smoking cessation treatments were offered in conjunction with significant changes in legislation. People knew that smoking was harmful but it took more than that for things to change. Obesity is another example. Allowing the spread of inappropriate foods (Burger chains in hospitals e.g.) and then hoping that people will eat vegetables might be close to the limits of optimism. The suggestion that people will just look after their health is not necessarily borne out of robust evidence. It is a nice thought though.

A couple of suggestions; it might be a good starting point to ask what sort of society do we wish to live in. What are our priorities as a society and what price are we prepared to pay for them. The discussion might include do we want a nuclear deterrent or.....Another question might be to ask what sort of services should the be provided through general taxation. This myth needs to be challenged that all is free as it is not. Some people pay for their prescriptions some don't. Certain treatments are refused on the grounds of cost-benefits and contrary to popular myth people can't demand what they feel is necessary, despite successive governments creating this impression.

Then the idea that suggesting that integration is a good idea, when everything is geared up to ensure fragmentation might be taken as ambivalence by some but outright hypocrisy by most on behalf of governments who may not wish to take difficult decisions. Then there are too many vested interests. The BMA laments the privatisation of the NHS, yet GP surgeries are perhaps best regarded as regional monopoly businesses. The pharma industry has become the big whipping boys of our era but hospital consultants and senior managers at the Department of Health and other bodies also have huge vested interests, not just in terms of their fairly inflated salaries but also in terms of the revolving door of lucrative advisory assignments and potential non-executive directorships, arguably means of buying insider influence.

So I would suggest that the analysis of health care needs to go beyond the usual bounds of health, social care, demographics and management and move into a more socio-cultural mode of analysis to decide what change to aim for and how to achieve that.

I agree with comments from Graham Brack, I have just presented at Bexley Shadow Health and Well-being Board and they were most interested in what pharmacy has to offer. Pharmacists are available without appointments and accessible to patients and the healthy population. This is a resource that is being recognised by commissioners if they want to deliver the care for LTC patients, reduce waste, reduce unscheduled hospital admissions and promote a healthy lifestyle for the general public. We need to be working together and engaging with willing partners to make health and social care more accessible for the population.

I very much enjoyed reading your paper – I agree that we need to think differently.

One of the 5 “aims” of the new commissioning approach is to prevent premature death – but there is no definition of what is meant by “premature”.

As a cardiac surgeon it is increasingly common for me to be asked to operate on someone in their mid 80s (and so has already lived beyond their “life expectancy”) who has a good quality of life with minimal angina, for “prognostic reasons” because a myocardial perfusion scan has shown some ischaemia. Is this preventing premature death? Or older patients being referred for heart transplantation or even mechanical circulatory assist devices (to prolong the act of dying).

We (not only cardiologists and cardiac surgeons) seem to have become lost in what we are trying to achieve with healthcare. It seems that patients are no longer allowed to die naturally without some form of intervention. Death is no longer an acceptable outcome.

It's 50 years since the groundbreaking work on 'paradigms' was written (T. Kuhn, The Structure of Scientific Revolutions, 1962) but it's key messages remain. When enough anomalies are recognised in the current paradigm, it will exist in a state of crisis - and even conflict - until a new paradigm emerges. New Paradigms are often identified outside of the existing, dominant structures and ways of thinking.
Healthcare as we know and practice it in the UK is, as this report indicates, out of date scientifically and economically.
Even the way new ideas and approaches are researched and tested is out of date: driven by economic silos rather than cross-organisational, cross-sectoral, or even cross cultural approaches to R&D.
My personal commitment is to support better leadership - in the NHS and elsewhere - as I believe that transformation starts with each one of us. I'm not referring to position or profession: we're all taxpayers and it's our financial contributions that are being spent (nay, wasted) here.
It takes courage and determination to transform services - as well as the vision to see that there are many better ways and new possibilities.
I believe that we can create affordable health services, free at the point of delivery - globally - given sufficient courage and determination.
As the Huffington Post blogger, Mitch Ditkoff, says "If not YOU, who? If not NOW, when?"

Based on my 30 plus years in the fields, I'd say the incremental change is related to minimal change at the margins. Sunday afternoon, I was reviewing the mid-1990s home of my own initiatives in the US, and indeed in practically an instant, the states were at guardianship and conservatorship of the funds for home purchasing; most of the group, of course, was on inheritance of the home or the parents acting as the guardian of the person. I also reviewed a Hispanic literature article on homeownership, and of course, no disability in the article; and no Hispanic findings (e.g., large proportion of immigrants) in the disability article...with that coalition start, it's amazing any change happens at the cross bridge. It's constant...integrationists act segregationally on integration funds...at all the high US finance agencies in states on that one.

Every Person, Purpose, & Process needs to be focused on & aligned with the interests of Patients & the Public. Too often, we read about the consequences of this not being the case.
How do we get the people with the Power to give the people with the Ability the Tools, Time, and Motives they need to make the required changes?