BMJ 2014;348:g2136 doi: 10.1136/bmj.g2136 (Published 20 March 2014)
Page 1 of 2
Editorials
EDITORIALS Independent Commission on Whole Person Care for the UK Labour Party Proposals would be good for patients and a big change for doctors 1
Alf Collins clinical associate , Anya de Iongh person who lives with long term conditions and patient 2 leader The Health Foundation, London WC2E 9RA, UK; 2Dorset, UK
1
The Independent Commission on Whole Person Care report for the UK Labour Party proposes that health and social care should do more to support people with long term conditions to become engaged in managing their health and healthcare.1 The commission goes further than the NHS Plan and the Wanless Report,2 3 which contained similar proposals. It highlights that health has physical, psychological, and social domains,4 and that an integrated understanding of health should inform how public services work with people with long term conditions and how services are organised and paid for locally and nationally.
The terms of reference for the commission required John Oldham and members from voluntary, NHS, local authority care, and social care to identify how to move from “the current system to one where coordinated, fully integrated care is the norm without major structural change and within existing resources.” The report broadly achieves this aim, and brings all the themes of whole person care into one document, which focuses on the needs of people who live with multiple long term conditions. However, in such a wide ranging report, the absence of recommendations on end of life care seems short sighted.
The report’s case for change is well made. It is hard not to agree that care should be organised around what matters to people who live with long term conditions (their personal outcomes, such as maintaining independence), and that the default place for care delivery should be in people’s homes. The organisation of public services to achieve this requires a major shift. Personalised care planning should be the norm, with carers, health and social care teams, and the voluntary sector working together as alliances of care and support providers. Some of this thinking is embedded in current national guidance for England.5 However, fewer than 4% of people who live with long term conditions currently have a care plan,6 and an understanding of how diverse organisations can be successfully integrated is only just emerging.7 Local organisations need to align around clear objectives to implement this vision. The report proposes that commissioning for outcomes that matter to patients would help achieve this
aim, with local integrated teams of providers working together with patients and their carers to create a set of person centred objectives. These teams would work within a single capitated budget, and commissioning responsibility for the system would sit with health and wellbeing boards. Such boards would be the local stewards of health and social care strategy; previous plans to place commissioning within local authorities have clearly been dropped. This systematic integration of physical and mental health and social care would resonate upwards through the whole structure of the NHS, with NHS England becoming Care England and Health Education England becoming Care Education England. Predictably, competition doesn’t have a strong role within this system, and although the document contains some inconsistencies, the over-riding message is “care first, competition second.”
The report predicts major changes to clinicians’ work in the future, with primary care working more closely with secondary care, social care, and the voluntary sector, and secondary care doing more to understand whole person care and work more effectively in local communities. The Royal College of General Practitioners and the Royal College of Physicians have already begun this work.8 9 But the report makes it clear that hospital specialists need to do much more to engage in the whole person care agenda, proposing that the financial incentives offered by the clinical excellence scheme should be awarded for whole person care. Interestingly, however, the report is relatively light on mechanisms to strengthen primary care, other than proposing that incentives are aligned with local system outcomes. Instead, it focuses on strengthening the (currently means tested) social care system. Several important challenges remain, not least the risk of social care funding being subsumed into health budgets both locally and nationally, and the challenge of embedding person centred outcomes into a system currently dominated by clinical outcomes data. The report strongly emphasises the role of information in supporting patients to manage their health and
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2136 doi: 10.1136/bmj.g2136 (Published 20 March 2014)
Page 2 of 2
EDITORIALS
proposes that all patients should hold their own care record. However, the current confusion around record sharing across primary and secondary care in the NHS (care.data) suggests that information governance might prove to be a considerable hurdle.
If fully implemented, the report’s recommendations would bring benefits to patients and substantial changes to the way that doctors work. Public services in the United Kingdom face unprecedented financial challenges, and the real lesson from the report is that we all need to change to ensure the medium term sustainability of public services.
This commission may not herald another structural change, but it does represent a seismic shift in the way we need to think about the delivery of care. The financial, moral, and clinical need for such a shift is clear. As the report highlights, this isn’t just about policy, it is about people’s lives. While appreciating the frustrations of political election cycles, for the sake of people who live with long term conditions, staff, and our health and care system, we can’t delay making whole person care a reality. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare that: AdI has none; AC is a paid consultant for the independent charity the Health Foundation.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Provenance and peer review: Commissioned; not externally peer reviewed. 1
2 3 4 5 6 7 8 9
Oldham J, Brearley S, Chapman H, Coulter A, Dinwoodie M, Hay P, et al. One person, one team, one system. Report of the Independent Commission on Whole Person Care for the Labour Party. 2014. www.yourbritain.org/uploads/editor/files/One_Person_One_ Team_One_System.pdf . Department of Health. The NHS Plan: a plan for investment, a plan for reform.2000. http: //webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/ publications/publicationspolicyandguidance/dh_4002960. Wanless D, Charlesworth A, Walker I, Beck M, Black J, Blue I, et al. Securing our future health: taking a long term view. 2002. www.yearofcare.co.uk/sites/default/files/images/ Wanless.pdf. WHO. WHO definition of health.1948 www.who.int/about/definition/en/print.html. NHS England. Transforming participation in health and care. 2013. www.england.nhs.uk/ wp-content/uploads/2013/09/trans-part-hc-guid1.pdf. NHS England. GP patient survey 2012-13 wave 2 and 2013-4 wave 1 results. 2013. www. england.nhs.uk/statistics/2013/12/12/gp-patient-survey-aggregated-2012-13-wave-2-and2013-14-wave-1-results. Goodwin N, Dixon A, Anderson G, Wodchis W. Providingintegrated care for older people with complex needs. King’s Fund, 2013. www.kingsfund.org.uk/publications/providingintegrated-care-older-people-complex-needs Royal College of General Practitioners. New coalition launched to make person-centred co-ordinated care a reality for people who live with long term conditions. www.rcgp.org. uk/news/2014/march/new-coalition-launched-on-long-term-conditions.aspx Royal College of Physicians. Future hospital commission. 2013. www.rcplondon.ac.uk/ projects/future-hospital-Commission.
Cite this as: BMJ 2014;348:g2136 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS Independent Commission on Whole Person Care for the UK Labour Party Proposals would be good for patients and a big change for doctors 1
Alf Collins clinical associate , Anya de Iongh person who lives with long term conditions and patient 2 leader The Health Foundation, London WC2E 9RA, UK; 2Dorset, UK
1
The Independent Commission on Whole Person Care report for the UK Labour Party proposes that health and social care should do more to support people with long term conditions to become engaged in managing their health and healthcare.1 The commission goes further than the NHS Plan and the Wanless Report,2 3 which contained similar proposals. It highlights that health has physical, psychological, and social domains,4 and that an integrated understanding of health should inform how public services work with people with long term conditions and how services are organised and paid for locally and nationally.
The terms of reference for the commission required John Oldham and members from voluntary, NHS, local authority care, and social care to identify how to move from “the current system to one where coordinated, fully integrated care is the norm without major structural change and within existing resources.” The report broadly achieves this aim, and brings all the themes of whole person care into one document, which focuses on the needs of people who live with multiple long term conditions. However, in such a wide ranging report, the absence of recommendations on end of life care seems short sighted.
The report’s case for change is well made. It is hard not to agree that care should be organised around what matters to people who live with long term conditions (their personal outcomes, such as maintaining independence), and that the default place for care delivery should be in people’s homes. The organisation of public services to achieve this requires a major shift. Personalised care planning should be the norm, with carers, health and social care teams, and the voluntary sector working together as alliances of care and support providers. Some of this thinking is embedded in current national guidance for England.5 However, fewer than 4% of people who live with long term conditions currently have a care plan,6 and an understanding of how diverse organisations can be successfully integrated is only just emerging.7 Local organisations need to align around clear objectives to implement this vision. The report proposes that commissioning for outcomes that matter to patients would help achieve this
aim, with local integrated teams of providers working together with patients and their carers to create a set of person centred objectives. These teams would work within a single capitated budget, and commissioning responsibility for the system would sit with health and wellbeing boards. Such boards would be the local stewards of health and social care strategy; previous plans to place commissioning within local authorities have clearly been dropped. This systematic integration of physical and mental health and social care would resonate upwards through the whole structure of the NHS, with NHS England becoming Care England and Health Education England becoming Care Education England. Predictably, competition doesn’t have a strong role within this system, and although the document contains some inconsistencies, the over-riding message is “care first, competition second.”
The report predicts major changes to clinicians’ work in the future, with primary care working more closely with secondary care, social care, and the voluntary sector, and secondary care doing more to understand whole person care and work more effectively in local communities. The Royal College of General Practitioners and the Royal College of Physicians have already begun this work.8 9 But the report makes it clear that hospital specialists need to do much more to engage in the whole person care agenda, proposing that the financial incentives offered by the clinical excellence scheme should be awarded for whole person care. Interestingly, however, the report is relatively light on mechanisms to strengthen primary care, other than proposing that incentives are aligned with local system outcomes. Instead, it focuses on strengthening the (currently means tested) social care system. Several important challenges remain, not least the risk of social care funding being subsumed into health budgets both locally and nationally, and the challenge of embedding person centred outcomes into a system currently dominated by clinical outcomes data. The report strongly emphasises the role of information in supporting patients to manage their health and
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2136 doi: 10.1136/bmj.g2136 (Published 20 March 2014)
Page 2 of 2
EDITORIALS
proposes that all patients should hold their own care record. However, the current confusion around record sharing across primary and secondary care in the NHS (care.data) suggests that information governance might prove to be a considerable hurdle.
If fully implemented, the report’s recommendations would bring benefits to patients and substantial changes to the way that doctors work. Public services in the United Kingdom face unprecedented financial challenges, and the real lesson from the report is that we all need to change to ensure the medium term sustainability of public services.
This commission may not herald another structural change, but it does represent a seismic shift in the way we need to think about the delivery of care. The financial, moral, and clinical need for such a shift is clear. As the report highlights, this isn’t just about policy, it is about people’s lives. While appreciating the frustrations of political election cycles, for the sake of people who live with long term conditions, staff, and our health and care system, we can’t delay making whole person care a reality. Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare that: AdI has none; AC is a paid consultant for the independent charity the Health Foundation.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Provenance and peer review: Commissioned; not externally peer reviewed. 1
2 3 4 5 6 7 8 9
Oldham J, Brearley S, Chapman H, Coulter A, Dinwoodie M, Hay P, et al. One person, one team, one system. Report of the Independent Commission on Whole Person Care for the Labour Party. 2014. www.yourbritain.org/uploads/editor/files/One_Person_One_ Team_One_System.pdf . Department of Health. The NHS Plan: a plan for investment, a plan for reform.2000. http: //webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/ publications/publicationspolicyandguidance/dh_4002960. Wanless D, Charlesworth A, Walker I, Beck M, Black J, Blue I, et al. Securing our future health: taking a long term view. 2002. www.yearofcare.co.uk/sites/default/files/images/ Wanless.pdf. WHO. WHO definition of health.1948 www.who.int/about/definition/en/print.html. NHS England. Transforming participation in health and care. 2013. www.england.nhs.uk/ wp-content/uploads/2013/09/trans-part-hc-guid1.pdf. NHS England. GP patient survey 2012-13 wave 2 and 2013-4 wave 1 results. 2013. www. england.nhs.uk/statistics/2013/12/12/gp-patient-survey-aggregated-2012-13-wave-2-and2013-14-wave-1-results. Goodwin N, Dixon A, Anderson G, Wodchis W. Providingintegrated care for older people with complex needs. King’s Fund, 2013. www.kingsfund.org.uk/publications/providingintegrated-care-older-people-complex-needs Royal College of General Practitioners. New coalition launched to make person-centred co-ordinated care a reality for people who live with long term conditions. www.rcgp.org. uk/news/2014/march/new-coalition-launched-on-long-term-conditions.aspx Royal College of Physicians. Future hospital commission. 2013. www.rcplondon.ac.uk/ projects/future-hospital-Commission.
Cite this as: BMJ 2014;348:g2136 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
