Hilary Brown

HSMC Policy Directors Hilary Brown and Catherine Needham have been out and about at the Conservative Party conference in Birmingham this week. Hilary was meeting prospective parliamentary candidates at a dinner hosted by Cancer Research UK, and joining in the discussion at a ResPublica event entitled The future of the NHS: Empowering patients. Catherine was hearing about 21st Century Public Services at a Reform/Fabian event, sponsored by the CBI.

What was striking at the two fringe events was the degree of consensus in the room – even when the panels had been selected to include difference (for example, the 21st Century Public Services had the Fabian Society and the Guardian on the panel as well as Eric Pickles and Reform). At the health event, the speakers agreed on the importance of the personalisation agenda, the need to integrate care and that integration should start with primary care. Stephen Dorrell talked about the elastic definition of health and care in which people engaging in self-care type pursuits such as taking exercise are still part of that continuum, an issue of demand-management which wasn’t far from what Andrew Harrop of the Fabians was talking about at the Public Services event. Commissioning for outcomes not outputs was a clarion call at both events. There was optimism about the scope for big data to tell us lots of new and helpful things about populations. The Better Care Fund was cited at both sessions as a bright hope for the future and an example of how more public services can get joined up. Everyone nodded when Eric Pickles talked about the valuable role that firefighters can play in identifying vulnerable families and the need for professionals to get together in more multi-disciplinary forums to support troubled families. It is hard to imagine how these conversations would have been any different at the Labour Party or Lib Dem conferences.

It was reassuring to see occasional flashes of ideological difference. The role of the private sector was a divisive issue at the public services event, with the Fabians suggesting a limit on private sector involvement and the CBI suggesting a more pragmatic response based on getting the best outcomes for users. John Cridland of the CBI gave the example of meals-on-wheels supplied by a private company in which van drivers fed back to the CEO the difficulties many older people had in heating up their meals, leading the company to think about ways microwaves could be better adapted for older people. He implied that a private company may do better at listening and responding to its frontline workforce than local government does – whilst recognising that some companies are much better than others about this.

The strong push on choice and exit to encourage a more flexible, responsive and diverse provider landscape was another bit of clear blue water. Stephen Dorrell was advocating this as a key to improving service provision, rather than relying on the voice of the ‘empowered’ patient. There was a call from the floor for more hospitals to be allowed to fail, to send out a message about poor performance.

Setting aside the limitations of some of these claims (for example a quarter of patients with colorectal cancer present as an emergency are not in a position to choose their provider in these circumstances), there was something rather unsettling about the mood of consensus. The language of empowering patients is itself problematic. People have a degree of power before they enter the ‘system’ and can be disempowered by being unwell and entering the health system. Empowerment should therefore not be seen as a ‘gift’ that is given by the NHS/providers but a right that is returned. Victor Adebowale from Turning Point talked about how people need to be engaged as citizens: the NHS is responding to ‘failure demand’ when people have had a crisis and it’s too late to do anything more preventive.

The optimism around outcomes-based commissioning, the Better Care Fund, big data and increased plurality of provision exist despite the lack of sustained evidence that anyone has cracked how to do these things well, and leave behind a concern that they may fail to offer anything that will make front-line public services work better.