Personal responsibility
Health Secretary Jeremy Hunt's speech to the Local Government Association annual conference.
Let me start with a thank you.
Right now the health and care sectors face a triple whammy: an ageing population, a budget squeeze and rising consumer expectations. And you are operating at the coalface of those pressures, and I want to thank you for the superhuman efforts you are making to make sure we do not let down our most vulnerable citizens.
Elections focus on the differences between parties. But 2 months on from this last one, we should reflect that there was actually consensus on a critical aspect of health and social care policy: all parties were committed to going further and faster on integration. It also appeared prominently in the Queen’s Speech - and as we have been talking about it you have been getting on and delivering it through the Better Care Fund, where remarkable progress has been made. This includes:
- 84,000 fewer hospital bed days; around 13,000 more older people remaining at home after discharge; and 3,000 more people being supported to live independently according to current plans
- every part of the country now on track to start sharing records with the NHS, the most vital bit of integration ‘plumbing’
- 72 areas - around half the total - actually putting additional money of their own into the pooling arrangements because they’re so enthused about its potential to improve care
And they are right to be enthused, because some of the plans we’re seeing are truly transformational. 75% of the pooled budgets are being ploughed not into NHS acute care, but into social and community care - exactly the shift we need to keep people healthy and happy in their own communities, to prevent rather than cure, and to avoid unnecessary hospital admissions.
One piece of the jigsaw, though, is missing as we embark on this journey, and that is effective metrics. Integrating health and social care is a first - perhaps a global first - so it would be fatal if the dead hand of Whitehall tried to tell you how to do it. But we do need to know how well it is going, area by area, so we can identify best practice, learn from each other and provide support where things are going wrong.
And to help that I am developing a set of unified metrics, bringing together the work on the Better Care Fund with the broader objective of health and social care integration. These will use a methodology agreed by the Department of Health, the Department for Communities and Local Government, the NHS and local government through the Local Local Government Association (LGA), they’ll be independently verified and published quarterly with the first set coming out in December. This way we will help ensure that the process of integration carries on at the pace we need over the coming years.
Money
Now integrated care is safe to talk about - because we all agree on it. Trickier is the other issue on your mind right now, which is the spending review. I know that you know I am not in a position to gainsay the Chancellor on this. But I can set out some of the principles guiding our approach.
The first is that proper funding for all public services in the end depends on a strong economy. So we do need to stick to our challenging deficit-reduction plans as outlined before the election - which we recognise will be particularly challenging for local government.
Indeed even with a protected budget it will be challenging for the NHS too. On a do-nothing scenario, demand for our services will rise by £30 billion by 2020, with only £8 billion of additional funding - so we are having to find £22 billion of savings, the most difficult efficiency ask of the NHS in its history.
I am of course only too well aware of the financial challenges that local government has faced over the last 5 years, and we all know there is still more to do.
But - and this is our second principle - we will fail in our responsibilities to the most vulnerable if we approach those efficiency challenges separately, allowing the pressure of budgets to entrench a silo mentality between the NHS and local government.
What happens in social care is inextricably linked to what happens in the NHS. A strong NHS needs a strong social care system and a strong social care system needs a strong NHS. It would be easy - but quite wrong - to balance the books by reducing access to care or the quality of care delivered. But if local authorities do that NHS A&E departments will be overwhelmed - and if the NHS does that the demand for permanent residential care that you will have to pay for will mushroom. So we must follow the harder path: finding smart efficiencies that improve patient care - something we can only do by joining forces and facing those efficiency challenges together.
Personal responsibility
But there is a third partner we need in this endeavour – and that is the people who actually use our health and care system.
When Beveridge first called for a National Health Service he attacked the five great evils of ‘want, disease, ignorance, squalor and idleness.’ His guiding principle was that the security of a national health service should be dependent on co-operation between the state and the individual. In other words, ‘the state should offer security for service and contribution.’
Sometimes the state has not delivered as well as it should - whether Shipman, Bristol Heart, Mid Staffs or Winterbourne View. So my biggest priority as Health Secretary has been a move towards intelligent transparency so we find out quickly where any problems might be happening.
As a result, for the first time we now know how good our local hospital is; we have independent ratings for GP surgeries and care homes; we publish consultant surgery outcomes and are looking to do the same for medical specialties. From next March Clinical Commissioning Groups (CCGs), too, will be held accountable for the overall quality of healthcare delivered in their area. The NHS is moving from a closed organisation to an open one, with real accountability to taxpayers and patients for the quality of service delivered.
But to deliver the highest standards of health and care the people who use those services need to play their part too: personal responsibility needs to sit squarely alongside system accountability.
And that is the national conversation I want to start today.
Personal responsibility for our health
We need to start by taking more personal responsibility for our own health.
The independent, American-based Commonwealth Fund recently ranked the UK first of all major health systems in the developed world. On access to health services the UK is unparalleled. On the safety of care we’re amongst the best. Yet on one key measure we fell far behind. When it comes to preventing illness or leading ‘healthy lives’, we are bottom of the pack, ranked 10th out of 11. That is deeply undesirable in a taxpayer-funded system that relies on a sustainable level of demand for services.
This country pioneered through local government clean drinking water and clean air in cities - we effectively invented what is now called public health.
But looking at some of the indicators you wouldn’t know it.
Despite falling smoking rates, nearly 8 million people in England still smoke, and treating smoking-related illnesses costs the NHS an estimated £2.7 billion a year. Half the difference in life expectancy between our richer and poorer areas is caused by smoking-related illness, with two-thirds of smokers starting as children.
We also have higher obesity rates than nearly anywhere else in Europe. This is closely linked to soaring type 2 diabetes rates - up 61% in a decade, now affecting 1 in 16 of the adult population and costing the NHS £8 billion a year. While childhood obesity has plateaued, are we really content with 1 in 5 children leaving primary school clinically obese, with three-quarters of their parents not even aware that they have a problem?
Thankfully people are starting to take more responsibility. Doctors report dramatic increases in the number of expert patients who Google their conditions and this can be challenging for doctors not used to being second-guessed. But it is to be warmly welcomed: the best person to manage a long-term condition is the person who has that long term condition. The best person to prevent a long term condition developing is not the doctor - it’s you. Which is why last year, following changes to the GP contract, the number of GPs offering their patients online access to a summary of their medical record has risen from 3% to 97%. This needs to be the start of a much bigger change where everyone feels firmly in the driving seat for their own health outcomes and an area where the NHS and local government can work together.
Responsible use of NHS resources
Part of this change in mentality needs to be more personal responsibility for use of precious public resources.
On the back of Lord Carter’s report on inefficiencies in procurement and rostering in the NHS, we have recently begun a big piece of work to bear down on waste in hospitals. We are insisting on a laser-like focus from the hospital sector to make sure every penny counts.
But there is a role for patients here too. There is no such thing as a free health service: everything we are proud of in the NHS is funded by taxpayers and every penny we waste costs patients more through higher taxes or reduced services.
Yet estimates suggest that missed GP appointments cost the NHS £162 million each year and missed hospital appointments as much as £750 million a year. That is nearly £1 billion that could be used for more treatments or the latest drugs. On top of which we spend £300 million a year on wasted medicines.
People who use our services need to know that in the end they pay the price for this waste.
So today I can announce that we intend to publish the indicative medicine costs to the NHS on the packs of all medicines costing more than £20, which will also be marked ‘funded by the UK taxpayer’. This will not just reduce waste by reminding people of the cost of medicine, but also improve patient care by boosting adherence to drug regimes. I will start the processes to make this happen this year, with an aim to implement it next year.
Responsibility for our families
The third and perhaps most important area where we need to take more personal responsibility is around care for the elderly. Here yet again health and local government must surely work together.
You don’t need me to describe the burning platform. By the end of this parliament we will have a million more over 70s, one third of them living alone. Yes the health and social care system must do a much better job at looking after them. But so too must all of us as citizens as well.
Shockingly, in Edinburgh last week police had to break down the door of a top floor flat because it had been so long since the door had been opened, they had to pick their way through mounds of unopened mail, to reach the body of a man who may have been left undiscovered in his flat for up to 3 years.
Statistics from the LGA indicate that in 2011 in England there were 2,900 council funded funerals. That is around 8 ‘lonely funerals’ every single day, half of which were for over 65s.
Are we really saying these people had no living relatives or friends? Or is it something sadder, namely that the busy, atomised lives we increasingly lead mean that too often we have become so distant from blood relatives that we don’t even know when they are dying?
In Japan nearly 30,000 people die alone every year, and they have even coined a word for it, kodokushi, which means ‘lonely death.’ How many lonely deaths do we have in Britain - where according to Age UK a million older people have not spoken to anyone in the last month?
It is not all bad news: we have 6 million carers in the UK who do a magnificent job, even if they do not always get the thanks or support they deserve. We have some of the most active charities and social support systems of anywhere in the world. But the uncomfortable truth is that praising that heroic army of carers and volunteers - as all politicians do - is not enough. If we are to rise to the challenges we face, taking care of older relatives and friends will need to become part of everyone’s life.
International comparisons
Other countries are starting to wake up to this challenge.
A Chinese proverb states that ‘an elderly person at home is like a living golden treasure’. At the moment, around 40% of Chinese older people live with their children, but in Beijing they have a policy to increase that to 90% by 2020. China even passed a new ‘elderly rights law’ against ‘neglecting or snubbing elderly people’, which mandated that people should visit their elderly parents often, no matter how far away they live, with fines or prison sentences as penalties.
Western traditions would rightly resist state interference on this scale. But France too passed an elderly care law in 2004 requiring its citizens to keep in touch with their elderly parents. They did this after a heatwave left 15,000 elderly dead, many of whom were left for weeks before they were found.
In Italy, they have a well-established system of ‘badanti’ – a system of au pairs or ‘nannies for grannies’. They provide the majority of elderly care in Italy and take care of older relatives while busy parents go out to work.
In the Netherlands, they’ve introduced a different type of au pair system for elderly people, where students are offered rent-free accommodation in nursing homes in return for spending at least 30 hours a month with some of the elderly residents.
Another model is championed by the remarkable organisation L’Arche’, which has adopted a revolutionary approach to the care of people with learning disabilities. As a young man in the aftermath of World War II, Vanier L’Arche visited a grim institution in Paris for people with learning disabilities. He was accosted by a young resident who asked him simply: “Will you be my friend?” He was so struck by this cry of loneliness that he invited 2 men from the institution to live with him in his home. This became an international movement where people offer a year of their time to live alongside their charges. As Vanier said: “When you share the same bathroom, and your toothbrush shares the same mug, it’s different”, and there are now 147 thriving L‘Arche communities in 35 countries including our own.
And we have some remarkable home-grown schemes, too, such as the HomeShare scheme in Dorset to Forth Valley, Scotland; and the Shared Lives programme in 150 locations from Bradford to Brighton. Or the extraordinary efforts of individual citizens like Maria Boot-Handford, a speech therapist from Greenwich, who was so moved by the plight of her elderly neighbours that she negotiated with her NHS employer to work 4 days a week so that she could use her Fridays to spend quality time with 3 different elderly neighbours and visit local nursing home residents.
But individual examples of inspiration should not mask our national shame: 1 in 10 older people have contact with their family less than once a month and 4 million people say TV is their main source of company. Despite many local examples of innate British kindness and decency, the national picture is far from kind and far from decent.
New carers’ strategy
We should also note the hard-headed economic arguments that impact on this debate.
All families have different needs and situations, and for some residential care will be right. But carry on as we are and we will need 38,000 more care home beds in the next 5 years - the equivalent of around 20 new care homes a month for the next 5 years. The impact of this on you, the local authorities who fund 40% of all residential care beds, would be disastrous. Care home residents are some of the most frequent users of NHS services, so the financial impact on the NHS would be equally severe.
Recent evidence suggests change is starting to happen - the latest ONS figures showed a welcome increase in multi-generational households. But with only 16% of older people living with their children in this country compared to 39% in Italy, 40% in China and 65% in Japan, we are starting from a low base and need to ask whether the pace of change is sufficient.
We are proud of the new rights for carers enshrined in last year’s Care Act and made a manifesto commitment to increase support for fulltime unpaid carers. Passing new laws requiring people to care for relatives is not the British way, but I do want to make sure we are learning from the best of what happens around the world. So I can also announce that my new Minister for Community and Social Care Alistair Burt will develop a new carers’ strategy that looks at the best of international practice and examines what more we can do to support existing carers and the new carers we will need.
The new strategy will ensure we deliver that - but it will do more. By looking at best practice from around the country and the world, it will seek to answer the big question: what do we need to do as a society to support people who are caring now, and crucially, for the millions who will have a caring role in the future? We can’t put our heads in the sand on this critical issue.
Conclusion: a new social contract
I have said before I want Britain to be the best country in the world to grow old in.
But the government - nationally or locally - can’t do this alone. Attitudes need to change too, so that it becomes as normal to talk about elderly care with your boss as about childcare. Family planning must be as much about care for older generations as planning for younger ones. A wholesale repairing of the social contract so that children see their parents giving wonderful care to grandparents – and recognise that in time that will be their responsibility too.
Responsibility for our health, responsibility for our families, responsible use of public resources. A revolution in personal responsibility to match the revolution in health and care provision that we are all determined to offer.
Thank you very much.