Philip Blond - 10th Anniversary Event - 20 June 2018 - Care after Cure

“We’re in a time of enormous flux,” Phillip Blond told Care Conversation delegates. “And in these times what really works is big ideas. You need them to be at a scale that will attract political attention and support.  If you can get political buy-in at that level then you can backfill the rest.”

Blond had been the first person to argue for health devolution to Manchester, he told the seminar. “ At the time policy specialists in Manchester said, ‘they’ll never give us devolved health,  I said that in public policy, big ideas work.”

The ongoing crises around health funding and how healthcare was conducted meant now was a very opportune time, he explained, with multiple shifting parameters. Everything was “on the move” and the bringing together of health and social care was “at least a topic of conversation”. No one, however, knew what model was going to be adopted. The Conservative election manifesto had been right to set out that “this has to be funded, but from somewhere”, and one option was from the “enormous capital gain” of people living in the South East of England.

“I would call the current age the age of insecurity,” he said. “Right across Europe, insecurity is the dominant factor. There’s economic and cultural fear, with people concerned about the fate of their children and their parents,” and the NHS was almost the “last great product of communitarianism”. Populists, whether the Front National in France or the Five Star Movement in Italy, were all essentially arguing for the recovery of the state, and “in terms of health anxiety we’re not dissimilar – the role of the state as the dominant provider is where we are.” People wanted some level of state underwriting or state credibility in their healthcare systems, he pointed out, so the question was whether that was the national or local state.  

There was now widespread recognition that the current health system is in crisis at multiple points, he stressed. “It’s a C19th acute model that’s not fit for purpose for our modern situation of endemic chronic disease.” It was, however, very difficult to move from a system that privileged the acute to one that intervened early in the chronic. “Acute systems can’t make people exercise or change their diet. We’re amputating the legs of diabetics because we failed to intervene with the lifestyle changes that would have prevented such extreme solutions.”

What was needed was a process of decommissioning the acute towards something that captured the wider determinants of health, he stated – “having a job, having friends, being happy, not being alone. How do we re-build or capture those? What we can do is we can lessen health inequalities – the gap of long-term ill health for people from disadvantaged backgrounds.” Closing that gap would significantly reduce demand on the system and therefore costs, he said.

“I can’t envisage a privatised system that can capture those wider determinants. It can only be a state enterprise, and really only the local state. Devolution to the right level of local authority is the only pathway to tackling the wider determinants of health.” The pathway of most health devolution post-Manchester had been “pretty poor”, however, with a failure to move forward at scale. “Budgets, risks, central mechanisms all have to be pooled and this creates enormous resistance from the already established players.”

The local state was inevitably the future of optimal healthcare systems, he argued – local authorities were the most popular and efficient form of the state as well as the easiest point of access for new technology. “The state can be an entrepreneur, but not at a national level.” Most crucially, however, issues like obesity were not something a centralised NHS could deliver on. “People won’t go out walking if they’re afraid of crime or if there’s nowhere nice to walk. Around 70 per cent of privately rented housing is inadequate in terms of heating – so if the GP of an asthmatic child could refer that dwelling to the local council for enforcement, that’s surely the type of model we want.”

Similarly, not having a job and status was one of the great killers of white working class males, he said. “They’re now the least well performing group in society – the NHS can’t tackle that, but recreating things like economic pathways and apprenticeships can. Creating that kind of local state would be the most crucial epistemological shift we could have, and it’s the only model we should be talking about.”

Getting to that from where we were now was the question, however. It would need entirely new indicators, and there was the key issue of whether outcomes would be measured in terms of costs or health. “Local authorities – unlike the NHS – can’t run up deficits. If we’re really going to have one-system, shared-pool commissioning then we need a provider that has a much more accurate picture of its costs.” This could involve securing five-to-ten-year framework agreements for the externalities it could not control, he explained.

When it came to the question of moving at scale from a voluntary model in which everyone has to stay within a “soft consensus” to a local state model it was “not likely at all”, however. “Two or three authorities probably would, with a ‘long tail’ of others. Are we going to let the health systems that result from the local state run up a deficit? It’s very difficult to see us going to that option from where we are.”

In which case what may well happen would be the NHS integrating as best it could, but without embracing those wider determinants of health. “Absent a radical political vision, that’s the most likely scenario. But that won’t give us a C21^st health system.”