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Will the government stick with unpopular primary care changes in the run up to an election?
A roulette wheelWhat does the recent Labour meltdown hold for the health sector? Gordon Brown now has the record for being the least popular leader in living memory, Labour is polling its worst rates since records began and London lost Ken and got Boris. Grim times for the government.

Political climate
The recent comprehensive spending review has assured that the NHS will continue to get above inflation growth between now and 2011 and the Conservatives have pledged to match that spending if they get into power. The real problem for Labour comes if general inflation grows and erodes the value of NHS finances.

Current trends suggest that inflation, fuelled by increased oil and food prices, is on the up. In the midst of this uncertainty, the NHS is undergoing a major review, led by Lord Darzi. Darzi's review will ultimately reshape acute care and dramatically change primary care, with less reliance on hospitals. The public does not like this at all. Any reconfiguration of district hospitals is certain to lead to local protest on a grand scale.

Testing times
In the run up to an election the political will to push through unpopular changes will be hard to call. Will the government put the Darzi review on hold? In marginal constituencies throughout England the Conservatives and Liberal Democrats will pledge to "save" threatened hospitals as an election looms. Will hapless Labour MPs in these marginal seats want to defend the Darzi-inspired shift from hospitals to primary care? This is going to create a real dilemma for Labour.

If the government stops the Darzi process and retains the number and shape of hospitals, two pressures will still need to be managed. Firstly, the costs of retaining the status quo will steadily rise and stretch NHS resources to breaking point. Secondly, the quality of care in many district hospitals will deteriorate as changes in the way we train junior doctors and other professionals begin to bite. To run an all-singing, all-dancing, quality acute service, there needs to be a critical mass of clinical skills, which many local district hospitals will be hard pressed to deliver.

Government will need to balance the political unpopularity of change against the economic and quality costs of stopping NHS reform. I lay bets that as the political pressures unravel in English marginal seats, the temptation to stop the Darzi review will be probable, leaving key decisions to a future government to solve. This would be a huge, if politically understandable, mistake.

Social care
Labour has also unveiled a complete review of social care in England, particularly for the costs of residential and nursing home care for older people. In Scotland nursing home care is technically free. In England there are regular stories in the tabloid press of families having to sell their parents' home to fund the costs of nursing home care. This does not play well in Middle England. The review of care is now out for consultation and if Labour can come up with a formula that will ease the costs of nursing home care for middle class voters, they will be on to a winner. The problem will lie in funding such changes when the public finances are decidedly tight.

If current care arrangements remain unchanged, the Department for Work and Pensions predicts that benefits paid to disabled people will increase by 50 per cent within 20 years. If social care remains unchanged, public spending on personal care will rise from £12.7bn in 2007 to £24.1bn by 2026 and £40.9bn by 2041.

As the UK population grows ever older, the potential costs of care for the elderly will skyrocket. This presents a real challenge for both policy makers and taxpayers.

The key to government thinking is to harness new and emerging technologies that focus on vulnerable people, often living with long-term conditions, to keep them living independently at home for as long as possible.

Around £31m has been invested in three pilot sites in Kent, Cornwall and Newham to test this idea. The pilots will be aimed at groups of any age at risk of current and future hospital admission due to diabetes, heart failure and COPD. A good proportion of these patients will be those older people. The pilots will also target people living with complex health and social needs and living with more than one of the above conditions. These schemes will involve some 6000 patients over the next few years.

New technology
Patients will be individually assessed on their ability to use and benefit from the new technology. Some ideas on offer involve the free provision of personal alarms that can be activated by a person in trouble at home through a central call centre. Other patients will be able to self monitor a range of signs and symptoms, such as blood sugar levels, blood pressure, respiratory function, and report the data electronically to either the GP surgery or a specialist team.

The idea is to spot problems early and prevent admission to hospital. These pilots should provide fascinating evidence about the public's ability to use such tools and on how acceptable they are to patients and professionals.

All research suggests that people living with longer-term conditions and older people prefer living independently, managing their own conditions and having real choice in how their care is supported and managed.

If the pilots prove successful, they might well keep more of the greying population out of hospitals and other forms of institutional care.

In the meantime, the Prime Minister has announced that the way in which acute hospitals and other providers are paid is also set to change. The plan is that all providers will be paid only for better performance.

At the moment issues of performance are judged by a plethora of professional regulators and commissioning geeks in PCOs. The next phase of NHS reform will ensure that the experiences of patients and their opinions of their care will carry more weight Gordon Brown does not have too long to bed in these changes in health and social care and to convince the electorate that the ideas have merit. He is also dependent on the ability of PCOs to improve their game and manage change quickly and effectively. We can also be sure that Conservative health policies will be aired in the months ahead and that they will be subject to scrutiny from every angle.

The election may be another two years away, but health and social care issues are already proving to be a fierce battle ground for ideas and credibility. Health professionals and others in the sector will hate the scrutiny and the political battles that lie ahead, but that is democracy in a largely tax funded system.

Don't you just love it?

The Author
Ray Rowden
is a health policy analyst

4th June 2008

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