Healthcare – June 25th 2009

My Lords, it is a privilege to share this debate with my noble friend Lord Walton. I begin my contribution to the debate on the future of the NHS by addressing my remarks to the opportunities presented by social enterprise for the future of health and, in particular, primary care.

In recent months, many of us have listened with growing concern to the unfolding story of Baby Peter in Haringey—one of the tragedies that point to the lack of joined-up working between health and social care services and to an insufficient focus on people. Despite years of talk about joined-up working and putting people first, this is still very patchy in practice. While we have moved some way down the road to co-locating services in primary care buildings and to recognising the role of social entrepreneurs in health, we still have a way to go in making greater use of community and integrated approaches to health and in using the talents and ingenuity of local people.

I was interested to hear my noble friend Lord Laming, in a Radio 4 interview, describing how difficult it was for Ministers to get the words about joining up health and social care off the pages of glossy reports and into reality on the streets of our towns and cities before yet another crisis erupts on to our television screens. I suggest that putting people before structures is the only practical way of joining up services and implementing a truly integrated approach to primary healthcare in this country. We need to use the innovative skills of social entrepreneurs and organisations that have a proven track record and to back such people by giving them the resources and freedoms that they need to transform the health and well-being of the communities that they serve.

Many of these people are doctors—I have worked with some of them. Many others are individuals working in third sector organisations and leading teams of dedicated people committed to improving health and social care services in their local communities. These people seldom appear on the NHS radar and, even when they do, are rarely valued for the contribution that they make. The tragedy is that despite the years of commitment to new commissioning structures—third sector compacts, social enterprise initiatives and the like—there is still little widespread procurement of local holistic services from social enterprises or the third sector. The true meaning of “third sector procurement” seems to be in the name itself. Successful third sector organisations and social enterprises often feel that they are the third choice—that the bits that the public sector might not want to deliver get passed down the line. Second in line is the private commercial sector and, finally, at the end of the queue, we have the third sector patiently waiting its turn for the crumbs from the table.

The poor souls in the third sector are no third-rate choice. The third sector is like any other sector—better in some places than others. Our approach to procuring health and social care services is ignoring some of the most talented and innovative individuals and organisations—people who have been working tirelessly in their communities for far longer than the perennially reconstituted PCTs and health authorities.

This is my experience over 25 years in Bromley-by-Bow in east London. Over the years, rhetoric around the holistic integrated model has never been matched by an integrated commissioning structure that delivers a Bromley-by-Bow-style approach to public service delivery, community regeneration and social enterprise.

I am afraid that I see little room for optimism in the latest polyclinic initiatives. The noble Lord, Lord Darzi, and his team have produced a programme for primary care that will produce wonderful new buildings and a new level of integration that has never been seen before. However, I have a profound problem with the scheme. At its heart it is still a biomedical model of healthcare that focuses on delivering clinical interventions for patients. Important as this is, it is only one dimension of a multidimensional problem. We are building not polyclinics but monoclinics.

I am sure that the Department of Health recognises the multicausal nature of chronic ill health in our communities. However, after all these years of rhetoric, we still seem unable in this country to create commissioning structures that cut across the departmental silos of government and focus on the customer. Why should that be? In my view, there is a problem at the core of our understanding of integration. Many in the public sector still think that this is about only traditional bits of the public services working more closely together.

We need holistic approaches to public service delivery that use social enterprises to deliver better services and better value for money across a range of measures. Where better to start this approach than in primary care? These solutions are particularly relevant today when the financing of the medical intervention model has been put under severe strain as a result of the financial crisis. However, I fear that despite the rhetoric the Government—and perhaps a future Government—still do not understand how practically to use entrepreneurs in the delivery of health services. I know that it works because in the past few years I have had the privilege of seeing and working with such entrepreneurial health organisations across the country. These organisations put people first because they understand and are part of their communities. They bring together health and social programmes. They are trusted, not because they engage in elaborate consultations but because they have a track record of delivering services that local people need.

There is of course no shortage of action by the Government. A multiplicity of programmes for the provision of integrated health services by the public, private and social enterprise sectors has been initiated. My concern as I travel across the country is that these initiatives, while well intentioned, by and large do not rely on the ingenuity and talent of entrepreneurs and local people but continue to use the old bureaucratic and paper-based mechanisms. Bureaucracies like talking to bureaucracies and doing many of the same old things that they have always done. We are putting old men in new clothes. The rhetoric has changed but in practice it is still difficult for social enterprises to win APMS contracts to run GP surgeries, despite that being possibly the best way to spread entrepreneurial talent in the health sector, as my friend Dr Michael Dixon of the NHS Alliance has suggested.

As I have listened to debates in your Lordships’ House in recent months, Ministers, including the noble Lord, Lord Mandelson, have highlighted in public conferences the virtues of social enterprise. Yet in the health sector basic conversations are still not taking place. I have spent the past five months since the publication of our report on social enterprise and health—here I must declare an interest—attempting to bring Ministers to the same table as colleagues from NHS LIFT and the Big Lottery Fund in order to bring new joined-up investments to support an integrated approach to health.

What the Government have done to date is commendable, but the NHS now needs to change its paradigm from the expensive clinical model to one based on networks and more modest-scale and sustainable initiatives that can be private, public or social enterprise—it does not matter. What matters is that entrepreneurial leadership and organisational culture put people, not systems, first.

If this Government—or a future Government—are serious about the future of the NHS and about social enterprise and community cohesion, I humbly suggest that a first step might be to do the following. First, they should ensure that their programmes are led by individuals with a strong track record of enterprise and appropriate risk-taking, as well as delivering innovation in mid-sized organisations. These should be people who understand the challenges of growth businesses; this is a job not for academic civil servants but for social entrepreneurs. Secondly, the Government must stop being fixated on new health initiatives and focus on making sure that the basic framework is in place to support communities in the delivery of their health services. Thirdly, they should move from a generalised support for social entrepreneurs to an informed support, which understands in detail how an entrepreneurial approach helps to deliver efficient services in the health sector. As always, the devil is in the practical details. Fourthly, they must start to assess health interventions not through reports and targets but through a focus on the health of patients and their care. Too often you get what you inspect and not what you expect. Fifthly, we need to ensure that all procurement opportunities by the Government are open to social enterprises and that procurement is not biased against small organisations. This applies very clearly to the procurement for GP surgeries under the APMS arrangement. Finally, we need to ensure that different interventions by the Government and actors talk to each other. This is not happening at a very basic level across the country. This is the road to enterprising healthcare and social cohesion.