Regional BGS Meeting

1. Regional BGS Meeting West Midlands, Droitwich October 7th David Oliver NCD for Older People (England)

2. What I’m not going to do • Convince you that geriatric medicine matters • Lecture you on how to do geriatric medicine.. • Or how to run your services... • I wouldn’t presume! • (Though I do have a decent idea what’s going on in services around the place – good and bad) • Use all my time talking at you, instead of listening

3. What I would like to do • Tell you something about my current role in government and what I have been up to • Explain some bits of emerging health policy relevant to health care for older people • Opportunities (for you to make a difference locally?) • Or by engaging via BGS nationally in national policy • Threats and risks in new health and social care landscape? • Give plenty of time for interaction and questions • Make sure you know how to get hold of me in future • (David.Oliver@dh.gsi.gov.uk)

4. How I got into all this... • Postgrad. training inc various Masters etc • First consultant job at QMH 1998 to 2004 • The Reading (Royal Berks/Reading Uni 2004...) • Service development • Management/Leadership • Research/Teaching • BGS Hon Sec and other roles • Advisory roles with national bodies • Secondment to DH as specialist clinical advisor • DH Interviews July 2009/Jan 2010

5. What the job involves • Not the same as being BGS spokesman and general s**t stirrer • Geriatric medicine just one part of a much wider agenda • Civil services rules and values • (Versus politicians/advisors/secondees to DH from services) • Need to stay in the job to be influential • But I do say often and loud the kind of things you would expect me to inside government

6. What the job involves • Outward facing role... • Bridging the inward/outward.. • Will evolve as policy settles down • No appetite for old style NSFs and “command and control/targets and terror” • Form and function of services a matter for localities... • A lot of what I do (whether positive of damage limitation) will never be badged as my work or apparent outside DH

7. Health and Social Care for older people as Political Hot Potato • National government • What piques their interest • Local government services

8. Stuff I have been up to internally e.g. • Influencing all the domains of the NHS outcomes framework • Clinical expert reference groups • Same for public health and social care • Integration/alignment agenda • Work with NICE on quality standards and CQC on inspection/registration/care homes • Parts of dementia strategy • Tariff changes (e.g. Readmission) • Equality Act • Work on falls and fragility fractures • Getting frailty and multiple LTC into the thinking of government • (First cross DH Older People Board Next week)

9. Context (irrespective of government) • Success story of population ageing • How its discussed/described • (Birth rate and old age dependency ratio) • Health and wellbeing of older people • Implications of ageing for health and social care • Long term conditions • Conditions of ageing • Cognitive, sensory or function impairment • Frailty medicine • Older People are the core customers of health and social care Older People R US • Long term sustainability of systems (financially)

10. Context (irrespective of government) • Efficiency Challenge (with older people as key) • Risind demand, consumer expectation, cost of treatment, access, equity etc etc • Poor integration between agencies and inefficiencies at hand offs • Care closer to home and out of hospital • Shift to prevention/wellbeing • Shift to personalisation with societal exp

11. Kings fund 2009 the “flat funding scenario”.“From 2011-14 NHS faces productivity gap of c £21 bn. Politicians need to be honest about this” 5-7% real increase year on year 2001-11 1.6% in real terms

12. Objective evidence of poor care • Equality Act Consultation (See Oliver BMJ 2009) • Centre for Policy on Ageing Review • Human Rights Enquiry • Dignity in Care Work • Differential treatment and diagnosis • Common conditions of ageing • Conditions common to old age and mid life • “acopia” “social admission” etc for frailty syndrome (Oliver D JRSM 2008) • National Audits and NHFD • Age UK Reports

13. Institutional Ageism? • Kings fund survey showed 3 in 4 senior managers in health and social care thought parts of their services were ageist • Roberts E et al 2000 • Survey of 1000 NHS managers for NHS Sixty Not Out features (HSJ 2008) showed older people to be most disadvantaged group • Help the Aged/BGS 2009, “specialist doctors label NHS institutionally ageist” • “Hungry to be heard” survey – two thirds of nurses would not trust hospitals to attend to the nutritional needs of their elderly relatives (Age UK 2010) • Findings from Mid Staffs enquiry....

14. Objective evidence of variable care • CQC HASCOP Data • CQC user of resources in social care data • Hip fracture • Etc etc

15. What did we have pre white paper? • NSF for older people • Other strategies (e.g. Carers, end of life care) • Various relevant NICE guidelines and others (e.g. “Blue Book”) • DH resources (e..g “prevention package”, work on dignity) • Operating framework and Constitution • PBR best practice tariff for hip fracture • Equality Act • Human Rights Act (inc parliamentary enquiry) • Dementia Strat (still going forward with 4 priorities.) • Centrally funded initiatives (e.g. POPPS, Integrated Care Pilots )

16. Value of good local and national leadership and advocacy “Bottom up” • A lot of change has been driven bottom up by excellent local clinical leadership and partnership working • e.g. Nuffield Trust Report on Integrated Care • e.g. St Thomas POPPS and OPAL • e.g. Early hip fracture services • And by professional societies/voluntary sector lobbying and awareness raising • e.g. Stroke Association and RCP • E.g. BGS/BOA work on hip fracture • E.g. Dementia UK and Alzheimers Soc on Dementia

17. May 2010 All change.....

18. The Political Context The Coalition: our programme for Government (May 2010) e.g. • We will establish a commission on long-term care. • We will break down barriers between health and social care funding to incentivise preventative action. • We will extend the greater roll-out of personal budgets to give people and their carers more control and purchasing power. • We will use direct payments to carers and better community-based provision to improve access to respite care. • We will help elderly people live at home for longer through solutions such as home adaptations and community support programmes. • We will prioritise dementia research. • We are committed to an NHS that is free at the point of use and available to everyone based on need, not the ability to pay

19. Emerging Priorities social care • Agree a sustainable settlement for the care and support funding system. • Set out the vision for social care that new funding system should support, with personalisation and prevention at its heart, and supporting carers and families. • Develop a single modern statute. • Achieve greater value for money in care and support services. • Identify efficiency opportunities. • Make clear the case for prevention and re-ablement. • Developing a “whole system” approach to care.

20. Secretary of state’s vision for health and social care

22. White Paper –“Liberating the NHS” • putting patients first through more information and greater choice and control over their care – ‘no decision about me without me’ • improving healthcare outcomes by ensuring professionals are free to focus on improving health outcomes so that these are amongst the best in the world. Improving the quality of care will become the main purpose of the NHS • autonomy and accountability involving giving power back to NHS professionals and healthcare providers, giving them more autonomy and, in return, making them more accountable to patients and the public • cutting bureaucracy and improving efficiency by continuing to reinvest savings of up to £20bn in front-line services by 2014 in line with the Quality, Innovation, Productivity and Prevention (QIPP) agenda.

23. The reformed NHS • By end 2010: Separation of SHA commissioning and provider oversight functions • 2012/13: SHAs abolished • From April 2013: PCTs abolished April 2012: Monitor established as economic regulator • April 2011: Shadow Board established as special health authority • April 2012: Board fully established • Autumn 2012: Board makes allocations to GP consortia for 2013/14 • 2013/14: All NHS trusts become, or part of, foundation trusts • 2013/14: All providers regulated by Monitor April 2012: HealthWatch established • From 2011: Choice of care – long-term conditions; diagnostic testing, and post-diagnosis • From April 2011: Choice of treatment and provider – some mental health services • 2012: Free choice of GP practice • 2013/14: Choice of treatment and provider – vast majority of NHS services • April 2011: Support for shadow health and wellbeing partnerships • April 2012: Health and wellbeing boards in place • 2011/12: Established in shadow form • 2012: All consortia formally established • April 2013: Consortia hold contracts with providers

24. Charlton Ogburn Junior, MerrillsMaruaders 1957 • “We trained hard, but it seemed that every time we were beginning to form up into teams we would be reorganised. … I was to learn later in life that we tend to meet any new situation by reorganising; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.”

27. Other outcomes frameworks • For Social Care • For Public Health • With alignment....

28. Opposition/Caution..... • From within DH? • From NHS Confed and Alliance? • From BMA • From joint academy of medical colleges? • From LGA/ADASS? • From Kings Fund? • (Read HSJ...)

29. Threats and concerns • Is such radical reform required? (see Kings fund report) • Cost and opportunity cost of change • Competency and Motivation of GP commissioners? • Other PCT functions? • Lack of piloting • “Any willing provider” and potential for fragmentation • Whole systems changes in services for older people with complex needs • Role of private sector • GPs as rationers • Centralism versus localism? • (People do want “how to do it” advice and story of stroke/hip fracture etc suggest this isn’t all bad) • Local government funding not ringfenced and impact on healthcare • Retreat into organisational intersests/silos

30. Opportunities/good news • 1. Older people with complex needs account for a great deal of activity spend and variation across all sectors • 2. Surely, we need to look closely at the pathways especially with efficiency challenge?... • 3. A number of binding outcomes lacking before in health, public health and social • 4. Potential alignment of outcomes • 5. Strengthened role for NICE guidelines and quality standards

31. Opportunities/good news • 6. CQC priorities and strengthened roles • 7. More opportunity for locally creative and tailored solutions • 8. Dementia strategy/carers strategy going forward • 9. Politicians interested • 10. Social care and public health reviews and outcomes • 11. Whole agenda of more joined up care, care closer to home, more preventative care etc • 12. Tariff changes round reablement, discharge and readmissions

32. How I think BGS can engage • Vigorous lobbying and awareness raising – more media presence • Making alliances round common interests: e.g. Age UK, BOA, Alzheimer’s, NCPC, ADASS, RCN • Continuing work on good practice guides • Getting experts on guideline groups • Responding to and influencing consultations and working groups • Can help me out by reinforcing points I make inside government from outside and providing experts/expertise

33. How I think BGS can engage • Crucial role in supporting local clinical leaders with resources, information, coaching, external endorsement • Need to engage with whole care for older people agenda and not focus excessively on geriatric medicine, doctors and hospitals • Need to engage positively with new initiatives that have some positive opportunities for older people instead of kneejerk hostility/scepticism seen on some occasions

34. How I think you can engage and influence locally • Need one or two consultants to look beyond own service to wider agenda inside and outside trust • Get on board the commissioning whole systems for older people train as early as possible • Engage with all the local partners • Offer geriatrics and our expertise as a posotive solution to system problems • Highlight activity/performance/audit/governance data showing that older people are where its at and that their care is key to whole systems • Be more pushy/persistent and bloody minded than we sometime are “geriatrics guerillas”

35. How I can help you.. • I am a geriatrician first and foremost and will be doing that long after I stop working in the Civil Service • I do pass concerns and comments on if I haven’t spotted or raised them before • I think its bad manners not to try and answer all emails and I do respond • If I don’t know the answer to your question or I can’t help I will tell you straight • But I often know people who do and can put you in touch. • David.Oliver@dh.gsi.gov.uk

37. Co-alition pledges relevant to older people • Commission on long term care • Reablement on leaving hospital • Reducing hospital readmissions • Improving discharge from hospital • Enabling community access to care and treatments • Help elderly people live at home for longer through solutions such as home adaptations and community support programmes • Put patients in charge of decisions about their care • Greater involvement of independent and voluntary providers • Break down barriers between health and social care funding to incentivise preventative action • Extend roll out of personal budgets • Improve access to respite care • Ensure greater access to talking therapies • Per patient funding for palliative care

38. Coalition our programme NHS • The Government believes that the NHS is an important expression of our national values. We are committed to an NHS that is free at the point of use and available to everyone based on need, not the ability to pay. We want to free NHS staff from political micromanagement, increase democratic participation in the NHS and make the NHS more accountable to the patients that it serves. That way we will drive up standards, support professional responsibility, deliver better value for money and create a healthier nation. • We will guarantee that health spending increases in real terms in each year of the Parliament, while recognising the impact this decision will have on other departments. • We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care. • We will significantly cut the number of health quangos. • We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line. • We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services.

39. Coalition Programme (NHS) • We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf. • We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise. • The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations. • If a local authority has concerns about a significant proposed closure of local services, for example an A&E department, it will have the right to challenge health organisations, and refer the case to the Independent Reconfiguration We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf. • We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise. • The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations. • If a local authority has concerns about a significant proposed closure of local services, for example an A&E department, it will have the right to challenge health organisations, and refer the case to the Independent Reconfiguration • Panel. The Panel would then provide advice to the Secretary of State for Health. • We will give every patient the right to choose to register with the GP they want, without being restricted by where they live. • We will develop a 24/7 urgent care service in every area of England, including GP out-of-hours services, and ensure every patient can access a local GP. We will make care more accessible by introducing a single number for every kind of urgent care and by using technology to help people communicate with their doctors. • We will renegotiate the GP contract and incentivise ways of improving access to primary care in disadvantaged areas. • We will make the NHS work better by extending best practice on improving discharge from hospital, maximising the number of day care operations, reducing delays prior to operations, and where possible enabling community access to care and treatments. • We will help elderly people live at home for longer through solutions such as home adaptations and community support programmes. • We will prioritise dementia research within the health research • We will prioritise dementia research within the health research and development budget. • We will seek to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests. • Doctors and nurses need to be able to use their professional judgement about what is right for patients and we will support this by giving front-line staff more control of their working environment. • We will strengthen the role of the Care Quality Commission so it becomes an effective quality inspectorate. We will develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS. • We will establish an independent NHS board to allocate resources and provide commissioning guidelines. • We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong. • We will measure our success on the health results that really matter – such as improving cancer and stroke survival rates or reducing hospital infections. • We will publish detailed data about the performance of healthcare providers online, so everyone will know who is providing a good service and who is falling behind. • We will put patients in charge of making decisions about their care, including control of their health records. • We will create a Cancer Drugs Fund to enable patients to access the cancer drugs their doctors think will help them, paid for using money saved by the NHS through our pledge to stop the rise in Employer National Insurance contributions from April 2011. • We will reform NICE and move to a system of value-based pricing, so that all patients can access the drugs and treatments their doctors think they need. • We will introduce a new dentistry contract that will focus on achieving good dental health and increasing access to NHS dentistry, with an additional focus on the oral health of schoolchildren. • We will provide £10 million a year beyond 2011 from within the budget of the Department of Health to support children’s hospices in their vital work. And so that proper support for the most sick children and adults can continue in the setting of their choice, we will introduce a new per-patient funding system for all hospices and providers of palliative care. • We will encourage NHS organisations to work better with their local police forces to clamp down on anyone who is aggressive and abusive to staff. • We are committed to the continuous improvement of the quality of services to patients, and to achieving this through much greater involvement of independent and voluntary providers. • We will give every patient the right to choose to register with the GP they want, without being restricted by where they live. • We will develop a 24/7 urgent care service in every area of England, including GP out-of-hours services, and ensure every patient can access a local GP. We will make care more accessible by introducing a single number for every kind of urgent care and by using technology to help people communicate with their doctors. • We will renegotiate the GP contract and incentivise ways of improving access to primary care in disadvantaged areas. • We will make the NHS work better by extending best practice on improving discharge from hospital, maximising the number of day care operations, reducing delays prior to operations, and where possible enabling community access to care and treatments. • We will help elderly people live at home for longer through solutions such as home adaptations and community support programmes. • We will prioritise dementia research within the health research • We will prioritise dementia research within the health research and development budget. • We will seek to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests. • Doctors and nurses need to be able to use their professional judgement about what is right for patients and we will support this by giving front-line staff more control of their working environment. • We will strengthen the role of the Care Quality Commission so it becomes an effective quality inspectorate. We will develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS. • We will establish an independent NHS board to allocate resources and provide commissioning guidelines. • We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong. • We will measure our success on the health results that really matter – such as improving cancer and stroke survival rates or reducing hospital infections. • We will publish detailed data about the performance of healthcare providers online, so everyone will know who is providing a good service and who is falling behind. • We will put patients in charge of making decisions about their care, including control of their health records. • We will create a Cancer Drugs Fund to enable patients to access the cancer drugs their doctors think will help them, paid for using money saved by the NHS through our pledge to stop the rise in Employer National Insurance contributions from April 2011. • We will reform NICE and move to a system of value-based pricing, so that all patients can access the drugs and treatments their doctors think they need. • We will introduce a new dentistry contract that will focus on achieving good dental health and increasing access to NHS dentistry, with an additional focus on the oral health of schoolchildren. • We will provide £10 million a year beyond 2011 from within the budget of the Department of Health to support children’s hospices in their vital work. And so that proper support for the most sick children and adults can continue in the setting of their choice, we will introduce a new per-patient funding system for all hospices and providers of palliative care. • We will encourage NHS organisations to work better with their local police forces to clamp down on anyone who is aggressive and abusive to staff. • We are committed to the continuous improvement of the quality of services to patients, and to achieving this through much greater involvement of independent and voluntary providers.

40. Coalition pledges: Social Care and disability • The Government believes that people needing care deserve to be treated with dignity and respect. We understand the urgency of reforming the system of social care to provide much more control to individuals and their carers, and to ease the cost burden that they and their families face. • We will establish a commission on long-term care, to report within a year. The commission will consider a range of ideas, including both a voluntary insurance scheme to protect the assets of those who go into residential care, and a partnership scheme as proposed by Derek Wanless. • We will break down barriers between health and social care funding to incentivise preventative action. • We will extend the greater roll-out of personal budgets to give people and their carers more control and purchasing power. • We will use direct payments to carers and better community-based provision to improve access to respite care.