1. The crisis in our health and social care systems, and what needs to happen to align the UK system with the needs of its citizens Ian R. Smith Chairman Four Seasons Health Care November 12, 2015

2.  The NHS is (at least) 4 things: free at the point of need (protects the most vulnerable); the beneficiary of wonderful advances in bio-medical science; dedicated clinicians; ….  ….and a bureaucratic system (who gets cared for, where, when, and by whom) that is profoundly broken.  The NHS system fitted the need perfectly in 1948….  …. But the need has changed dramatically in the last 67 years: the system has not.  The system is seriously broken. Executive Summary (1): The NHS system is stuck in 1948

3. Government policies are creating a deep crisis: the Vicious Spiral Shocking reductions in spending on social care Deteriorating health and social care outcomes Creates a huge crisis in the NHS (GPs and A&E) At a time of rising need and cost Funding sucked from social care to solve the NHS crisis 30% reduction in number of elderly receiving social care in the last 5 years 5% real reduction in care home fee rates in the last 3 years

4.  “Patients are dying due to overcrowding in accident and emergency units as hospitals are forced to close their doors and turn away ambulances.” The Times, July 2015.  “65% of people admitted to hospital are over 65 years old, and an increasing number are frail or have a diagnosis of dementia”. Royal College of Physicians, 2012.  The number of older people with care needs will rise by more than 60 per cent in the next 20 years.  From 2012 to 2032 the populations of 65 to 84 year olds and the over-85s will increase by 39 and 106 per cent respectively.  Already 850,000 people in the United Kingdom are living with dementia. By 2025, the number is expected to rise to 1.14 million.  There is a predicted funding gap of more than £30 billion for the NHS between 2014 and 2021 (22%). This assumes that the health budget will remain protected in real terms. System at breaking point, and the stresses are growing

5. Mortality from non-communicable diseases, 2012 (National Research Council and Institute of Medicine) The Commonwealth Fund ranks 9 criteria. On health outcomes, the UK ranks 10 th out of 11 (2014).

6. Economies of scale and scope: Health Centres ‘Integrated Care Organisations’ for out-of-hospital care A system aligned with modern health and social care needs ‘Academic Health and Science Centres’: consolidate clinical units and advance bio-medical science Personalised Medicine/Care Health and social care. Acute and chronic. Specialist and generalist. Primary and secondary. Episodic and preventive. Mental and physical. Consolidation of clinical units (e.g. London Stroke). Put the marvellous advance in genetic medicine to the service of the individual citizen.

7. Eight imperatives to achieve integrated care  Merge health and social care right now: from scale-efficient health economies down to ministerial level.  Merge the ‘entitlement systems’.  Introduce scale-efficient expert commissioning that wraps money around the individual (‘Better Care Fund’ is not the answer).  Support care packages to solve the present danger created by frail older people being in acute beds inappropriately – and, over time, build an intermediate care sector (disband ‘system resilience groups’).  Accelerate the introduction of personal budgets.  Create one regulator for the system and one for skills/competencies and regulate for cycles of care.  Mandate minimum fee rates for nursing homes and domiciliary care (regulate for return on investment as well as quality).  Support (from HEE) for a new intermediate nursing qualification in the community (similar to the former SEN position).

8. The Virtuous Circle driving integrated care, clinical excellence and scientific progress Health and social care market produces better outcomes High quality information drives providers to produce the best patient outcomes…. ….which allows patients/citizens to choose to use the best providers…. ….expert commissioners manage an orderly market…. ….innovation produces better outcomes for patients at lowest cost to taxpayers…. …. money follows the patient and services reconfigure around need…. 5 4 3 2 1 A skilled and adequately-sized workforce Purposeful leadership and supported management Productive and supportive regulation Funding that is appropriate to a modern nation Politicians communicate a compelling narrative 1 2 3 4 5