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Andy Burnham interview: Doing better for the vulnerable

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Having fetched me a cup of coffee, the shadow health secretary talks about his day, complete with domestic details: 'I travelled down from the North this morning after packing my kids' lunches, one of them was poorly, and it's been pretty hectic since I got in'.

We met in the back of the shadow health team's crowded office to discuss how Labour Party policies might affect primary care nurses (PCNs). He initially talked about their role in his well-publicised vision for an integrated system of health and social care.

'If I'm looking to the 21st century, I don't see how we can rise to the challenge unless we refocus the system … where the home not the hospital is the default setting for care,' he said.

Cambridge educated, Mr Burnham rose quickly up the political ranks after joining the Labour party as a teenager. In 2009-10 he was health minister in the last Labour government before the Coalition came to power. At this year's Labour party conference, he received no less than three standing ovations (a response usually reserved for party leaders) for a speech that lent heavily on the heritage of the NHS and his vision for an integrated system of health and social care. However, respect for the history of the NHS and his absolute belief in its core principles has not stopped him from thinking radically about how it will work in the 21st Century.

'What I am very clear about is whole-person care; bringing physical, mental and social care together, caring in somebody's own home, giving them one point of contact for all usual points of care. It's highly personalised, highly integrated.

'I want to change the way the payment system works in the NHS to support that.'

'What I want to move to is what I would call a 'year of care' budget ... for people who are identified by the council as having on-going needs.'

Reorganising services

Mr Burnham has pledged to repeal the Health and Social Care Act, and reverse the Coalition's NHS reforms. He has repeatedly said the market is not the answer to 21st Century healthcare.

In an interview with the HSJ, Mr Burnham explained how his 'year of care tariff' would work: health and wellbeing boards would become the commissioners while CCGs remain in an 'advisory capacity'.

'This reflects what I feel about the NHS,' he said, 'that people matter not profits'.

He says he does not want to do a top-down restructure of the NHS. However, many believe that is what this rethinking of services amounts to.

'I hope to reassure people that it is not. For me, the definition of a top-down reorganisation is when you dismantle organisations and then create new ones.

'I will work with the organisations I inherit from this government.'

The local health and wellbeing boards will be instrumental in his integration plan. 'They are a partnership organisation between the health service and local government. And by definition, they will help you adopt a social model of support, rather than a more narrow medical model.

'If we have a 'year of care' payment system for those people, immediately we would create an incentive for those people to be cared for in their own home, rather than in the hospital.'

He believes that the role of primary care nurses will be more valued as a result.

'Why has it traditionally been the case that community nursing has been cut, and more work is done in hospitals? That's the way the current system works. There is an incentive to draw resources into the hospital, the episodic tariff earns that money, gets drawn in and trapped there ... If an organisation is paid on a 'year of care' basis, including social care, immediately the incentive becomes to keep people at home, not treat them in an expensive hospital. The workforce would then be put in to support that model of care

'Now, I'm not saying this can be done overnight, absolutely not, but I think for the first time in a serious way the NHS would have an incentive to support staffing in [community] settings, as opposed to them being the easy or the first target for cuts, as has traditionally been the case.'

His belief in funding as a lever was behind Labour's announcement that they would raise £2.5bn through taxing the rich to fund 20,000 extra nurses. This number of nurses he says, was arrived at as a result of RCN analysis of vacancies in the workforce, projected vacancies, current recruitment and Labour analysis.

When asked how many of these nurses would work in primary care, he said: 'It has to be about staffing to deal with the future NHS, rather than putting people into "traditional" roles. Rather than saying how many go to secondary and how many go to primary care, the investment in staff will support our integrated care organisations ... which will work across a much wider footprint, from the home to the hospital, and specifically recruit people to work in a range of settings, actively managing and supporting the vulnerable and the at-risk population.'


He believes the NHS must be refocused onto prevention, not reaction, to survive the future.

'We have got to aspire to work in a different way so the people we know are the most at risk of hospitalisation are supported in a more preventative way. In terms of how it would work, if this 'year of care' tariff or budget is paid to an NHS organisation, it creates an incentive for those organisations to begin to refocus what they do, to become an integrated care organisation. So yes, if you're running a hospital you should begin operating a much more home to hospital service. That would mean changing the balance of the workforce and that's how I see things developing.

'Or it could work in partnership with a trusted GP practice that employed practice or community nurses, or with a community provider ... It's not so much exactly how you do it, it's what you are trying to achieve. And what we are trying to achieve is one team around the vulnerable person that is highly integrated and preventative.'

This could mean a very different way of working for primary care nurses, he thinks.

'I don't think people would mind working differently, I think that's the point when people like me come up with these grand plans and people think ''well it's pointless'' and they rightly question why are we having to change again, there's no benefit. This idea is about recognising services really aren't working. Look at the system at the moment, the pressure on A&E, the number of old people in hospital, that is a sign of failure. There are just too many vulnerable older people in hospitals and we must, between us, be able to do better than this for those people. That's why I hope [primary care nurses] will buy into this journey.'

Pay review

The interview took place on the day of the second strike by nurses over pay, so it seemed remiss not to ask his thoughts.

'I find Jeremy Hunt's refusal to accept the NHSPRB recommendation really perverse, I don't understand why he's doing it. Because it looks at affordability, it doesn't just look at pay in isolation in the health service, if it's affordable elsewhere [Scotland and Wales], why isn't it affordable [in England]?

'Cynics would say that if they hadn't had a £3bn reorganisation, they may have some money to pay staff decently ... The way he has handled this is pretty appalling really.'

And how would Mr Burnham, have handled it?

'I'd have accepted the recommendation of the pay review body. In the end [arm's length bodies] are a minister's best friend, because they were created so that pay wasn't politicised, and it wasn't an annual argument. The structure of the NHSPRB is designed to be fair to both sides, to look at the affordability questions which ministers obviously have to worry about, but also to look at the fairness to staff and unions, and come to a fair accomodation.

'I think what this secretary of state has done is allow the NHS to be on the brink of a very dangerous winter with morale literally shattered. He doesn't understand NHS staff, and he doesn't have a sense of how hard it is for them.'

Nurse recruitment

In light of the negative messages surrounding nursing and what looks to be an ongoing strike over pay, how would Mr Burnham encourage 16-18 year olds into the NHS.

'What I'd like to do is plan for the 20,000 by massively expanding NHS apprenticeships. There are far too few at the moment. Give kids at secondary school a clear route through to aspiring to be nurses in their early to mid-20s.'

Would he encourage his son or daughters to become a nurse?

'I definitely would, absolutely. I don't want my kids to be money orientated, I want them to know the change they can make and, as hard as it is, it is still the case that you can make a massive difference to people [as a nurse] ... Our health service is still the best in the world to work for because if you come into it you serve people, you don't serve shareholders.'

Drive to improve health

It was on children and mental health that Mr Burnham became animated.

'I think that a single budget at local level for children and their health and social and educational needs, if all the savings from early interventions are going to come back to that budget, you create conditions for early intervention. That really gets me going, that's what I'm in this thing to do something about. To change the lot of those kids. It is scandalous how kids who have mental health or health needs with relation to speech and other things don't get the support when they need it and don't come close to fulfilling their potential in life.'

It had been a Labour amendment to the Health and Social Care Act that called for mental health to have parity with physical health, he said.

'I think there has been too much talk and not enough action since everyone supposedly signed up to that notion.'

'So how could you make parity between physical and mental health a reality in primary care? It is by giving people instant access to therapy and counseling as you would to medication... I am looking at whether we can give people the rights to therapy, the rights to counseling in the NHS constitution, and that would have to be provided without a wait at local level ... I think we need to have a better response at primary care level to mental health, rather than just the default option of antidepressants or medication.'

Mr Burnham was passionate, convincing and honest. What I didn't glean from our 45 minute conversation was any of the difficult detail around the big-picture policies, but perhaps what is needed after years of cuts and efficiency savings is vision that has people's needs at its heart.

However, Labour's success in next year's general election might hang less on his dedication to the NHS and more on whether or not the leadership rumours are true. He reassured me with a smile:

'The job I want is health secretary. The NHS is ... in a dangerous position right now, and it certainly couldn't have another parliament like the one we just had: cuts, privatisation, low morale. Five more years of this and I think the NHS will be gone.

'It is a mission for me. I have this plan about bringing social care in and really remodelling a 21st century NHS. That's what Ed [Miliband] has asked me to do and that's what I'm proudly doing.' IN

Key quotes
Five year vision
'We very much supported NHS England's five-year forward view ... it echoed and endorsed a lot of what we'd been saying, so that was very pleasing. I'm open minded about how different models of care and how different organisational structures may evolve in practice.'
Primary or secondary care
'People seem to have a loyalty to primary care or a loyalty to secondary care ... we need to blur those boundaries and have a loyalty to the public or the local community as opposed to a set of bricks and mortar in a particular setting.'
Children's health
'That really gets me going, that's what I'm in this thing to do something about. To change the lot of those kids.'
Dismissal of the NHS PRB
'It was a highly provocative move and in the end a counterproductive move...To just dismantle [the NHSPRB] and discard them, it destroys goodwill, it destroys trust.'
Palliative care
'In Torbay more people spend their last days in their own homes than anywhere else in England. And that is a product of a system that really highly integrates in the home ... Day to day, it is very nurse led.'
Nurse prescribing
'I think there is scope for much to continue that whole process. Part of the future is about empowered, capable, resourceful, resilient practioners working in a range of settings, given the training and authority to do more.'
Mental health
'I am looking at whether we can give people the rights to therapy, the rights to counseling in the NHS constitution, and that would be something that has to be provided without a wait at local level.'

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