The King’s Fund has identified three big challenges for the NHS in England:
- sustaining existing services and standards of care
- developing new and better models of care
- tackling these challenges by reforming the NHS ‘from within’
How can we address these challenges? Drawing on our work and a lecture given by Chris Ham to the Cambridge Whitehall Group in December, we offer some practical solutions to help the NHS address one of the biggest crises in its history. They represent the essential actions needed to ensure that the service can be both sustained and transformed.
Sustaining existing services and standards of care
What is the challenge?
The NHS faces unprecedented financial and operational challenges as a result of a rising demand for services and constrained resources. NHS providers recorded a record deficit in 2015/16, general practice is in crisis and mental health and community services are under huge pressure. Performance is suffering, with targets for waiting times being missed.
These challenges are amplified by cuts to social care and public health and by the requirement for the NHS to deliver £22 billion of productivity improvements by 2020/21.
What should be done?
Focusing on better value offers many opportunities to improve productivity. In individual organisations, better outcomes can be delivered while minimising costs by engaging clinical teams in reducing variations and changing the way care is delivered. The main focus should be on improving clinical practice, building on past experience in areas such as generic prescribing, day surgery, and reduced lengths of stay in hospitals, as well as acting on the themes identified in the Carter review.
Locally, organisations should work together in place-based systems of care to decide how to use the resources available and to break down barriers between services. Opportunities for delivering better value include providing integrated care for older people, children and people with long-term conditions and supporting people to die in the place of their choice, with health and social care budgets being pooled to deliver truly integrated care.
To address the crisis in general practice, additional investment is needed, accompanied by new ways of working. There is also an immediate need to ensure that workforce numbers across the NHS are sufficient to meet demand. In 2015 we identified shortages of mental health inpatient nurses, GPs and community nurses, and we are also aware of vacancies in a number of consultant specialties. Urgent action is needed to tackle these shortages and to make the NHS an attractive career choice.
In the long term, as the Barker Commission set out, we should move to an integrated system for health and social care with a single local commissioner of services. The aim should be to bring public spending on health and social care up to 11–12 per cent of GDP by 2025. The Commission argued that this was both affordable and sustainable if hard choices are made about how to find the additional resources.
In more detail
- See our quarterly monitoring reports for the latest NHS performance data, and read Mental health under pressure for details of the current pressures within mental health.
- The NHS productivity challenge: experience from the front line describes how six trusts have been grappling with the productivity challenge.
- Better value in the NHS: the role of changes in clinical practice shows there are significant opportunities for the NHS to get better value from its budget through changes in clinical practice.
- Variations in health care: the good, the bad and the inexplicable explores the widespread variations in care.
- Place-based systems of care: a way forward for the NHS in England looks at how the NHS can work together in place-based systems of care to address the challenges they collectively face.
- Understanding pressures in general practice assesses the patient factors, system factors and supply-side issues driving the current pressures in the service.
- Crossing professional boundaries: a toolkit for collaborative working sets out how to enable collaboration between finance and clinical staff.
- The Spending Review – what does it mean for health and social care? Our briefing, developed jointly with Nuffield Trust and the Health Foundation, gives our view on the impact of the 2015 Spending Review on NHS and social care services.
- In Spending on health and social care over the next 50 years: why think long term? John Appleby analyses the factors that influence demand for health and social care.
- The final report from the Commission on the Future of Health and Social Care in England discusses the need for a new settlement for health and social care and Options for integrated commissioning: beyond Barker explores options for making a single local commissioner for health and social care a reality.
What is the challenge?
The ageing population, changing patterns of disease – with more people living with multiple long-term conditions – and rising public and patient expectations mean that fundamental changes are required to the way in which care is delivered (see Transforming the delivery of health and social care: the case for fundamental change).
What should be done?
Realising this transformation will require a radical shift to involve individuals more fully in their own health and care. This will include making shared decision-making a reality, giving people the support and information they need for effective self-management, involving families and carers, giving people personal budgets where appropriate, and engaging people in keeping healthy. The evidence is clear: most people want to be more involved, and when they are, decisions are better, health and health outcomes improve, and resources are allocated more efficiently.
Much greater priority should also be given to public health and prevention. Because of the complex range of influences on population health, this will require collaboration between the NHS, local government, the third sector, employers and others. It will also require action by government, as exemplified by the proposed levy on the soft drinks industry to help tackle childhood obesity. We have outlined opportunities for local authorities to use their powers to improve the health of their populations as part of a broader move towards population health systems.
The implementation of new care models should build on those outlined in the NHS five year forward view. Closer clinical and service integration is needed between hospitals, community services and general practices, health and social care, and physical and mental health. Our work has described examples of specialists working more closely with primary care teams and of general practices collaborating in federations and networks to show how new care models can contribute.
We need a workforce that is fit for purpose, able to adapt to changing demographics and aligned to the new care models outlined in the Forward View. To address this, a national workforce strategy is needed to attract, train, retain and develop the talent it requires to succeed in the long term. This strategy should include consideration of remuneration, training, culture and career development.
We also need to embrace innovations in digital and other technologies, for example, implementing an electronic care record to facilitate access to information about patients wherever they seek care.
In more detail
- Specialists in out-of-hospital settings: findings from six case studies explores the potential for hospital consultants to take on new roles in the community.
- Commissioning and funding general practice: making the case for family care networks describes how federations and networks of practices can deliver extended services and raise standards of care.
- Acute hospitals and integrated care: from hospitals to health systems explores a fundamentally different role for acute hospitals, working collaboratively with local partners to build integrated models of care.
- Bringing together physical and mental health: a new frontier for integrated care makes the case for supporting people’s physical and mental health needs in a more integrated way.
- Making our health and care systems fit for an ageing population sets out a framework to help local leaders improve services for older people.
- Population health systems: going beyond integrated care argues for joining up the dots between those involved in integrated care and public health.
- Improving the public’s health: a resource for local authorities brings together evidence-based interventions about ‘what works’ in improving public health and reducing health inequalities.
- Workforce planning in the NHS highlights the need for a more joined-up approach to ensure sufficient capacity and skill mix to support future care models.
- The future is now looks at existing examples of innovative care and The digital revolution: eight technologies that will change health and care examines the technology most likely to change health and care in the coming years.
- People in control of their own health and care: the state of involvement sets out eight priorities for transforming an individual’s involvement in their own health and care.
Reforming the NHS 'from within'
What is the challenge?
Successive governments have sought to reform the NHS through a combination of targets and performance management, inspection and regulation, and competition and choice. Much more emphasis is now needed on strengthening leadership and capabilities for improvement.
What should be done?
A much higher priority must be given to valuing and developing leadership at a time when NHS leaders say they are under huge pressure and there are difficulties in filling senior leadership vacancies. Leadership is important at all levels of the NHS, from ‘the ward to the board’, to sustain services and transform care. Attention must be paid to leadership styles and organisational cultures to ensure that staff are valued and supported to provide the best possible care within available resources.
Adopting a quality improvement strategy is essential if the NHS is to deliver better value through changes in clinical practice in the way described above. Priorities should include every NHS organisation making a board-level commitment to quality improvement, working with partners to share learning in improvement collaboratives, and training clinicians and managers in quality improvement skills.
To make a reality of reform from within, national bodies should change the way they work with NHS organisations, adopting a more proportionate approach to regulation and inspection, offering practical support to organisations in difficulty, and creating an environment in which innovation is encouraged and rewarded. The cycle of fear that exists in many parts of the NHS needs to be tackled as a matter of urgency. There should be zero tolerance on bullying and a recognition that improvements in care take place in environments that support leaders and staff to perform to the best of their abilities.
In more detail
- Reforming the NHS from within: beyond hierarchy, inspection and markets argues that the NHS should rely less on external stimuli and more on change within its own organisations.
- Improving quality in the English NHS: a strategy for action makes a practical case for developing a single quality improvement strategy across the NHS.
- The chief executive's tale draws on the views and experiences of 12 departed or departing chief executives, illustrating the realities of leadership in today’s NHS.
- Watch Don Berwick speak at our breakfast event on quality improvement in the NHS.
- Developing collective leadership for health care outlines the process for developing a collective leadership strategy.
- Medical engagement: a journey not an event describes what good medical engagement is and how, in four NHS trusts, it has been created and sustained.
- Leadership vacancies in the NHS: what can be done about them? details the level of vacancies and their impact and identifies some of the underlying causes.
- Intentional whole health system redesign: Southcentral Foundation’s ‘Nuka’ system of care analyses the factors behind Southcentral’s achievements and draws lessons for the NHS.
- The quest for integrated health and social care: a case study in Canterbury, New Zealand looks at the drivers for change, leadership values and lessons that can be learned from this case study.
As well as addressing these three challenges, the NHS and social care will need additional funding towards the latter end of this parliament (and possibly sooner). While there are many opportunities to provide better value and release resources through the approaches we have described, we do not believe this can be achieved at the pace or on the scale needed to deliver £22 billion in productivity improvements by 2020/21. The Spending Review settlement provides for very low increases in NHS budgets in 2018/19 and 2019/20, which are simply not enough to balance the books and meet rising demand from patients. The impact of the Spending Review on social care is uncertain, but overall will not be enough to close the funding gap, which we estimate will be between £2.8 and £3.5 billion by the end of the parliament.
The short-term fixes currently being deployed to address funding shortfalls (such as transferring resources from capital to revenue) are storing up problems for the future and cannot substitute for an honest debate about how to find the resources needed to sustain health and social care. Without this debate, the crisis in funding and performance could become much worse, with serious adverse consequences for patients and their care.