Richard Murray: The current funding situation

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  • Posted:Thursday 06 December 2018

At The King's Fund 2018 annual conference, Richard Murray talks about the current funding situation and what it means for health, social care and public health.


There’s a lot more to population health than the money that just gets spent on. There’s a whole series of things you can do through regulation, through taxation, through engaging with the public. However, the money still matters. Some of the money, particularly the more medicalised end is protected, Vacs and Imms screening sits within the NHS budget and isn’t facing a cut but of course the Public Health Grant is. 

It’s difficult I think to frame a strong narrative about population health and prevention if you’re simultaneously cutting one of the most visible and important elements, just before the start of the financial year while we all wait for our green paper or reform to social care. Some extra money appears just to push the service through the year and into the start of the next, never quite enough to match demand, but just enough hopefully to keep the social care system ticking over and indeed also to avoid pressures rising in the NHS. 

I think we’ve got two versions of the future. One is that the Green Paper delivers on a credible series of options on funding reform for social care. The second is that it doesn’t and we carry on slightly drip feeding the patient. That’s not the environment in which you’d really want to serious reform of social care or an easy environment really to bring it closer to the health service and integrate services. 

Spending on public health and spending on social care are dwarfed, absolutely dwarfed by spending on the NHS. So fairly small amounts of money by NHS terms are actually huge sums of money by prevention terms and really quite large sums of money by social care terms as well. 

We in The King’s Fund, along with our sister foundations have recently been saying that there’s effectively a crisis in, certainly in the healthcare workforce. There’s more to that than just training but clearly as a long-term solution to problems around staffing, training has to be absolutely key and we also don’t know about capital spending. 

We’ve got 20.5 billion real terms growth for the NHS, not quite the long-term average for health spending and I think I wouldn’t want people to take away the fact that that means a management of decline, because if you think about where the NHS was in the 1940s, there was no joint replacement, a lot of we’ve just said on Vacs and Imms didn’t exist and that is all within that growth number. At least 2 billion of that will go to mental health. At least 3.5 will go on community health services and primary care and some of it on cancer, probably on cancer waiting times. The acute sector, which would perhaps see as the area we don’t really want most of the growth to go into, if we’re really trying to reform, they are absolutely full and we’re moving into winter and so there’s a big pressure on demand. Even if we know, if you’re thinking again about the longer term, the reform agenda pushes you very strongly to investing in exactly those community health services in primary care and in prevention that may provide the solution to those long term pressures in the acute sector. 

The problem is you have to invest first and manage the demand that’s already in the system. You can’t do one without doing the other. 

I think there is a risk that we do end up with a shopping list when what we really want is a coherent and comprehensive shift towards a more population health based system that can help confront the problems that we’re going to face in the future. So something that hangs together both as a vision and as a plan that is absolutely deliverable and avoid too many extra things added in that the NHS may struggle to deliver. 

And then lastly, I’m sure most people here would, if we were to vote, would vote for better community health services, would vote for population health, would vote for better primary care. If you look at what the NHS has tried to over the last few years, the shortage of GPs is not caused by a lack of money. I really am convinced that NHS England has got the budget and it did mean to spend it on it. The problem is there aren’t any GPs, that’s the problem.

If you look at community health services, there’s been a long-term decline in key elements of the workforce in district nursing, in community nursing and the trend pipelines look pretty empty at the moment. So the other thing we’ll need from the plan to really tie into the reform is a credible answer on how you do some of this. How is it we draw on other staff groups that we have, draw on the power of the public, of patients, of volunteers and try and feel some of those short-term gaps in the workforce, because I’m afraid without that we might have a vision but we will not have a plan.