Ruth Robertson: How are financial pressures affecting patient care?

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Part of The impact of NHS financial pressures on patient care

Ruth Robertson, Fellow in Policy at The King's Fund, shares findings from our report, Understanding NHS financial pressures: how are they affecting patient care?

This presentation was recorded at our breakfast event, How are financial pressures affecting patient care?, on 14 March 2017.

Transcript

Thanks Chris. So as Chris said I’m going to give you a bit of a whistle stop tour through the findings of our report that we published today and I think there are copies of our summary that you can pick up and take away with you, but if we spark your interest a little more I do encourage you to go onto our website and have a look at the 430 page report because there’s so much analysis and data in there that I won’t even be able to touch on in my ten minutes today.

As you can probably tell from the title, we’ve been trying to get underneath the top line financial figures and understand what impact NHS financial pressures are having on patient care and before I go into the findings, I just wanted to make a couple of points of context, and I think in this audience, everybody will be very aware of the scale of the financial challenge currently facing the health service. You can see from these figures that average annual growth in spending on health over the last parliament was much lower than the growth rates we’ve seen in the past.  We all know that demand for healthcare is increasing at a faster rate than spending, that gap is widening and that’s why the health service has been posting deficits in recent years. 

But when we went in this work, looking at NHS financial pressures, we were very aware that funding is just one of many factors that affect quality and access of patient care.

On this slide you can see some of those and I could just pick out workforce as an example; over the past year or so I’ve spoken to many chief executives from trusts, finance directors who tell me that in their area, even if they were given extra money, they actually wouldn’t be able to find the staff to spend it on, so there are many other factors affecting patient care which are often independent to the funding challenge and we very much went into this work with that in mind.

So, to move on to our research, we started out with this very broad question of how financial pressures are affecting patient care? We obviously had to narrow it down a bit.  We’re interested in whether those pressures were having different impacts in different parts of the system.  So we selected four service areas to look at in depth and we tried to select four areas that really reflect a variety of types of care being provided, they’re commissioned by different organisations, they’re funded via different contracting routes and they’re also delivered by a range of different providers. 

In each of these four areas we reviewed literature, we looked at national data when it was available and sometimes it really wasn’t available, and then we also conducted a series of interviews. So we spoke to national stakeholders, patient representative organisations. We also spoke at a local level to people who are commissioning services, service managers and clinicians who are delivering care, about 100 interviews in all.

So, what I’m going to do now is just tell you a few lines on what we found in each service area. So, again I really do encourage you, if you want more detail, to look at our report and I’ll start at the top of the scale in terms of acuity and perhaps the bottom of the scale in terms of the age of patients who are involved and the first area we looked at is neonatal services, and that’s our example of an NHS England commissioned specialised service. 

In this area, actually, there’s a lot of data available on quality. There’s a lot of audit data, and we’ve seen over the past few years that on a number of indicators the quality of neonatal services is actually improving. There is variation between units but overall quality seems to be going up.   We did find a number of longstanding pressures in this service area, so for example there are staffing shortages which means some units are struggling to meet the recommended staffing ratios.  There are also longstanding issue with occupancy rates, high occupancy rates, which means sometimes babies have to be transferred for non-clinical reason and further away from their families, but these were very much longstanding issues.  We didn’t find that financial pressure on this service had increased in recent years, or that the recent financial pressures were having an effect on patient care.

So if I move one step down the acuity scale, the next service area we looked at was elective hip replacements, and this is our example of a high throughput CCG funded acute service which is funded by tariff so the money goes up as activity does. And here, actually, when you look over the past few years, there’s quite a positive story. The number of hip operations conducted in the NHS over the past six years has gone up by around 11% and waiting times, for the average patient, have remained broadly stable at around eleven weeks, but when we look at more recent data and for more recent data we have to broaden from looking at just hips to looking at trauma and orthopaedics that hips falls within, we see that actually waiting times are starting to creep up.  So, in October 2016 the average patient was waiting a week longer for their trauma and orthopaedic appointment and we also see more patients experiencing longer waits so a 45% increase in the number of patients waiting longer than 18 weeks over that year period.

Now we move out into the community. The third area we looked at was district nursing services.  This is our example of a CCG funded service that’s provided to patients in their homes.  It’s usually funded by block contract that don’t adjust as activity increases, and here there actually wasn’t really any national data on activity and quality but we spoke to people and heard about services really struggling to cope with static or reducing budgets, increasing demand for their service and a really critical shortfall in the nursing workforce.  This is impacting on patient care in terms of access because some services are having to tighten their referral criteria, there are some longer waits for non-urgent appointments and we also see quality being affected because nurses are having to spend less time with each patient, they’re stretched, they’re having to rush through visits in some cases and they don’t have time to do the full thorough assessment that we would hope from this service.

The final area we looked at was GUM, genitourinary medicine services that provide STI testing and treatment. This is our example of a public health service and since 2013 public health services have been funded by local authorities and this is actually the only area where we could get really clear data on service level spend. So, spending on GUM between 2013/14 and 15/16 has reduced across England by around 4%.  There is a lot of variation, it’s not just a clear national picture.  In some areas, in some local authorities spending has increased and services have expanded, but there are also local authority areas where funding’s been cut by more than 20% and we see patient care suffering as a result.  Some clinics have been closed, moved to less convenient locations, opening hours have been reduced.  We’ve got some evidence that it’s more difficult for some patients to access appointments within 48 hours.  We’ll also see the quality of care affected, there’s changes to staffing models with less consultant input, fewer health advisor posts in some areas and I think quite importantly they’ve been cuts to some really important preventative and outreach services.  These are the services that target high risk patients and bring them in for testing. 

So the cuts we’ve seen to public health budgets are of a different order to what we see in NHS care, and I think what we see in this area is particularly worrying because we know that rates of some STIs like gonorrhoea and syphilis are going up at the moment.

So that’s the end of my whistle stop tour around the four service areas but I think the real value of our study comes not just from what we found in these individual areas, it’s from looking across and taking a look at what this tells us about the whole picture in the health system.

So, before I finish up I’m just going to go through a few key messages from taking that broader view.

The first point which hopefully came across from what I just said, is that services in different parts of the health system have been affected in different ways, but we saw of the service areas we looked at, GUM and district nursing were particularly under strain. We did say patients affected in some ways that were quite explicit and easy to see, like the longer waits for operations but a lot of the impacts we saw are quite difficult to detect with currently available metrics.  So, some of these impacts are really going unseen at the moment.

We saw staff, particularly in district nursing services, working longer hours, under pressure in order to protect patient care. I think this is not sustainable and it’s particularly worrying when we know there’s a lot of evidence about the link between staff wellbeing and the quality of patient care they provide.

I said upfront that there are a range of factors affecting patient care and we did find money is not the only problem, for example in our report we go through all the pressure that services face. I could pick out GUM there, there’s been a fragmentation of commissioning in 2013 it’s led to a lack of accountability and some problems with coordination of different services.  In district nursing there is a critical problem with workforce that money alone will not be able to address.

It wasn’t all bad, we heard lots of stories of innovation being sparked, lots of teams working hard to develop new models of care, to maintain quality in the current environment, but we also heard examples where innovation had been stifled because there really wasn’t the money to invest to allow people to develop services.

There’s been a lot of attention recently on the STP process and Chris mentioned our work on that earlier, collaboration between system level leaders to develop plans for their local areas, but I was really struck from our research of the importance of collaboration between commissioners and providers at a service level, and often we found that those relationships weren’t working well at the moment.

I was also struck by the fact that the slowdown in funding growth which started in 2010/11 had taken some time to impact on patient care but we really are now seeing the impacts and they look set to spread and intensify in the future. If I pick out GUM for an example, if we look at planned spending this year it shows further cuts to budgets.

And I’ll just finish on a broader point, we obviously just looked at four service areas, so I don’t want to generalise too much in what we found, but in the five year forward view the NHS says it needs to strengthen community based services and focus on prevention but it was exactly that core community service of district nursing and the public health service that we looked at in GUM that we saw under the most strain from the current pressures. So, I really think there’s a challenge there for the health service.  If it wants to keep patients healthy and out of hospital we really need a renewed focus on these community based and public health services.

And I’ll just finish up by thanking my co-authors who I think are in the audience and other researchers who helped us with the work.

Thank you.

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