Three challenges and a big uncertainty for the NHS in 2015

The NHS faces three major challenges in 2015.

The first is to prepare for the spending review that will be initiated after the election. National bodies, led by NHS England, have set out their views on future spending requirements in the NHS five year forward view, and the major parties have all acknowledged the need for additional funding. While this is welcome, it is not yet clear whether any of the parties will commit to finding an additional £8 billion a year by 2020/21.

Ahead of the election, more work is needed to spell out how the NHS will find the £22 billion of productivity improvements expected of it under the five year forward view. We shall be playing our part by publishing an analysis of how the NHS can deliver better outcomes at lower cost. We shall also be working with colleagues at the Health Foundation to explore how a transformation fund might be used to support the development of new care models. Both projects will report in the first half of 2015 with a view to influencing the incoming government.

The second challenge is to achieve much closer integration of health and social care, both within the limits of the current system, and through a new settlement – as outlined in the Commission on the Future of Health and Social Care in England’s final report, published last year. As the Commission argued, there is a compelling case to bring the funding of health and social care together through a single ring-fenced budget, enabling entitlements to social care and health care to be more closely aligned and reducing the unfairness and complexity of the current system.

Implementing a new settlement would be a fundamental change and may well take a decade to deliver. Hard choices would have to be made to find the required resources, and the Commission was clear that older people, as the principal beneficiaries, would need to contribute some of the cost. The prize to be won is equal support for equal need and an end to the current fragmented system, which is often distressing for the people who most need help and support.

The third challenge is to ensure that the NHS has the leadership in place to deliver the highest possible standards of care within available resources. Our recent survey with the Health Service Journal found worryingly high levels of vacancies among executives on NHS boards. There are many reasons for this, including a punitive regulatory regime that is currently inclined to replace leaders who get into difficulty rather than support them.

The NHS needs to move beyond heroic and pace-setting leadership to an approach that is collective and distributed and engages staff at all levels in improving care. High priority should also be given to developing collective leadership in local systems of care to sustain existing services and implement new care models. We shall be publishing the results of our research on what it means to be a system leader at our annual leadership summit in May.

In tackling these challenges, the NHS also has to deal with the uncertainty around the general election in May when there is every prospect that no party will emerge with an overall majority. The rise to prominence of smaller and so-called insurgent parties means that another coalition is likely, quite possibly involving three parties rather than two.

This would have implications for the NHS. As Nick Timmins showed in his seminal study of the Health and Social Care Act 2012, negotiations inside the coalition had a significant influence on the White Paper, Liberating the NHS, and the subsequent legislation. This included the decision to abolish strategic health authorities and primary care trusts even though the coalition’s programme of government included a commitment ‘to stop the top-down reorganisations of the NHS that have got in the way of patient care’.

In the light of this experience, NHS leaders would be well advised to plan for the election by setting out clearly their priorities for the incoming government. These priorities should include changes to be avoided – like top-down reorganisations – as well as positive proposals for action. The NHS has done well to absorb the impact of major restructuring but desperately needs a period of stability to be able to focus on its core business of improving patient care.

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#449805 Helen Ray
Chief Operating Officer
North Cumbria University Trust

Having worked for 9 months in a trust in special measures (aim my 32nd year as an NHS worker) these challenges ring true. Combine these with recruitment challenges and the current locum spend in a sellers market and the scale is magnified.

#449979 Noel Finn
unemployed nurse whistleblower

Difficult to take serious what NHSEngland really want and why they would lead on is a contradiction to then say remove top down control in the same breath . It seems not clear to me what government want they have depended on this institution for one reason ...votes !....does the government really want to let go ...? I don't think so.. not yet anyway....until NHS has been diluted enough that private business have a stronghold. ..the purposes for public healthcare was equality rich or poor a healthy nation...which all government have lost sight of sadly.

#450315 Terry
Member of the public

I am one of the millions of members of the public who are regularly told that 'we are at the centre of the NHS wheel'. Whilst not overlooking singular dedication and extreme efforts generally, I continually feel that the wheel is not only wobbling but about to unnecessarily drop off. I say this as what is proposed again is repeated year on year in various guises and if it was not so serious it would be a laughing matter. Sadly many think we are at that stage now.
No doubt, in an effort to pacify us, there will again be endless and unnecessary time wasted on meetings after meetings, reviews after reviews producing similar action plans to that of previous years with nothing changing, other than perhaps a whisper touch to the tiller to justify themselves.
The public deserves and expects much better but as long as such delaying tactics are permitted, nothing will. I cannot believe that something as fundamental as integration for instance, whilst difficult, should be so to those that we are paying to be the great minds to lead us. Perhaps their 'pips are not squeaking enough' to really gel their minds and that some lack the real ability and drive to ensure that change actually takes place.

#450402 David Dundas
Ex Governor (7 years)
ex Burton Hospitals NHS Trust

I was a Governor of a District General hospital for 7 years but recently resigned when my wife was diagnosed with MS.
NHS hospitals could raise a great deal of extra funds by inviting overnight patients to contribute towards their board and lodging; £ 10 a night would raise a huge amount of money and most people who could afford it would be very happy to contribute.
While better integration of social care is very important, so is better communications between GPs and health care providers, not only to avoid mistakes, but also to speed up the diagnostic process.

#451720 Pearl Baker
Carer Independent Advocate and Advisor
Independent Mental Health Advocate and Advisor

I Support everything Terry has said, a member of the public making sence

#454728 Mark Duman
Patient first, other things next

I would have hoped The King's Fund would have highlighted proper and sustained patient and public engagement as a major cure? Given that "activated" patients can save 20% of provider costs should we not give them a proper chance rather than continually rely on system changes which continue to disappoint?

#458842 Chris Ham
Chief executive
The King's Fund

Thanks for your comment. we agree about patient activation and published a report on this in 2014

#467660 Dinesh Nagi
Clinical Director Medicine
Mid yorkshire NHS Trust

I became a CD, having had several local and national roles in the profession, which I enjoyed and having locally lead the Loval models of integrated service fior patients in diabetes. The single most reason for taking the CD post was to help influence and contribute to quality of patient care in General and acute medicine and other specialities.
My frustration, for not been able to progress any significant local change has made me reflect and come to the conclusion, that the complex systems in place in the NHS actually stand in the way of clinical leaders trying to deliver a patient focussed agenda and waste an enormous amount of valuable time on assurances, actions plans and feeding the needs of the Beast,mwhich the NHS has created. The top down system of management which actually has been encouraged and comes from the central goverment and the systems of regulation does not allow any room for manoeuvre to really focus on improving quality of care.

#474560 Barbara
Health trust

How right Dinesh is. I have worked in the NHS for forty years and seen massive changes. The decline came when we became a business, started chasing targets and management exploded. Gradually over time decisions were taken out of the hands of clinicians and I have seen young dynamic phycians with good ideas for improving the patient experience lose out to our inhouse management decisions. Put clinicians back into making the decisions in supporting patient care, after all they are best placed to know what patients need. Good care.

#474894 Smoke To Live

I like this post. It's really good to see the researchers are working on it.

#475836 Sarah
senior nurse
district general hospital

Thank you, Chris, for your blog. I have >25yrs experience working within the NHS in District General Hospitals and, latterly, also experience as a user of services by proxy, given both my mother and father's health problems. It seems to me that the strength of the NHS lies in its emergency medicine provision. The weakness of the NHS lies in its management of chronic disease. Given the exponential rise in demand of the latter, surely the key challenge for the NHS lies in its ability to survive at all. Let's be clear, the system is in crisis as never before. Repeated top down structural change has not resulted in cost saving - it has only forced cost up, whilst also wearing down those that have had to implement these changes. Experienced clinical staff have left in droves in recent years, leaving a huge vacuum. Perverse incentives inherent in the purchaser/provider system and the focus on targets perpetuate waste and, often, poor care. Mid staffs weren't an exception. They were just the ones that got caught and provided a welcome target for politicians and the media. I had a great belief in the NHS when I started out all those years ago. I believed it was the best health care service in the developed world. I now think it's one of the worst. Surely it's time for an open and honest discussion about its future.

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