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Preventing a recurrence of this winter’s crisis

The pressures engulfing the NHS this winter were not only predictable, they were predicted. Quarterly surveys of NHS performance carried out by The King’s Fund since April 2011 have reported growing financial challenges, increasing difficulties in achieving key standards such as a maximum wait of four hours in A&E departments for 95 per cent of patients, and rising pessimism among NHS leaders about the prospects for their own organisations and the systems of which they are a part. Declining performance is a consequence of rising demand for care from a growing and ageing population at a time of constrained resources.

Drawing on these surveys and research into the impact of financial pressures on patient care, we warned in 2015/16 that the NHS would experience a full-blown crisis in care if the government did not act. That crisis has now materialised, with the additional funding announced in November’s budget arriving too late for hospitals struggling to cope with the expected increase in demand from patients at this time of the year. The recent statement from senior doctors that patients are now dying in overcrowded A&E departments is a stark and tragic reminder of what happens when politicians fail to heed the warning signs.

The key question now is: what needs to be done to stabilise the NHS and ensure that this winter’s crisis does not recur? Three priorities stand out: first, to commit to a long-term plan that provides the funding and staffing needed in the future; second, to redouble efforts to improve productivity and extract as much value as possible from available spending; and third, to expand work to reform the NHS by giving greater emphasis to prevention and population health and to the integration of care. The growing financial and performance challenges facing the NHS also require a different approach to the funding and provision of social care.

Funding and staffing the NHS and social care

Taking the long view, the NHS budget has increased by around 4 per cent in real terms each year since its inception, compared with only 1 per cent in the past seven years. A long-term plan for funding is needed and this should draw on analyses by The King’s Fund, the Health Foundation and the Nuffield Trust and the Office of Budget Responsibility on the increased funding required to meet the needs of an ageing population and the cost of medical advances. Surveys show that a majority of people would be willing to pay more in taxes to fund additional spending on the NHS.

Increases in social care funding will also be required. Work on the social care Green Paper should build on previous reviews, including those by the Royal Commission on Long Term Care (1999), the Dilnot Commission (2011) and the Barker Commission (2014), to make recommendations on the balance of private and public spending needed in future. As the Barker Commission argued, there is a strong case for a new health and social care settlement involving additional public funding on social care. The Commission outlined options for ways to raise this funding, including by increasing taxes and National Insurance contributions for some groups.

Additional spending on the NHS and social care will only bring benefits if there are skilled staff available to provide care. There is worrying evidence of growing staff shortages in many areas of care, including community nursing, general practice, mental health and some specialist services. These shortages are being exacerbated by the uncertainty around Brexit. The draft health and care workforce strategy published by Health Education England in December 2017 shows that these issues are belatedly receiving attention and now need to be taken forward with urgency.

In the short term, the main priorities are to redouble efforts to retain staff working in health and social care, for example by stemming the rising tide of early retirements among staff such as GPs. More also needs to be done to fill gaps in staffing through overseas recruitment and by making the NHS an attractive place to work, recognising that this is difficult when staff have been under so much pressure during the winter. In the long term, the principal aim should be to increase the number of people being trained for roles in health and social care, taking account of changing attitudes to working lives and the rise of part-time and portfolio careers.

Improving productivity

There are many opportunities to improve productivity in the NHS and extract as much value as possible from available spending as the Carter review has shown. The most important opportunities lie in tackling unwarranted variations in clinical care, as illustrated in the Getting It Right First Time programme, which has documented the scope for making savings and improving outcomes in orthopaedic surgery and other specialties. Realising these opportunities depends on engaging clinical teams in all parts of the NHS, building on past experience in areas such as generic prescribing, day surgery and reduced lengths of stay in hospital.

There is evidence to suggest that value could also be increased by tackling overuse of some services. Examples include diagnostic tests and screening programmes that are unnecessary; drugs that are of marginal value; medical and surgical interventions that are of little or no benefit, for example for patients at the end of life. The NHS in Scotland and Wales has recognised the challenge of overuse in initiatives on realistic medicine and prudent health care respectively, as has the Choosing Wisely movement. Involving patients in decisions about treatment options is one way of making progress.

Resources can also be used more effectively by reducing spending on management costs that bring little value. Three examples stand out: first, the transaction costs in the commissioner/provider system, particularly the costs of negotiating and monitoring contracts and in regulating performance, which add little if any value. Second, duplication in back-office functions such as payroll, IT and estates management can be reduced, as is beginning to happen in hospital groups that are making savings by bringing these functions together. Third, the overhead cost of national NHS bodies is significant, with one estimate suggesting that £1 billion could be released by slimming down and integrating the work of NHS England and NHS Improvement alone.

Evidence suggests that productivity has been increasing in the NHS faster than in the wider economy. As further improvements are pursued, it is important to recognise the paradox that in some circumstances increasing efficiency may itself be inefficient. An example is the reduction in hospital beds to the point where the NHS lacks sufficient capacity to deal with peaks in demand. This can lead to operations being cancelled at short notice and surgical teams standing idle when patients require urgent care.

Reforming the NHS and social care

There is widespread acceptance that current models of hospital-centred care need to change to better meet the needs of the growing and ageing population. A high priority is to give greater attention to prevention and population health through the NHS working closely with local authorities, the third sector, employers and others to tackle the wider determinants of health and wellbeing. Government also has a role through legislation, regulation and taxation in helping to bring about improvements in health, for example in the case of obesity and in action on air pollution.

Also important is to extend the work of the new care models set up under the NHS five year forward view to integrate care. Promising innovations include general practices working at scale to provide a wider range of services in the community in the multispecialty community provider programme, and hospitals working closely with community, mental health and social care services in the primary and acute care systems programme. Early evidence reported by NHS England shows that the integrated services established in these programmes are moderating demand for hospital care more effectively than the rest of the NHS.

The work of the new care models is being taken forward in some areas through accountable care partnerships and systems. NHS organisations and their partners in local government and the third sector are coming together in these areas to agree how to use their resources to improve health and care for the populations they serve. These developments mark a further shift away from the market-based reforms that have been pursued since the early 1990s as collaboration takes precedence over competition.

The emphasis on planning services and providing care for populations in accountable care systems and partnerships needs to go hand in hand with work to involve people more fully in their own health and care. This includes giving people the information and support they need to manage their own medical conditions, offering people personal health budgets where appropriate, and engaging people in keeping healthy. Innovations in digital and other technologies have the potential to give people much more control over their health and wellbeing.