The NHS 10-year plan: how should the extra funding be spent?

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The government has announced increases in NHS funding over five years, beginning in 2019/20, and has asked the NHS to come up with a 10-year plan for how this funding will be used. After eight years of austerity, growing financial and service pressures within the NHS and the damaging and distracting changes brought about by the Health and Social Care Act 2012, there is now an opportunity to tackle the issues that matter most to patients and communities and to improve health and care.

In our view, the centrepiece of the new plan should be a commitment to bring about measurable improvements in population health and to reduce health inequalities. Health outcomes in the UK are not as good as those in many comparable countries despite recent progress in some areas such as cancer survival rates (Dayan et al 2018). Action is required across government as well as in the NHS in order to give greater priority to prevention and to tackle the wider determinants of health and wellbeing. Goals for improving health should be set following widespread consultation with the public and stakeholders.

Improving health and reducing health inequalities depends on making further progress in integrating health and social care, building on the development of new care models, sustainability and transformation partnerships (STPs) and integrated care systems (ICSs). An immediate priority is to communicate more effectively about why integrated care matters and about the benefits it will bring to people and communities. Some of the additional funding that has been announced should be earmarked to support the further development of integrated care with a focus on the needs of older people with frailty, people with complex needs and children.

Improving population health, reducing health inequalities and integrating care are the most important system challenges facing the NHS and its partners now and for the foreseeable future. They are a means of improving the outcomes and experiences of people with physical and mental health needs both in hospital and in the community. Framing the plan around these system challenges is essential if specific service priorities, for example relating to conditions like diabetes and cancer, are to be addressed effectively.

The government and the NHS need to set out a coherent and credible strategy for implementing the plan and realising its ambitions. Our view is that reforming the NHS from within needs much more emphasis, drawing on the intrinsic motivation of staff and supporting them to improve health and care. The NHS and its partners must also work closely with people and communities, understanding what matters to them and supporting people to take more control of their health and wellbeing as part of a new deal with the public.

Having made a welcome commitment to increase the NHS budget, the government must increase funding for the social care and public health services provided and commissioned by local authorities to help deliver these priorities. The NHS and the government must also work together to produce a comprehensive workforce plan and bring forward proposals to put social care funding on a sustainable basis in the Green Paper expected in the autumn. Failure to do so will undermine the credibility of the 10-year NHS plan and could be fatal to delivering its ambitions.

Even with the funding increases that have been announced, the NHS faces hard choices about what improvements in health and care can be delivered. Ambition needs to be tempered with realism about the deep-seated difficulties facing the NHS and social care and the time needed to address them. The temptation to over-promise and under-deliver must be resisted, recognising that sustained improvements are possible if the government and NHS leaders demonstrate clarity of aims and constancy of purpose.

Learning from the past

The recent history of health policy is littered with examples of plans setting out how services need to change to be fit for the future (see box). Some of these plans have made more impact than others, and there has often been a gap between policy ambitions and practical achievements. Governments have changed course too frequently and have not given sufficient attention to how plans should be implemented.

Learning from this experience, the 10-year NHS plan should build on the foundations laid by The NHS five year forward view (Forward View) and should be underpinned by a coherent and credible strategy for realising its ambitions.

Here we outline the priorities The King’s Fund believes should be at the heart of the plan and the approach that NHS organisations and their partners should take to seize the opportunity that has been offered. We believe these priorities offer the best hope for the NHS to lead the world in integrating care and improving population health over a 10-year period. Extra funding should be used mainly to transform health and care and not to shore up services that in their present form are struggling to meet the population’s needs.

NHS staff should be as fully involved as possible in developing the plan, recognising the tight timetable that lies ahead. Local authorities, patient organisations and the public should also be engaged as they are critical in helping to deliver improvements in population health and closer integration of care.

The funding context

NHS funding has grown by slightly more than 1 per cent a year in real terms since 2009/10. This is well below the long-term average increase of 3.7 per cent a year and the increases of more than 4 per cent a year needed based on projections by the Office for Budget Responsibility (The King’s Fund 2018). As a result of lower funding growth, pressures in the NHS have grown substantially and have been accentuated by cuts in spending on public health and social care (Nuffield Trust et al 2017).

Rising demand from a growing and ageing population helps to explain these pressures (Maguire et al 2016). Analysis shows that overall funding increases since 2009/10 all but disappear when allowance is made for population growth and the impact of population ageing (Johnson et al 2018). Patients today have more complex needs that require more time and support to resolve, meaning that staff workloads are increasing.

By the end of 2017/18, the cumulative impact of several years of slow funding growth had become clear. A winter crisis in A&E, the depth and duration of which had not been seen for more than a decade, resulted in more people waiting to be diagnosed and treated and many others having their appointments for elective treatment cancelled (Kershaw 2018). Just as important are continuing difficulties in ensuring parity of esteem in mental health and deep-rooted problems in general practice and community health services.

These pressures mean the NHS is missing many of the standards for patient care set out in the NHS Constitution. The NHS has not met the standard that 95 per cent of patients should be seen within four hours in A&E since July 2015. The number of people on waiting lists for elective treatment is now more than 4 million, and the standard that 92 per cent of patients should start treatment within 18 weeks of referral has not be achieved since February 2016. The standard that 85 per cent of patients should begin definitive treatment for cancer within 62 days of referral was last achieved in quarter three 2013/14 (NHS England 2018a, 2018b).

The new funding settlement proposed by the government will go some way to providing the necessary finance to address these and other pressures. The settlement applies to spending covered by the Mandate to NHS England – amounting to £114.6 billion in 2018/19 and expected to increase by £20.5 billion by 2023/24 in real terms. This translates to an average annual increase of 3.4 per cent a year in real terms, though it is likely the settlement will be frontloaded in the first two years.

Importantly, it is currently unclear how some elements of spending in the wider Department of Health and Social Care budget will be treated over this period. These elements include spending on staff training budgets, capital spending on buildings and equipment and the public health grant to local authorities. The details of the final settlement will be agreed as part of the 2018 Autumn Budget and 2019 Spending Review processes. The Spending Review will also reveal the outlook for social care, though the direction of travel should become clear in the promised Green Paper in the autumn.

The increases proposed for the NHS represent a substantial level of investment but fall below the minimum 4 per cent increases that The King’s Fund and others have argued is needed to modernise and improve services in the future (Ham et al 2018). Tough choices remain in determining which areas of spending are given priority and what improvements can be delivered when within this funding envelope.

Opportunities to improve productivity

NHS finances and performance

The scope for improving health and care will depend not only on increased funding but also on the ability of the NHS to use resources efficiently and reduce waste.

Productivity in the NHS has grown by around 1.4 per cent a year on average since 2009 and has generally outpaced that in the economy as a whole (Johnson et al 2018). One of the conditions attached to the government’s multi-year funding settlement is that productivity should continue to grow at the same rate over the next five years. This will be extremely challenging given that the long-term trend (since 1995) has been for health service productivity to grow by around 0.8 per cent a year and higher levels of growth recently have, in part, been based on pay restraint.

A recent OECD study argued that health care systems around the world could do much more to tackle waste and release resources for reinvestment (OECD 2017b), including through eliminating adverse events, reducing the number of patients who are in hospital because more appropriate alternatives are not available and cutting administrative costs. The OECD estimates that around one-fifth of spending on health care makes no or minimal contribution to health outcomes. Like other health care systems, the NHS must redouble efforts to reduce waste and ensure that scarce resources are used well.

Some of the most important gains in productivity have been achieved through changes to clinical practice. This is illustrated by the move to generic prescribing in general practice, the adoption of day surgery and reductions in the average lengths of stay of patients in hospital. Analysis shows that increases in generic prescribing between 1976 and 2013 had saved the NHS £7.1 billion, increases in day surgery between 1998 and 2013 had saved around £2 billion and over the same period, if lengths of stay had not fallen, the NHS would have needed another 10,000 beds and the staff required to provide care for patients in these beds (Alderwick et al 2015b).

Variations in clinical practice across the NHS show that there are many ways of improving care and releasing resources. The NHS has developed a series of programmes to tackle these variations under the leadership of senior doctors, for example in orthopaedic surgery (Timmins 2017), on a scale not seen in other health systems. Potential savings are estimated at £6 billion by 2020/21 and require NHS trusts to develop the capabilities needed to reduce variations and waste (National Audit Office 2018).

There is also evidence of inappropriate overuse of services. In Scotland and Wales, national programmes on realistic medicine and prudent health care respectively (NHS Scotland 2016; Bradley and Willson 2014) and across the UK the Choosing Wisely programme are seeking to tackle overuse. Examples include reducing overuse of antibiotics and of medical and surgical procedures of limited clinical value. Shared decision-making in which patients are informed of the risks and benefits of treatment options is one way of avoiding the ‘silent misdiagnosis’ that occurs when decisions are taken without their involvement (Mulley et al 2012).

Looking beyond clinical care, there is considerable scope for reducing the complexity of the organisational arrangements resulting from the Health and Social Care Act 2012 and the transaction costs of the internal market. Substantial resources could be released for investment in patient care through simplifying the commissioner/provider system and streamlining management arrangements, for example by reducing the number of national bodies and the staff they employ and moving away from annual contract negotiations. Equally important is to reduce overreliance on inspection and regulation to free up managers’ and clinicians’ time.

Priorities for the plan

The NHS is currently working to get back on track in delivering the access standards set out in the NHS Constitution, invest in mental health services and general practice, bring about further improvements in cancer care and outcomes and redesign urgent and emergency care services. The NHS is also seeking to further transform care by implementing the new care models described in the Forward View with the aim of integrating health and social care and improving population health. STPs and ICSs are the principal means of delivering transformation.

Our view is that these are the right priorities, but it will be difficult to deliver them all even with the new funding that has been announced. Policy-makers should resist the temptation to add additional service priorities to those listed above, other than where there are exceptional reasons to do so. An example of this would be mental health, where progress towards parity of esteem with physical health has been slow and where more ambitious goals for improvement are needed.

Policy-makers should earmark resources for further developing new care models, as argued by the House of Commons Health and Social Care Committee (2018), to better meet the population’s needs now and in the future. These resources are needed to embed integrated care as the main way of delivering services in England, and examples such as the Canterbury District Health Board in New Zealand illustrate what can be achieved through integration (Timmins and Ham 2013).

Integration is particularly important for older people with frailty and those with complex medical conditions, who are often in contact with different health and care professionals. It is also a priority for children for whom outcomes are not as good in England as in many other countries and whose needs have been identified as a priority by ICSs in Greater Manchester and Surrey. The aim of the 10-year plan should be to support the ambition to make the biggest national move to integrated care of any major western country (NHS England 2017).

One of the benefits of integration is that it enables resources to be used more effectively. Early evidence suggests that the new care models put in place following the Forward View are moderating demand for hospital care and enabling patients to be discharged from hospital in a timely manner (NHS England 2017). Even more important is the opportunity to improve patient experience and outcomes by improving access to care and co-ordinating the contribution of different health and social care staff around the needs of patients. Digital innovations, especially shared care records, have an important part to play in supporting co-ordination.

Our work shows that integrated care needs to be built from the bottom up, starting in neighbourhoods and extending to places and systems (Ham 2018). The government and national NHS leaders have made clear that ICSs are central to their plans for the future, and the 10-year plan should set out a timeline for all STPs to become ICSs as soon as feasible. It should also commit to removing financial, regulatory and other barriers to the development of ICSs and work with local leaders to identify changes to the law that would help accelerate progress (see below).

Improving population health

Work to integrate health and care is a step on the road to improving population health and wellbeing over the 10 years covered by the plan (Alderwick et al 2015a). For all its achievements, the NHS remains first and foremost a treatment service, and successive governments have paid too little attention to prevention and health improvement. The Forward View argued for a radical upgrade in prevention but there has been little progress and the NHS has fallen well short of the fully engaged scenario outlined in the Wanless Report (Wanless 2002).

The scale of the challenge is revealed by the statistics: the UK has the highest rates of childhood obesity in western Europe; 57.1 per cent of women and 65.7 per cent of men were classified as overweight or obese in 2016 (OECD 2017a); 7 in 10 adults in England do not meet government guidelines in relation to two or more risk factors including poor diet, physical inactivity, excessive alcohol consumption and smoking (Evans and Buck 2018). These risk factors are linked to ill health and premature death related to cancer, heart disease and diabetes.

Figure 1 graphic showing the focus of population health systems.

The case for giving greater priority to prevention and health improvement has been made in public health White Papers over many years. It has been strengthened by authoritative reviews, such as those led by Douglas Black (1980), Donald Acheson (1998) and Michael Marmot (2010), which drew attention to the persistence of inequalities in health between socio-economic groups. The NHS has a part to play in improving population health, but even more important are actions by central and local government and others to tackle the wider determinants of health and wellbeing such as poverty, housing and jobs (see Figure 2).

Figure 2 graphics shows a framework for designing strategies to improve population health.

This is recognised by the public, a majority of whom support the government using legislation and regulation to improve outcomes and seem less concerned about the ‘nanny state’ than politicians and some national newspapers (see Figure 3). The pejorative connotations of the nanny state need to be replaced with recognition of the need for intelligent action by government, for example in the smoking ban, which has led to a measurable reduction in smoking rates, and in the recent actions of the Scottish government on minimum pricing of alcohol.

Figure 3 graphic shows views on how easy or difficult people find it to undertake healthy behaviours.

The positive impact of government intervention is illustrated by the comprehensive strategy to reduce health inequalities adopted by the 1997–2010 Labour government. Evaluations show that action on job creation, the minimum wage, changes to tax, investment in early years and many other public policies contributed to measurable progress in tackling health inequalities in England (Barr et al 2017). Subsequently, health inequalities have widened in the context of the weaker economy since 2008/9 and the austerity policies that followed. The contrast with the approach taken by the coalition government between 2010–15 based on seeking voluntary agreements with industry is striking.

Local authorities also have a major contribution to make alongside central government. In Wigan the council has been working for several years with partners to support local people live healthier lives, including by investing in those communities and working in partnership with them. The Healthier Wigan Partnership seeks to use assets in the community to improve health and wellbeing using a multiagency approach involving not only the council and the NHS but also the police, fire and rescue services, housing agencies, the Department for Work and Pensions and, most importantly, the community itself.

The partnership includes early intervention with children, support for troubled families (referred to in Wigan as confident families) and engagement with community groups to combat loneliness and provide food to people on low incomes. Investment in leisure services is designed to enable people to keep healthy and active in local parks and leisure centres. Evidence shows that population health outcomes are improving with reductions in smoking rates, suicides and premature deaths from heart disease and cancer (Ardern 2016).

One of the most important ways of improving population health is to tackle the increasing number of people, including children, who are overweight or obese. A start has been made with legislation to reduce the amount of sugar in soft drinks, but much more needs to be done to deliver the target in the updated childhood obesity strategy to halve childhood obesity by 2030 (Department of Health and Social Care 2018). While central government must play its part, for example through tougher regulation of food content and labelling as well as pricing, the NHS has a role in restricting the availability of unhealthy foods on health services premises, and local authorities can do more to support healthy eating and lifestyles in schools, for example through the Daily Mile programme.

The clustering of risk factors in specific communities and population groups underlines the case for policies and programmes that work to address unhealthy behaviours together rather than separately. Specific policies to tackle obesity, smoking and other health risks must be pursued but the reality is that most people experience these in combinations and this is still not sufficiently recognised in policy or practice. A different approach to behaviour change is required, centred on integrated health and wellbeing services treating people holistically and linking through to other support, for example, with debt and housing problems (Evans and Buck 2018).

Integrated health and wellbeing services are making use of social prescribing to improve population health in many areas. This approach offers support to people that goes well beyond services provided within the NHS. Examples include volunteering, arts activities, cookery, gardening, advice on accessing benefits, and a range of sports. Innovative general practices like the Bromley by Bow Health Centre in east London is one of the longest established and best-known examples of how these forms of support bring benefits. Many other areas are now offering social prescribing alongside mainstream NHS preventive services like vaccination and immunisation and screening.

A new deal with the public

Alongside action by central and local government, improving population health requires public agencies to develop a new relationship with citizens and communities in which people are enabled to remain independent for as long as possible and communities support each other. In Wigan this involves staff from the council receiving training in having ‘different conversations’ with people about what matters to them, listening to their concerns and acting on them. The council has also established an investment fund to support the work of community groups and to revitalise community facilities.

Wigan Council’s philosophy is expressed in the Wigan deal (see Figure 4) which underpins its relationship with the community (Hall 2018). At a time of deep cuts in spending, difficult decisions have been made about the services that can be provided with an emphasis on reducing demand for care and support by working differently with residents. Conversations with the public have helped to identify more effective forms of care and support drawing on the contribution of people and communities.

Figure 4 graphic Wigan Council's 'deal'.

The Council has also changed the way in which it commissions and provides services. An example was the decision to shift the focus in social care from the 3 per cent of the population living chaotic lives to the 22 per cent who were ‘just coping’ in order to prevent further deterioration into complex dependency. Commissioning a social enterprise to provide preventive services has enabled these services to be delivered more effectively and at a lower cost.

Wanless’s fully engaged scenario was based on the insight that improving population health should be everybody’s responsibility (Wanless 2002). It sought to carve out a middle way between approaches that emphasise the role of government and public agencies in health improvement and those that focus on what people should be supported to do to change the behaviours and lifestyles that give rise to ill health. Survey evidence shows that people understand that they have a responsibility to stay healthy even if their choices do not always reflect this (Evans 2018; McKenna 2018).

The middle way emphasises the assets of communities and focuses on the agency of people and communities in contributing to health improvement. It is part of a growing critique of the welfare state that highlights the needs of people who have been failed by public services. Cottam (2018) has made an important contribution to this critique, arguing – as Beveridge did in his report on voluntary action – that alternative solutions to those offered by the public sector are needed.

These solutions often arise out of the actions of third sector organisations that use innovative approaches to meeting people’s needs. The vital contribution of these organisations is demonstrated in the work done by many small and medium-sized charities around the country in filling gaps left by statutory services (Gilburt et al 2017). These charities have found new ways of delivering services that often seem beyond the reach of the NHS and its public sector partners, for example by making imaginative use of volunteers and experts by experience.

We believe that a new deal with the public is needed that recognises what people themselves can contribute alongside the NHS and its partners. A new deal would build on the NHS Constitution by placing more emphasis on people’s responsibilities alongside their rights to care. It should be developed locally under the leadership of NHS organisations, local authorities and others. The work of the Southcentral Foundation in Alaska, in which there is shared responsibility between people receiving and delivering care, is an example of how this can be done effectively (Collins 2015).

There are many opportunities to put patients and service users in control of their health and wellbeing. Examples include the use of integrated personal commissioning and apps that enable people to monitor and manage their conditions. Self-care support for people with long-term conditions is also important, as in the Expert Patient programme and disease-specific variations of the programme for people with diabetes and other long-term conditions. The way in which people with HIV and AIDS have taken control of their health and wellbeing holds lessons for other areas of care (Baylis et al 2017).

Funding and reform of social care

Social care

Publicly funded social care has not received the same protection as the NHS in recent years, and in England spending by councils on social care per adult fell by 11 per cent in real terms between 2009/10 and 2015/16. About 400,000 fewer older people in England received publicly funded social care in 2013/14 than in 2009/10 as local authorities responded to cuts by giving priority to people with the most severe care needs (Nuffield Trust et al 2017). These cuts have also meant that the fees local authorities pay to providers have been held down and this has created instability in the market.

The Green Paper on social care expected in the autumn is an opportunity to propose solutions to these challenges. Previous reviews – comprising 12 consultations, Green and White Papers and five independent commissions over the past 20 years – have fallen on stony ground, with the notable exception of Scotland, where the government introduced free personal care in 2002. The immediate priority should be to address the projected gap in funding for social care in England of £1.5 billion by 2020/21 (Bottery et al 2018).

For the longer term, the aim should be to work towards a single health and social care system as advocated by the Barker Commission (Commission on the Future of Heath and Care in England 2014). The division between the NHS and social care may have made sense 70 years ago when life expectancy was much shorter but there is now widespread recognition that a different arrangement is needed. The Barker Commission argued that this should be based on a ring-fenced budget and that entitlements to social care should be aligned progressively with entitlements to health care. A move to free personal care in England would be a step in the right direction and would cost an additional £14 billion by 2030/31 (Bottery et al 2018).

A properly funded social care system would facilitate the move towards full integration of health and social care that Jeremy Hunt has argued for (Lintern 2018). It would also enable the NHS to get back on track in delivering access standards for patients and in managing winter pressures. The insurance market has not come forward with products that enable people to protect themselves against the costs of care; action by government is essential to address market failure and create a sustainable solution. This must go well beyond the ‘cap-and-floor’ funding options that have been discussed.

As with the NHS, social care provision needs to be reformed to give people more choice and control over their care and to invest in preventive services. Social care should also embrace the opportunities being created through advances in technology to enable more care to be provided in people’s homes. Areas of England that are most advanced in pooling budgets and integrating services are demonstrating the benefits for patients and service users and there is the potential to go much further if the government can find the will to succeed where its predecessors have failed.

Securing the future workforce

To make use of the new funding that has been announced, the NHS must now find the additional staff to spend it on; the depth of the existing workforce shortages means this challenge must not be underestimated. There are three main ways for the NHS to secure the workforce it needs: new staff coming out of education and training; attracting, retaining and retraining the existing workforce; the recruitment of staff from other countries. All three levers are needed to overcome the existing shortages in key professions that have led to high levels of vacancies.

The training of more – and different – staff is key in the longer term, and already, from 2018/19, the government has committed to a 25 per cent increase in the number of medical school places (NHS Employers 2018a). However, the training of new staff is a long-term lever, as these new doctors will only qualify in 2023 and be available as consultants and GPs from 2030–32. Additional student nurse places are also in the pipeline, but these nurses are also years away from joining the qualified workforce.

Both at national and local level, employers are looking to develop new staff roles that can potentially provide a faster route to alleviating staffing problems and offer career development opportunities that could also help improve retention. These include expanding physician associate and new nursing associate roles and making best use of apprentices following the introduction of the Apprenticeship Levy. Local communities, as well as the NHS, benefit from the jobs created.

Examples include Barking, Havering and Redbridge University Hospitals NHS Trust, which has supported its nurse staffing by introducing new roles, such as nursing apprenticeships, and mapping out career pathways from apprentice through to chief nurse (NHS Employers 2018b). Lancashire Teaching Hospitals NHS Foundation Trust has led five local trusts to create an apprenticeship strategy right across the local health economy. Similar changes are under way in some community services and general practices.

Understanding why staff leave and designing programmes to encourage them to stay has helped to reduce turnover and vacancies in many organisations. NHS Improvement is now providing more direct support to the NHS on retention and on the spread of best practices including more flexible working arrangements. These schemes – and linked initiatives to encourage return to work – need to be expanded to make the most of the existing workforce.

Reducing the attrition from training can also increase the numbers of newly qualified staff, and efforts are under way at national level to raise the retention rate of junior doctors (Health Education England 2018). To succeed, action is needed at local level, and employers like Birmingham Women’s and Children’s NHS Foundation Trust are already innovating to improve the working lives of junior doctors (West et al 2017). These examples need to be emulated and adapted elsewhere to secure the workforce of the future.

Local action needs to take an integrated health and care perspective – there is no benefit in the NHS poaching social care staff, and indeed many of the workforce challenges facing the NHS overlap with workforce problems in social care. Ensuring that ICSs and STPs have clear oversight of the workforce in their areas will be essential to delivery and reform.

The 10-year workforce strategy issued as a consultation in December 2017 (NHS and Public Health England 2017) will now be published alongside the plan itself. While this will need to confront the existing staff shortages in the NHS and social care, it will be increasingly important to ensure the NHS is also training the workforce needed for the future. This means avoiding the mistakes of the past – usually characterised by training too few rather than too many.

Importantly it also means training the right staff. This includes re-balancing the workforce towards more community and primary care staff; making good the need to integrate mental health and physical health and reflecting this in staff training; providing more holistic person-centred care for people with complex health and care needs. It also means recognising the workforce assets that exist in the wider community – whether in people volunteering with the NHS or in the voluntary sector – and the unique talents that they can bring.

There is still great variation across NHS trusts in how extensively they use volunteers and in the opportunities to extend volunteering into other parts of the health and care sector whether in general practice or in finding innovative ways to increase the impact of volunteers (Gilburt et al 2018; Galea et al 2013). Alongside providing a valuable resource and opportunities for people to contribute to the NHS, volunteers can also help connect NHS providers with their wider communities. Beyond volunteering, more than 6.5 million people provide some element of informal care, and finding ways to support them more effectively is essential (Carers UK 2015).

There needs to be a clear read-across from the priorities set out in the 10-year plan to the workforce plan. There is little point in setting out, for example, a new public offer on cancer unless there is the workforce to deliver it. Failure to deliver on the workforce means the NHS will not be able to deliver its commitments. Indeed, unless it can find significant numbers of new staff, the NHS may find itself handing some of the money that has been promised back to HM Treasury.

How to make it happen

NHS reform

The 10-year plan must be underpinned by a credible and coherent strategy for improving health and care. This means recognising the limits of the main approaches to health care reform that have been adopted by successive governments since the late 1980s – targets and terror, inspection and regulation, and competition and choice. Much more emphasis should be placed on reforming the NHS from within, drawing on the intrinsic motivation of staff delivering care and moving from a culture of compliance to one of commitment, learning from organisations in the NHS and elsewhere (Ham 2014).

Nowhere is this more important than in relation to productivity improvements, many of which rest on the adoption of new ways of providing clinical care to patients and service users. In a professional service organisation like the NHS, improvements in clinical care cannot be mandated by managers and organisational leaders. Rather, they rely on the actions of frontline teams, and large-scale improvements result from the accumulation of many small changes in care. Organisational leaders have a role in facilitating these changes by providing the training, resources and time for teams to bring about improvements (Ham et al 2016).

International experience shows how this has been done in high-performing health care systems. A well-known example is Intermountain Healthcare in the United States which has delivered better outcomes at lower cost by engaging medical leaders and others in identifying variations in clinical care, developing guidelines on how care should be provided, and using peer monitoring and review to improve care. The success of Intermountain in implementing what it calls ‘organised care’ has parallels in other systems like Kaiser Permanente and is underpinned by systematic training of staff in improvement methods and a culture in which clinicians are committed to continuous improvements in care.

Work to integrate care can also learn from international experience. The transformation of the Veterans Health Administration (VA) in the United States in the late 1990s is a powerful case study of a shift from a fragmented hospital-centred system to a series of regionally based integrated service networks that competed with each other to improve care for those they served (Ham 2014). Transformation was achieved through complementary approaches to reform in which the VA’s leaders set a clear direction while devolving responsibility for implementation to network directors (Ham 2014).

The priority given to strengthening leadership at all levels of the VA is particularly relevant to the NHS. The traditional command-and-control, military-style punitive culture was replaced with much greater delegation to network directors who were appointed on the basis of their leadership skills and experience. A substantial investment was made in clinical leadership and in equipping clinical leaders with the skills and capabilities to bring about change. The change programme focused on patient safety, quality of care and outcomes rather than on financial performance or efficiency, on the basis that this would resonate more effectively with clinical leaders.

Studies have documented the benefits that were delivered in the VA as a result of its transformation, even though its performance recently has been criticised. These benefits included reducing the use of hospital beds by more than 50 per cent and improving the quality of care on a number of indicators (Ham 2014). As in the NHS, expenditure continued to rise in response to growing demand, but over time resources were redirected from hospitals to other services to enable the right care to be provided in the right place at the right time.

Experience of transforming mental health services during the lifetime of the NHS offers other important lessons on how to manage large-scale change. New forms of care in the community progressively replaced the old asylums, and execution of the new policy was enabled by changing views among staff providing mental health services about the most appropriate way of delivering care. Mental health services were transformed over many years as a result of shifting social attitudes, innovations in treatments, changes to the law, and strategic leadership by regional health authorities underpinned by additional funding (Gilburt et al 2014).

The clear conclusion is that strategic leadership and additional funding are also essential in making further progress on integrated care and delivering improvements in population health. Reforming the NHS from within depends critically on building capability among leaders and staff as less reliance is placed on external interventions from regulators and others. It also means investing in leaders who are able to work across local systems as well as providing excellent leadership in their own organisations. Action to address leadership vacancies and cultures that deter experienced staff from taking on leadership roles is also needed (Anandaciva et al forthcoming).

The ambition to develop integrated care at scale and pace will require changes to the law to remove some of the barriers to progress. For example, ICSs should be established in law as NHS bodies, changes to the role of regulators will be required to achieve closer alignment with the emphasis being placed on system working and to enable the full merger of NHS England and NHS Improvement, and the law relating to procurement and mergers of NHS organisations will need to be reviewed. We agree with the Health and Social Care Committee that proposals should be brought forward from within the NHS on what changes are needed and should be scrutinised by parliament.

Ambitions to improve population health will only be realised if there is alignment around these ambitions at all levels and clarity about goals that should be agreed after widespread consultation. These goals need to be incorporated into a single outcomes framework covering the NHS and local government. ICSs should be held to account for their performance on these outcomes and the results published to enable the public to compare the performance of different systems. Over time, the outcomes framework would become the main way of managing the performance of ICSs (Ham et al 2015).

More also needs to be done to enable worthwhile innovations and improvements in care to be spread, adopted and adapted throughout England. Passive diffusion will not achieve this. Evidence shows that peer-to-peer connections are more effective than central edicts and can be enabled through learning networks, improvement collaboratives and communities of practice. No one method is superior to others, and experience shows that it is often beneficial to use several in tandem with an emphasis on using the NHS’s own expertise and reducing reliance on management consultants (Charles and McCannon 2018).

Finally, while there is understandable urgency among politicians and NHS leaders in bringing about improvements in health and care, the clear lesson from previous NHS plans and from international experience is that large-scale, transformational change takes time. We welcome the commitment to plan for 10 years and to be ambitious about what can be delivered with the funding that has been promised. Constancy of purpose linked to clarity of aims and skilful implementation, drawing on the commitment of the 1.4 million staff working in the NHS, holds the best hope for the future.

References

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We are grateful for comments and help received from Siva Anandaciva, Simon Bottery, Dave Buck, Anna Charles, Richard Humphries, Patrick South and Dan Wellings.

Comments

John Kapp

Position
director,
Organisation
SECTCo
Comment date
12 July 2018

Well said, Sir Chris, and others. I heartily agree with everything, (except your disparaging remark: ' damaging and distracting changes brought about by the Health and Social Care Act 2012' which shows that it has been mis-interpreted - even by the Kings Fund) That Act reflected a paradigm shift to holism in society whereas the NHS and medical profession are still stuck in the materialistic medical model.
However, if you mean that HSCA hasn't yet worked, I agree, as we (society) are now worse off than we were before 2012, It delegated control over 2/3rds of the health budget (£80 bnpa) previously ineffectively exercised by DoH, SHAs and PCTs to Local Authority Health and Wellbeing Boards, but they have failed to take responsibility for the wise spending of it, and are even in denial that they are in receipt of it. If you don't believe me, look at your Council's budget statements, on which 'health' does not appear, so has gone into and accounting black hole (9.129 www.reginaldkapp.org) The resulting lack of political support for GPs means that they cannot perform their new statutory role of clinical commissioning, which frustrates them into voting with their feet, and taking early retirement now at the average age of 55.
That has created the crisis in primary care, but the good news is that we can easily get them back by councillors giving them support. As you rightly say, we need to create a new deal with society, involving the statutory and voluntary sectors, which helps citizens to take more responsibility for their health and wellbeing, built bottom up, as Wigan is doing with social prescribing and a policy of 'medication to meditation'. Treatments which should be mass commissioned include NICE recommended Mindfulness Based Cognitive Therapy (MBCT) 8 week courses plus supporting meditations, including Family constellation Group Therapy to heal disfunctional family patterns inherited from ancestors traumas. Every £1 investment in these interventions saves at least £7 invested in 'pills for every ill', which generally is doing more harm than good.

Andy Knox

Position
Director of Population Health,
Organisation
Bay Health and Care Partners
Comment date
14 July 2018

This is an excellent blog and highlights some important issues that deserve real consideration and debate. Improving population health and closing the health inequlaity gap are the two most important things for the NHS to focus on, if we are to have a heath and care service that works for everyone and is sustainable long into the future. It is not an easy nettle to grasp and is full of complexity, which is highlighted in this paper, but fundamentally, if we do not see a cultural shift, and ownership of these issues across the public sector, with population (and environmental) health written into every policy combined with a collaborative social movement for change, we will still be talking about this in another 15 years.

The reorganisations of the last few decades have been exhausting at so many levels and have not achieved what we have needed them to. It is indeed vital that we learn from these lessons and commit to at least a 10 year focus on improving population health, tackling health inequalities and integrating services, ensuring that we embed a culture of joy, kindness and excellence as we do so. We have reached a pivotal moment and we must break through our silos and see things tip towards a new commitment to improve the population’s health, together.

The funding question will not go away and it is really important that we are honest and open about what is actually going to be possible within the new funding agreement for the NHS and what will not be, especially if there is not a substantial investment into Social Care. Much of what we mean by prevention in Population Health relies heavily on other public sector partners, like Public Health, Education and the Police and the reality of their funding decline will make the transformation we need to see, especially in young people’s mental health very difficult, especially as the new deal for the NHS is not what it neeeds to be. For many Integrated Care Systems, the savings still required are so colossal that doing the simulataneous transformational work of population health and tackling the widening health inequality gap is a very hard task. It is a huge ask of finance directors to meet the constant demands of the regulators whilst also trying to be brave and shift resource towards more long term gains that do not meet the short termism of yearly budget requirements. The increase in demand due to more frailty and complex health issues, eye watering cuts to local government budgets (with profound knock-on effects to social care and public health), a target driven environment and low staff morale is making this all very difficult. It is not impossible but it is going to need realism and pragmatism about what can be achieved, by when. The choices being made about the funding of our public services are ideologically driven, and we need to ensure that feedback about the reality of austerity leads to necessary changes, so that we can have truly evidenced based policies.

Here in Morecambe Bay, we have recently launched the ‘Poverty Truth Commission’, one of several around the country. Many leaders from across our region sat with tears streaming down our faces as we heard story after story about the reality of poverty and destitution for people in our area. We heard from one young man, Daniel about how the closing of the youth centre on his estate and his local high school (both the only places where he knew he belonged and was safe), left him and many of his friends vulnerable to gangs. Moved, again and again through private rented housing, in order to provide for his siblings, he ended up selling drugs and guns, simply to put food on the table, ending up street homeless, with serious addiction problems himself. Many of us wondered how often we think about the short and long term consequences of the cuts being made and what kind of risk assessment is done in these situations. In her very powerful book, ‘Radical Help’, Hilary Cottam writes of need to put relationship back into the heart of our public service care provision, as we grapple with the joint issues of funding constraints and human need.

The points raised about improving productivity are important. Where we can be more efficient, we must continue to be so. Let’s pause to recognise, though, just how much has been achieved already. Culturally, we must learn to celebrate the positives and recognise the great work already being done in this area, which will inspire more of the same. The sharing of best practice and creating environments where we can learn from one another is absolutely key. This will most effectively happen through collaboration not competition. So, yes - integration must be a priority, but it comes with a health warning - if we don’t get culture right from the start, everything else will ultimately fail.

A Population Health approach is the only game in town. Wigan have achieved some really wonderful things, but there are some important things to understand about the context of Wigan that have made it more possible there. Firstly, there is clear political unity. The idea of population health is owned across all spheres and levels of government, and “safe seats” have led to a political continuity that has made long term planning far more successful. The ongoing politicisation of health and social care in other contexts makes this kind of transformation much more difficult. Secondly, there is a real humility in style of leadership that has been a) willing to openly share the complex issues and choices being faced, with the people of Wigan and b) deeply listen to the communities and therefore finding a way through the problems together with a profound sense of joint ownership. It is this two-edged sword of necessary culture change and brave leadership with a social movement that makes it possible to cut into new ground together. We must be brave in talking to people in our local communities about the choices ahead of us and understand the importance of agreeing together who is going to take responsibility for the various pieces of th jigsaw which need to occur.

We know that 40% of our health depends on the every day choices we make as individuals, for example around what we eat or how much exercise we take. However, it is not as lovely and simple as this. There is far less choice available for our most deprived communities. Supermarkets do not stack the same amount of healthy food in their shops in our more deprived areas. Children have little choice over the adverse experiences the go through, how much sugar is in their breakfast cereal not what is pushed at them through targeted advertising. The number of junk food outlets is far higher in areas of greater deprivation (see Greg Fell’s excellent analysis of Sheffield). So, when we talk about choice, especially in the context of poverty and education, we need to take a reality check and not simply point the finger of responsibility. This is where a people’s charter can be really powerful. Those in leadership play their part in taking care of the needs of the population and bringing in appropriate governance and a fair distribution of resource, whilst citizens commit to playing their part in staying healthy and well, and learning about conditions which they live with, so they can play an active role in being as well as possible, dependent on their circumstance.

Given the lessons from Wigan, or from global cities, like Manchester, and Amsterdam and what they are beginning to achieve around population health, there is a powerful argument, not only for combined health and social care budgets, but also for increased devolution of budgets. If we see what has been achieved in the Black Forest of Germany, with a very holistic transformation of services, including the connecting of communities through far improved transport links, we begin to reimagine what might be possible at a larger scale. Devolved budgets though must be a fair deal and not an opportunity for central government to make further cuts and then leave the blame in the locality. Devolution, if it is to work well, must come with new and fair legislation around taxation and proportionate allocation of resources.

All of this is only possible with the right workforce. I completely agree that we need both short-term and long-term strategies. I am not yet confident that enough work is being done at a predictive analytical level to really work out what kind of workforce we will require, if we shift to a fully integrated, population health model. This is the kind of workforce we must then build and it will by its very nature, be much more community and relationally focussed. This will allow us to build culture from the ground up and create the kind of working environments that are healthy and well, enjoyable to work in and therefore with a high retention level of staff. Perhaps our short term solutions need to be less reactionary and more proactive in building towards the future we need. Perhaps there are also more short term international opportunities and partnerships to be built whilst we plan for our reimagined future.

In making all of this happen, I think we need a little caution in too much over-comparrison with the American insurance-based systems. The ICS development we see there is based on a very different model and can look very appealing, because it overlooks too readily the 50million Americans who cannot afford a decent level of care. Yes, there are some impressive things to learn and some very data savvy things we can apply into our systems, but the fundamental differences between our ideologies and practices must cause us to pause and think about what is transferable and what we can do diffferently to ensure that everything we do works to close the health inequality gap, rather than widen it. This is where our greatest test will be. It is too easy when creating new agreements with the public to work with those who are already highly motivated to change. In so doing, we might actually make things worse, rather than better in terms of inequality. It is going to take determined effort and brave focus to ensure this doesn’t happen.

In short (!) I am very grateful for this paper and the issues it highlights. It deserves real contemplative reflection and a commitment by all to embrace this future together. We cannot achieve population health and the tackling of health inequalities alone, but together, we can.

Joanne warren

Position
Business Owner,
Organisation
Sunrise Home Support
Comment date
22 July 2018

As an ex Environmental Health Officer I can confirm that I have had many a conversation with medical health professionals over the need for more funding in prevention rather than it all beings sucked up into cure. After 27 years I gave up and left Local Government. I was tires of our view being treated with disdain and our over 100 years of achievements being dismissed. I now have my own business as an Independent Advocate supporting older people an their families trying and navigate the broken system that exists between the NHS and Social Care. I sometimes think I am a glutton for punishment. I do hope your advice and this report is heeded.

Steve Iliffe

Position
Emeritus Professor of Primary Care for Older People,
Organisation
UCL
Comment date
16 September 2018

At the informative meeting on Priorities for the 10-year plan, on September 13th, Caroline Clarke from the Royal Free Trust said she had been having the same conversations about the NHS since she joined it in 1991. Thinking about this I came to the conclusion that my experience was similar, but had a slightly earlier start date, in the early 1980s. If the conversations are the same, is it because we cannot remember what was said before, or is it because talking is a way of avoiding action and conflict?

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