The NHS at 70

Concerns continue to be raised about the future of the NHS. With improvements in medicine, increasing survival rates, and health care costs rising sharply as we age, the NHS is a victim of its own success. The increasing costs of medicines, rising expectations and standards, and a period of relatively flat funding have led to demand outpacing resources. Recent funding increases have focused on tackling hospital deficits (£2.6 billion in 2015-16) rather than making services more sustainable. Over half of the British public (52%) now see the NHS as one of the biggest issues facing Britain, the highest level of concern since June 2002. In its 8th decade the NHS will also face the added uncertainty of Brexit, and what this might mean for a health and social care system reliant on overseas staff.

The key challenges are well rehearsed. They include:

– Does the funding settlement for health and social care need to be revisited, and is fundamental change to the funding model required?

– What do funding pressures mean for access to services and quality of care, and for the NHS workforce?

– Can the redesign of health services, and plans to integrate health and social care, improve outcomes and ease pressure on hospital services?

Funding challenges

Since 2010 real-terms health spending has increased by an average of 1.4% a year, well below the average annual growth rate of 4% over the past 60 years. It is not keeping pace with growing demand and increased costs. The whole will only increase by £4.5 billion in real terms over the five years to 2020-21, due to real-terms cuts in other areas of spending (including public health and education and training).

The squeeze on social care funding is also adding to NHS pressures: unnecessary A&E attendances, emergency hospital admissions and delayed hospital discharge.

A new settlement?

In the last Parliament, Select Committees, health think tanks, and organisations representing NHS staff, providers and patients called on the Government to revisit the financial settlement for health and social care. The House of Lords’ inquiry on the Long-Term Sustainability of the NHS recommended the establishment of an Office for Health and Care Sustainability to assess future demand and advise on funding allocations.
A variety of different funding structures for the NHS have been proposed, but appetite for major changes to the current model (funding through central taxation) seems to be limited. More changes to the way social care and public health services are funded are likely, though.

Waiting times and access

While most health services have maintained good quality care, A&E and other waiting times have worsened across a large majority of hospital trusts in England. With on-going financial pressures, concerns continue to be raised about the rationing of services, longer waits, higher eligibility thresholds, or decisions not to fund certain treatments, like fertility services.

NHS England has said the demand for planned treatment like hip and knee replacements is likely to continue to outstrip capacity, and suggests this may cause further increases in average waiting times. It is expected that hospitals will not meet the English NHS Constitution standard of 92% of patients waiting no longer than 18 weeks. The King’s Fund investigated the impact of financial pressures on specific services. It found that in genito-urinary medicine and district nursing, access to services and quality of patient care have been negatively affected.

As an alternative to local rationing decisions, calls have also been made for more systematic scrutiny of treatments that are not cost-effective. There is likely to be public and political opposition to stopping services, even when they are not supported by evidence.

Patient outcomes

The quality of NHS care is improving and outcomes for most major conditions are dramatically better than in the past, but stroke, heart
disease and cancer survival rates still lag behind the best performing countries in Europe, and within the NHS there is evidence of variation in care. A number of recent reports and reviews have exposed serious failures, and it is widely acknowledged that children’s mental health services need substantial improvement.

Workforce pressures

Although staff numbers have increased, in many areas there are problems recruiting enough nurses and GPs. Health and social care staff report increasing pressure and lower morale after a prolonged period of pay restraint. There are also fears that Brexit will make it harder to retain and recruit EU staff. There is a growing consensus that one of the biggest challenges facing the NHS is finding and keeping the right number of
people with the right skills needed to deliver high quality care.

Integration

Successive Governments, across the UK, have sought to integrate health and social care better by focusing on care outside the hospital – at the patient’s home or in their community. In England, the NHS Five Year Forward View (FYFV) called for better integration of GP, community health, mental health and hospital services, as well as more joined-up working with home care and care homes. Early results from parts of the country that have started doing this –‘vanguard’ areas – have seen slower growth in emergency hospitalisations and less time spent in hospital compared to the rest of the country, particularly for over-75s.

Sustainability and Transformation Plans (STPs)

STPs are intended to accelerate the implementation of the FYFV. The 44 STPs across England are expected to show how local services will improve quality of care, promote population health, and become more financially sustainable. There is likely to be a good deal of variation in the speed and scale of change across different STP areas, with Greater Manchester (Devo-Manc) providing the most advanced test-bed for devolution and integration. The chief executive of NHS England, Simon Stevens, has commented that several STP areas may, over time, become “accountable care systems”, fully integrating their services and funding for the population in their area. However, with concerns about possible cuts to local hospitals and lack of additional capital to set up new services, patient groups have called for the public to have more say.

Efficiency

NHS England has set out plans to use technology to deliver better care and meet rising demand. Three recent reviews have looked at potential to improve efficiency:

The Carter review (February 2016) considered unwarranted variation in productivity and concluded that NHS hospitals could save £5 billion each year by 2020-21 through measures such as better procurement and shared back office support.

The potential of digital technology to improve efficiency, and the challenges of implementing new IT systems in healthcare, were addressed in the Wachter review (September 2016).

The Naylor review (March 2017) highlighted how better management of the NHS estate could generate up to £5 billion (and land for 26,000 new homes). It also estimated that £10 billion of capital investment is needed to address the backlog of maintenance in the NHS, and to deliver STPs.

Conclusion

As the NHS approaches its 70th birthday, its founding principles of equal treatment for equal need, free at the point of use, still command huge public support. However, the NHS was originally designed to treat short-term episodes of ill health and is now caring for an ageing population with increasingly complex needs. A series of reorganisations have attempted to address problems that partly relate to this, including the split between NHS and local government services, particularly social care; the dominance of the hospital sector at the expense of community and mental health services; and the lack of investment in primary care and prevention.

Current calls for a political consensus on funding, a long-term approach to planning, greater public say in changes to services, and more investment in public health, have a familiar ring. But there is a sense that the current crisis is different from those in the past. Recent efforts to devolve responsibilities for health and to integrate health and social care are just the latest in the long line of reforms, and will face similar challenges. Devolution of health and social care in Greater Manchester may provide one model for the future of health and social care services, in England at least, but engaging with the public about what they want from the NHS is more important than ever.

This article is part of Key Issues 2017 – a series of briefings on the topics that will take centre stage in UK and international politics in the new Parliament.

For more on the NHS, please see Commons Library briefings on health services.

Image: Pills by Jamie Dobson. Creative Commons Attribution 2.0 Generic (CC by 2.0)

Devo-Manc

Since 1 April 2016, health and social care budgets worth £6 billion have been pooled across the Greater Manchester combined authority area, and funding decisions are made by a Joint Commissioning Board formed of all the regions’ CCGs and local authorities.

The NHS in 2030

The House of Lords’ inquiry on the Long-Term Sustainability of the NHS asked what the healthcare system of 2030 should look like. A number of consistent themes emerged:

1. The need to shift more care away from the acute sector into primary and community settings
2. Widespread support for closer integration of health and social care services
3. The need to resolve the current fragmentation of the health system and a move toward place-based systems of care