09 JAN 2017

The current pressures in the NHS

I wrote the following article for the British Medical Journal (published on 3rd January 2017)

The current pressures in the NHS can be traced back to 2009 and what became known as the Nicholson challenge. In the aftermath of the economic crash this ushered in an unprecedented period of efficiency savings against a headwind of rapidly rising demand and costs. The incoming coalition government then imposed a disruptive and demoralising reorganisation that distracted from the key challenges. Rather than seizing the opportunity to integrate health and social care and to design a sustainable long term financial settlement, the Health and Social Care Act 2012 led to greater fragmentation at a time when our demographic changes demanded a different approach.

In the decade to 2015, the number of people living to age 85 and beyond increased by 31%.1That is a cause for celebration, but there has been a striking failure to plan for what this means for health and social care. The same is true for the rapidly rising cost of preventable conditions and expensive new drugs and technologies.

Over the last parliament, funding for the NHS increased annually by an average of just 1.1%, far below the actual increase in costs or the long term average of around 3.8% since 1978-79.2 The real terms increase in Department of Health spending for the current review period is just £4.5bn3 (€5.3bn; $5.5bn) and will result in reduced spending per person.2 The accompanying cuts to social care combined with a serious workforce shortfall have left more than a million older people going without the personal care that they need to live with dignity in their own homes.4 It is no surprise that so many are ending up in more expensive settings in an already overstretched NHS.

The political response to a health and care system in severe distress, and more importantly to the people it serves, has been dismal. No one listening to the yah boo of debate in the Commons would be filled with optimism. There has been a failure to grasp the scale of the financial challenge facing both health and social care and the consequences and inefficiency of their continuing separation. A serious shortfall in capital, as a result of ongoing raids to plug deficits, is undermining the prospects for the transformational changes necessary to produce future savings.

Likewise, area based joint commissioning is at risk if the financial squeeze is so unrealistic that health and social care retreat to protect their own budgets. Sustainability and transformation plans hold the possibility of moving away from a competition based approach to one based on integrated commissioning but they must be realistic and supported by the funds to deliver.

There have also been missed opportunities in public health. In her first speech on the steps of Downing Street, the Prime Minister, Theresa May, spoke compellingly of tackling the burning injustice of health inequality. That ambition now needs to be matched by effective cross government policies across the wider determinants of health. It will also require investment in public health in order to achieve the radical upgrade in prevention which underpinned the Five Year Forward View.5

At her recent appearance before the Liaison Committee of all select committee chairs, Theresa May confirmed that the government is working on a new settlement for social care but also that this doesn't currently include the NHS or involve other political parties. She should urgently revise her terms of reference to include them both.

The public has repeatedly made clear the value it places on our NHS and that it wants to see it properly funded. The financial challenge of providing sufficient funding for health and social care to cope with inexorably rising demand will be the same for whichever party is in power over the coming decades. It is in all our interests for them to work together to agree a way forward compatible with the founding principles of the NHS. Political instincts, however, have tended to focus on division and to duck the problem through arguments about data.

The most remembered statistic of the EU referendum campaign was the £350m a week for the NHS—a cynically deployed and rapidly disavowed non-fact for which no one can be held to account. Misleading data have consequences. If the chancellor believes that the NHS is receiving an extra £10bn, it is easier to see why he and the prime minister might resist the calls for more, especially having overseen far reaching cuts to the Ministry of Defence and the Home Office in their former roles.

The public has a right to expect accurate and consistent figures on total health spending, and it matters that we correctly insist on the true figure of £4.5bn. It also matters to keep setting out the facts on rising demand as well as the efficiency, fairness, and value of our NHS.

I often meet health professionals who think that politicians have no grasp of the scale of the problems they are facing. Never underestimate the impact you can make during a personal visit to MPs' surgeries or through an invitation to your workplace. We need as many MPs as possible to understand the urgency that they work together to find a sustainable long term settlement and the consequences for their constituents of political failure.

References

  1. Care Quality Commission. State of care. 2016. http://www.cqc.org.uk/content/state-of-care
  2. Office for Budget Responsibility. Economic and fiscal outlook, March 2016. http://budgetresponsibility.org.uk/efo/economic-fiscal-outlook-march-2016/
  3. Commons Health Select Committee. Impact of the spending review on health and social care. 2016. http://www.publications.parliament.uk/pa/cm201617/cmselect/cmhealth/139/13902.htm
  4. Age UK. 1.2m older people don't get the social care they need. 2016. http://www.ageuk.org.uk/latest-news/12m-older-people-dont-get-the-social-care-they-need/
  5. NHS England. Five year forward view. 2014. https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

3 comments

As a Wirral GP in my mid 50s I whole-heartedly agree with much of the above, especially the first sentence of your final paragraph, sadly I very much doubt that individual MPs have any impact on government policy however sympathetic to the GP 'cause' they maybe. Assuming the majority of the your colleagues on the Health Select Committee share your views, why is it that you have not been more effective in persuading the Government to change tack? I see from your Twitter feed that you have criticised Thersa May's latest demoralising attack on GP's, but I believe a far stronger, more public, response from you is essential if you are to retain any credibility in the eyes of the medical profession. If the PM continues in this vein unchallenged may I suggest that you should carefully consider your position as chair of the committee?
- Neil Cookson

I do not support the Conservatives but I admire and respect what Sarah Wollaston is saying and doing about the N H S . She obviously cares about the way in which is it currently being undermined and I hope that there is some way on which we can do some perching to save a system that was widely admired and which did so much good for our people and their health. I hope she gains support and tHat she is able to achieve what she is trying to do
- I do notservatives but I must say how impressed

I do not support the Conservative party but I wholeheartedly support and admire what Sarah Wollaston is saying and doing. Our Health Service did so much for the nation's health and was admired world wide. Now doctors and nurses are being over stressed and hospitals are under far too much pressure. They still do great work under enormous pressure but they are reaching breaking point. I hope Sarah can get support and that we can save our wonderfully caring system from disintegrating under too much pressure and inadequate support. Go for it Sarah, and your supporters"
- Audrey Webb

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