Providing care at home will not save money for NHS in next five years, Monitor says

BMJ 2015; 351 doi: (Published 14 September 2015) Cite this as: BMJ 2015;351:h4889
  1. Nigel Hawkes
  1. 1London

New models of care being promoted in the NHS in England are unlikely to break even within five years, even if well designed, the health service regulator Monitor says in a new report.1

Its analysis of the financial impact of models that aim to provide care closer to home showed that, even under the most optimistic assumptions, savings would accrue only if they reduced the need for further investment in acute care trusts. “Schemes can deliver care at lower cost, but it’s pretty marginal,” said Chris Walters, Monitor’s chief economist, at a conference held by the Reform think tank on 9 September.

New models of care are the cornerstone of NHS England’s Five Year Forward View and are being developed at vanguard sites across the country.2 The future of the NHS depends on them, NHS England’s chief executive, Simon Stevens, has said.

Monitor’s analysis did find that four of the modelled schemes—short term treatment in a community rather than an acute care hospital; telehealth; rapid response and supported discharge schemes that aim to reduce admissions and speed up discharges by providing care at home; and reablement services—can all provide care at lower cost than in an acute care trust. But they were most likely to do so when they substituted for investment in new hospitals. They could in theory save money if they replaced existing capacity, but Monitor said that this would be difficult to achieve, and providers and commissioners would need to be sure that the new schemes worked before closing wards or reducing beds. “Taking this in to account, we find it unlikely that even well-designed schemes will be able to break even in five years,” the report concluded.

Justin Whatling of the IT company Cerner said that similar schemes in the United States had achieved cost savings but that many had failed to meet quality targets. The more successful schemes had taken five years to achieve success. “It is hard to deliver new models when still being held to account on the old models,” he said. “Hospitals will look different so we have to change how we hold them to account.” An example was length of stay in hospital: the current pressure is to save costs by reducing it, but if more patients are treated in the community, those in hospital will be those with more serious illness and may need longer rather than shorter stays.

Payment systems also needed to change, Whatling said, because evidence showed that capitated budgets provided greater incentives for change. Walters said that Monitor was doing its best to facilitate change within the existing tariff system, given that legislation would be needed to change it.

There was less consensus in a session that examined whether the NHS was “a learning organisation.” Barbara Young, a former chair of the Care Quality Commission and now chief executive of the charity Diabetes UK, found little evidence of learning. More was known about diabetes than any other condition, audits were comprehensive, a huge amount of information was available—yet remarkably little of the evidence was implemented, she said, and very little was done about making best practice universal.

“The people [in the NHS] we have to worry about are the duffers,” she said. “They need to be helped to take simple information and make sure it is adopted. Commissioners don’t read the data; the poorer ones haven’t got the gumption and need help. We need to see that those overseeing commissioning actually do that job.”

Steve Field, chief inspector of general practice at the Care Quality Commission, said that more than 2000 general practices had now been inspected. Four per cent of these were outstanding and 4% inadequate, with the rest falling between the two extremes. The poorly performing practices, which covered more than 330 000 people, were “chaotic and disorganised, with a poor culture of safety and learning, deaf to complaints and with no outcome measures,” he said. “It’s completely unacceptable. The lack of quality has been known about for donkey’s years, and people should have intervened.”

David Rosser, executive medical director at University Hospitals Birmingham NHS Foundation Trust, said that the secondary care sector did learn but that the question was what it should be learning. The health system’s leadership was fractured, and contradictory messages were being delivered, he said, and CQC reports made different recommendations about the same organisation, while NHS England and Monitor offered conflicting advice.

“We’re seeing a return to type as money gets tight,” he said. “Some targets are too complex. The cancer target is 808 pages long. Targets are important, but they can’t be that complicated.”


Cite this as: BMJ 2015;351:h4889


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