The three crises facing the NHS in England
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5495 (Published 14 October 2015) Cite this as: BMJ 2015;351:h5495All rapid responses
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Chris Ham is right that the NHS is in crisis and that ministers need to be honest with the public about the consequences. But he misses the most serious long term problem underlying the crisis. As do other commentators.
All the immediate solutions involve either an urgent injection of more money or significant cutbacks in care. Neither satisfactorily address the underlying problem but merely postpone the reckoning to some unspecified date in the future.
Perhaps the fundamental problem is that we don't spend enough. The UK spends a lower proportion of GDP on health than many similar countries. But this metric is at best a dubious one for two reasons. Firstly, the fastest way to improve it is to have a major economic recession which makes no sense. Secondly, the experience of doubling the NHS budget (which happened in real terms during the Blair government) was that the recurrent budgetary problems didn't go away and were not even much postponed.
Some have argued that the problem is the commissioner-provider split and that abolishing it would immediately allow an extra 14% of the budget to be spent on more care. But this is based on a zombie statistic that has been widely repeated despite its lack of credibility (see the rapid responses to the Calum Paton BMJ piece that was one of the first to mention it: http://www.bmj.com/content/340/bmj.c1979 ). The lack of credibility of the 14% should also be obvious since the Scottish NHS continued to underperform the English NHS and saw no significant change in performance when it abolished the commissioner-provider split.
Others have argued that they NHS has run out of ways to "squeeze" more performance out of the current budget. There is an element of truth in this but only if we ignore everything other than top-down changes.
Top-down structural changes seem to have a very limited ability to drive improvement in quality or productivity (see more detailed commentary on this here: http://policyskeptic.blogspot.co.uk/2015/09/top-down-changes-wont-bridge... and here: http://policyskeptic.blogspot.co.uk/2015/09/government-policy-on-nhs-get... ). Even hospital mergers, which in theory should deliver economies of scale, in reality seem to lead to lower productivity (see, for example, the recent Centre of Health Economics study of hospital productivity: http://www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP117... ).
This failure of top-down initiatives points towards the real failure. The NHS is far too prone to spending money on short term palliative fixes than on investing in the things which might lead to sustained bottom-up improvement from better operational processes. In many cases extra money to solve short term crises is entirely misdirected and fails to achieve anything other than the appearance of action. For example, the NHS has probably spend close to £1bn in the last 3 years trying to avert the regular winter crisis in A&E. But little of this money has been directed at the most significant cause of A&E problems (the poorly managed flow of patients through acute beds) and a great deal has been spent on initiatives that are unlikely to make any difference at all to A&E performance (see the Monitor report analysing the key causes of A&E problems: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil... ).
The real fundamental problem is the NHS's inability to invest intelligently in bottom-up operational improvement which, over time, will yield far larger benefits in productivity and quality that any top-down initiative. Real sustainable change comes from small incremental changes in each specialty and in each ward supported by management and information systems that enable medics and nurses to identify and measure the impact of better ways of organising care. But this requires investment (and some in the politically unpalatable areas of management skill and IT) and not just short term palliative actions to address immediate problems. But the system seems so concerned to fight fires in the short term that there is no time, effort or money left to install smoke detectors or to design and build fireproof systems.
Whatever extra money is conjured up now, it will not yield a better NHS tomorrow if the money is spent firefighting rather than fixing the causes of the fires. This is the real crisis facing the system that neither Ham nor other commentators address.
Competing interests: No competing interests
In his editorial, Chris Ham highlights three crises facing the NHS in England [1]. Mental health services have suffered even greater challenges due to the impact of the economic downturn on employment [2], reduction in benefits, housing and community supports from rationalisation of local authority services and third sector organisations. Suicides are rising [3], beds have reduced and recruitment and retention in an already shortage area has become even more difficult against a backdrop of safer staffing initiatives [4]. Then the differential deflator on block contracts [5] has confounded the problem institutionalising the perennial vulnerability of mental health budgets to being raided.
Political commitment to achieving parity of esteem between mental and physical health services by 2020 promises additional funding for the access and waiting time standards [6] but can it deliver - funding is not ring fenced. Yet better access and delivery of mental health care could have an impact across the system – there are a multitude of patients, who, due to poor access to mental health services use emergency services, primary care, accident and emergency and general hospital care.
Promotion of resilience and independence can reduce reliance on social care, benefits and the criminal justice service: economic recovery can therefore only be promoted by providing employees, parents, indeed anybody who suffers to a greater or lesser degree with mental illness, with effective but heavily rationed evidence-based treatments.
References
[1] Ham, C. (2015). The three crises facing the NHS in England. British Medical Journal. 351:h5495.
[2] Dorling D. Unemployment and health. BMJ, 2009; 338, b829.
[3] The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report 2015: England, Northern Ireland, Scotland and Wales July 2015. University of Manchester.
[4] Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. www.midstaffspublicinquiry.com/report.
[5] NHS Providers (2015). Funding for mental health services: moving towards parity of esteem?
[6] NHS England. (2015).Guidance to support the introduction of access and waiting time standards for mental health services in 2015/16.
Competing interests: No competing interests
Chris Ham describes very clearly the scale of the financial crisis facing the NHS., and rightly points out that a greater proportion of our GDP could easily be justified in helping to resolve some of these problems. However, he too easily accepts at face value the present government's good faith and commitment to the NHS, and fails to explore the possibility that the financial crisis is all part of a plan to make the NHS unworkable so that it can be fragmented and privatised. The latter explanation would fit in better with the record of the actions of this government, as opposed to their verbal pronouncements. In support of this thesis is the almost constant negative campaigning against the NHS and attacks on doctors, most recently with the campaign for a Seven Day NHS and attempts to impose contracts.
While everyone repeats ad nauseam the increasing burden of an ageing population as one of the main reasons for the current problems, the fact remains that the NHS is still the most cost-effective way of meeting the needs of the whole population. Unless the aim is to withdraw free medical care from everyone over the age of say 75 and let the poorest of them die from lack of treatment, then the NHS must be preserved from all these attacks.
There is one easy solution already available, and this is to abolish the Internal Market once and for all. In 2010 the Select Committee on Health divulged that even under the Labour Government the cost of administering the Purchaser-Provider Split was already 14% of all NHS spending. The current cost must have risen to something like 25% with all the costs of commissioning and tendering. The only purpose of the internal market was to soften up the NHS for privatisation, and it should now be abolished. Scotland and Wales have already successfully abolished the market in their devolved versions of the NHS and the sky has not fallen in.
The freeing up of this proportion of NHS spending for patient care could solve almost all the above problems at a stroke.
To this end the profession should be putting its weight behind the NHS Reinstatement Bill, which includes the above measures as a key element. It comes up for its second reading in March.
Competing interests: No competing interests
In the eyes of Chris Ham, the ‘crisis’ in the NHS in England is confined to hospitals. No mention is made of the many challenges facing primary care; or to mental health and community services. For example, in recent years, primary care services in England have seen a reduction in their proportion of the NHS budget from around 11% to 8.4% with further reductions likely in the future unless government spending plans change.[1] Primary care, community and mental health services have all been left in a fragile state and are struggling to cope with their current workload. Increasing proportions of people are reporting difficulty in getting timely appointments to see their GPs, and there are growing recruitment and retention problems in primary care. Primary care, community and mental health services are the backbone of the NHS and if their situation continues to deteriorate, this will inevitably affect population health outcomes as well as putting further strain on the NHS hospital sector in England.
References
1. Majeed A. Primary care: a fading jewel in the NHS crown. London Journal of Primary Care 2013;7:89-91. http://www.tandfonline.com/doi/full/10.1080/17571472.2015.1082343
Competing interests: I am a GP Principal at the practice of Dr Curran and Partners in London.
One almost cant really analyse the issues without oversimplifying them to a point where the analysis becomes non-relevant, nonetheless........
On the one hand everyone understands that there is not enough money to do everything for everyone even though we choose to ignore this issue when it does not suit us on a given day, or if some aspect of research and development rewards us personally..
On the other there is an never-ending belief that there is some slack in the system that, when better managed clinically and in a general sense, will free up money or resource to be used in other pursuits.
We tend to focus on the second thing explicitly, largely because the first is odious to talk about and likely to be poorly received by one or other interest group. From time to time when some restrictive practice does arise, for instance denying access to new chemotherapy or recombinant immune modulation agent, the outrage is of course genuine and understandable.
Unfortunately after many years of trying to manage our way to better more productive health systems, it is unlikely we will find too many more low lying fruit as the popular saying goes.
As the focus changes more to limiting "waste" we will need tremendous courage to move the conversation from who should get what, to who should not get too much, not in a general sense but in a specific sense.
This second conversation is much harder since it involves everyone being reasonable, something that has never happened in the history of mankind, or active discrimination on the basis of age, frailty or some other indicator, something we have spent decades disavowing.
For example, when I started working in critical care practice in the late 1980's no person over the age of 60 years was admitted to the unit I worked in. In the 1990's when working as a reliever on a cardiology run, the then Professor trumpeted that fact that people over the age of 80 were not to be found in cardiology undergoing interventions, but were instead in general medicine by design.
We have come a long way.
In many ways health systems of a similar nature to the NHS are a step behind the cycle of investment and inevitable reductions that follow when times get tough. What will we learn from the NHS as it tries to deal with issues we have forecast for a long time, but kicked down the road to be solved at a later date?
What will we learn?
Competing interests: I am a practitioner of very expensive care
Re: The three crises facing the NHS in England
"The cause of the current financial crisis is not mismanagement but insufficient funding to deliver the care the public expects."
While this may be true it would be a mistake to assume that mismanagement has not contributed to the financial crisis. For example, one has only to look at the revolving door of redundancies and associated payments, followed by rehiring of many of these individuals into broadly equivalent positions. Other examples include the exorbitant fees paid to some consultants, and extensive use of agencies.
Competing interests: No competing interests