Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Wishful thinking won’t save the NHS

BMJ 2016; 354 doi: (Published 22 August 2016) Cite this as: BMJ 2016;354:i4544
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

Annual funding for the NHS is falling ever further behind increases in activity costs. The government’s promise in 2015 of an additional £8bn assumed heroic savings of £22bn over a five year parliament, which health policy experts think unattainable.1 2 The NHS now has the biggest deficit in its history.3 4

Various NHS leaders, policy makers, and commentators propose big ideas for better value and quality.5 The strength of the evidence base varies, but, even where the evidence for magical solutions is stronger, can these ideas save services from the financial precipice? Here’s my personal classification of five broad proposals that are often mooted:

  • Primary prevention and reduction of health inequalities. In turn, this could reduce the burden of disease by tackling lifestyle factors and wider determinants of health—for instance, by compressing morbidity into the last years of life or reducing prevalence of conditions such as diabetes or dementia.6 7 These approaches should include wider community elements such as housing and transport and a focus on wellbeing and independence.8

  • Shifting care closer to home. The NHS England boss, Simon Stevens, claimed that we’d need no nursing homes if we invested in telecare and telehealth.9 Digital solutions are often promoted as a magic key to more efficiency and better healthcare.10 11 12 The health minister Lord Prior said that we should close hospital beds quickly to save the system.13 Repeatedly, commissioners plan to reduce emergency hospital activity, assuming that alternatives in the community are cheaper and more effective and that hospital beds are actually closed and stay closed.14 15

The NHS now has the biggest deficit in its history

  • Personalised care and supported self care. More proactive, anticipatory care coordinated for individual patients, rather than for diseases, can reduce the chance of complications and crises.16 17 This secondary prevention is for people who already have long term conditions.18

  • Integrating services. Integrated primary, secondary, mental health, and social care ensures that we have the right patients in the best value service for their needs at the right time.19 20 This theme runs through NHS England’s admirable New Care Models report.21

  • Minimising unwarranted variation and standardising processes. Clinical pathways, activity, outcomes, and NHS operational practices vary tremendously geographically, as the NHS Atlas of Variation and Lord Carter’s report on hospital efficiencies show.22 23 Some savings could be achieved by getting the rest as good as the best. And the Carter review identified £5bn of potential savings.

If we implemented each of these at scale and pace, could they save the NHS from its current financial and workforce crisis and declining performance? Surely only a funding settlement that meets demand and funds an adequate workforce will do so. Will that happen? Now, that really is wishful thinking.



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