Labour’s tenure has seen massive progress in areas including access to services and cardiac and cancer care. But the greatest changes must now follow fast - things can only get different
Historians will look back on the noughties as the decade in which Labour increased NHS spending at a much faster and sustained rate than ever before. They will also observe substantial improvements in patients’ access to services and in high priority clinical areas like cardiac and cancer care. Spending increases have enabled many more staff to be employed and they have resulted in the acquisition of additional medical equipment and the rebuilding of many hospitals and surgeries.
The additional spending has meant doing more of the same and innovation is thin on the ground
On the other side of the balance sheet, the scale of Labour’s extra investment has not been matched by increases in activity, meaning that productivity has fallen. A main reason had been the failure to realise the potential of the new contracts for GPs, consultants and other staff. The increases in pay that resulted from these contracts have absorbed much of the additional spending on the NHS but there is no evidence this has benefited patients. Additional spending has meant doing more of the same and genuine innovations in care have been thin on the ground.
Despite this, Labour can claim with justification to have moved the NHS out of intensive care and into active rehabilitation during its stewardship. The most recent British social attitudes survey shows a real improvement in the public’s views on the NHS, and the international surveys conducted by the Commonwealth Fund also indicate continuing progress in relation to other countries. While there is much to do to restore the NHS to full health, there is also a solid record of achievement on which to build.
Building on Lord Darzi’s next stage review, one of the biggest challenges for the future is to shift from increasing the quantity of care to improving quality and patient safety. Greater emphasis must also be given to care outside hospitals and taking prevention seriously.
More work to do
The evidence shows that although premature deaths from cancer and particularly cardiovascular diseases have been falling quickly, the UK has more work to do to improve cancer survival rates and to tackle risk factors such as obesity and alcohol misuse. And as the recent Marmot report demonstrated, health inequalities persist even as all groups in the population experience improvements in health. The NHS has its part to play in tackling these issues in partnership with other agencies. Equally important is the need to rise to the challenge of long term conditions. The demands of an ageing population, in which conditions such as heart failure and dementia are increasingly prevalent, risk overwhelming the health and social care system. To avoid this, the same attention must be paid to long term conditions as has been paid to improving access to acute services.
This includes giving much more attention to self-management support and to care planning; testing out the use of personal health budgets to empower people to make their own choices about their care; and ensuring that home based technologies of proven value are made available to enable people to remain independent for as long as possible. The vision should be of the “home as the hub” for care, with admission to hospital or residential facility becoming a last resort.
In supporting people in managing their conditions, NHS organisations must work in partnership and foster greater clinical and service integration. The benefits of integration can be seen in long established health maintenance organisations in the US like Kaiser Permanente, which achieves good outcomes for its members and makes much less use of hospital beds than the NHS. Kaiser delivers these results through a model of care in which capitation funding creates incentives to give priority to upstream interventions and minimise costly inpatient care.
Another example of the benefits of integration in the US is the Veterans Health Administration, which was transformed in the late 1990s from a fragmented hospital centred system into a series of regionally based service networks. It reduced its use of hospital beds by more than 50 per cent while improving the quality of care. Both the Veterans and Kaiser emphasise the role of doctors in driving improvements in care, supported by the use of information and the electronic medical record. They also work relentlessly to reduce variations in how services are delivered and to implement best practice systematically.
Within the NHS, Torbay has been adapting lessons from Kaiser Permanente in improving services for its population. This is being done through establishing integrated health and social care teams focused on meeting the needs of a rapidly ageing population.
The results can be seen in reduced use of hospital beds and in lower emergency admissions among over-65s than in areas with a similar demographic profile. Torbay has also made progress in reducing delayed transfers of care. The recent state of care report from the Care Quality Commission drew on the experience of areas like Torbay to suggest that around £2bn might be released if other parts of the NHS were able to achieve similar reductions in hospital use.
As all of these examples illustrate, the healthcare system of the future needs to make a reality of care closer to home. Services out of hospital must be available 24/7 for people with urgent needs, with much better integration between primary care, community services and social care. If a major objective in the noughties was to increase planned hospital admissions to reducing waiting for treatment, then in the next decade the focus has to shift to seeing unplanned admissions as a system failure and cutting hospital capacity.
To make this happen, hospitals must be viewed as cost centres rather than profit centres. Incentives within the NHS need to be aligned to support the provision of care in the most cost effective locations rather than simply rewarding more episodes of care under payment by results. A radical rethink of the flow of resources within the NHS is required to facilitate care closer to home.
Planning acute services across hospital networks is fundamental in bringing about these changes, as is a much more sophisticated understanding on the part of politicians as to why changes are desirable. Making trade-offs between maintaining the public’s access to services and improving outcomes has never been easy but these trade-offs are simply inescapable at a time of funding constraints. NHS leaders need to be taking this debate to politicians and the public as a matter of urgency.
The other urgent need is to find a fairer way of paying for long term care. The good news is that the weaknesses of the system are recognised across the political spectrum. The bad news is there is as yet no consensus on alternative arrangements. A partnership approach in which care costs are shared between the public purse and individuals, as the King’s Fund has proposed, should be actively pursued.
At the heart of this approach is the need for much greater certainty as to what will be paid for publicly, and what people approaching retirement will be expected to contribute. Equally important is the need to develop new ways of supporting people who require long term care, centred on the vision of the home. Implementing this vision requires the NHS to be much more receptive to the independent sector and a willingness to embrace the disruptive innovations that funding pressures demand.
These pressures mean that doing more of the same is no longer an option. The mantra for the next decade has to be “doing things differently”, making a virtue of scarce resources to bring about the shifts in care that have been long been discussed but have yet to be implemented.
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