The Autumn Statement is the perfect time to remind ourselves that the health service can no longer succeed in isolation, argues Stephen Dorrell
In last year’s spending review, George Osborne announced an immediate cash injection for the NHS and plans for further significant increases for both health and social care towards the end of this Parliament.
There were always at least three basic problems with this plan:
- First, the immediate cash did no more than cover historic deficits; it made no allowance for current and continuing increases in demand for NHS services;
- Second, planned reductions in spending in other public services were always going to stoke demand for NHS services. This is most obviously true in social care, where reductions result in more demand in GPs’ surgeries, more hospital admissions and more delayed discharges from hospital. It is also true that reduced spending on other local services including social housing, schools and public health all have the same effect of increasing demands on the NHS;
- Third, even if the arithmetic did add up by 2020, the next two years presented an implausible scenario of continuously rising demand and virtually flat real resources.
The Autumn Statement provides Philip Hammond with the opportunity to address the unreality of the public spending plans he inherited and provide a framework within which leaders of the NHS and other local public services have a realistic chance of meeting the expectations of their communities.
Last December NHS chief executive Simon Stevens asked NHS leaders to engage with local authorities to develop local plans which look across the organisational silos which disfigure many public services.
After a generation in which the NHS has been subject to successive rounds of increasingly pointless bureaucratic reorganisation, leaders of NHS trusts and clinical comissioning groups have been asked to meet each other, together with their local authority counterparts and other interested parties, to develop plans which focus on eliminating wasteful process and improving care for citizens.
This call for NHS and local government leaders to prepare “sustainability and transformation plans” has inevitably generated its own jargon and process – and it has certainly worked better in some areas than others – but it represents a move towards joined-up thinking about public services which is long overdue.
It would seem to be little more than common sense that provision for social care should rise at least as fast as provision for the NHS
As this process has developed, the linkages between the NHS and social care have become increasingly and glaringly obvious. This recognition led Simon Stevens to tell an NHS audience in the summer that “were extra funding to be available, frankly we should be arguing that it should be going to social care”.
It is not difficult to see why. It is unsurprising that a growing older population leads to increased demand for NHS services, but failure to provide for increased demand for social care compounds the problem. It is simply perverse that over the last decade social care spending has been flat at a time when NHS spending has risen by a quarter. At a time when demand from elderly people accounts for a rising share of NHS activity it would seem to be little more than common sense that provision for social care should rise at least as fast as provision for the NHS.
But even that approach misses the point, because it understates the opportunity that is available from improved partnership between different public services. We know that spending on housing support, home care services, mental health support in schools, or probation services for young offenders all contribute to wellbeing and that if we cut spending on these services, the result is increased attendances in accident and emergency departments.
Too often the NHS becomes the National Illness Service – treating illnesses and conditions which should never have arisen
We know these things but we persist in believing that the NHS is a special case. Politicians of all parties claim credit for protecting the budget of the NHS while cutting other public service budgets which help people stay healthy. The result is that too often the NHS becomes the National Illness Service – treating illnesses and conditions which should never have arisen, but which developed because we failed to take advantage of opportunities to prevent it happening.
That is bad social policy and insane economics, but it is what we do. It is the perverse consequence of protecting NHS budgets at a time when the resources available to other public services are reduced.
The NHS is one of the most efficient healthcare systems in the world, but it cannot work efficiently in isolation. Public services work most efficiently when they work together. The NHS must be a fully engaged partner with other local public services, and increasingly local people, through their councillors – and sometimes their directly elected mayors – must have a voice in the way its services develop.
The NHS can no longer be a “city on the hill”.
Stephen Dorrell is chair of the NHS Confederation and a former health secretary