The Health and Social Care Act, which came into force two years ago, probably represents the biggest shake-up of the NHS since its inception. The debate sparked by the act has led to the future of the NHS becoming one of the most hotly-discussed topics in the run-up to this year’s election.
Given the controversial nature of the act, there is a surprising measure of consensus among the healthcare sector about what direction the NHS needs to take. The Five Year Forward View, published by NHS England last year, presents a strategy for the NHS that transcends party political boundaries. Its widely-welcomed recommendations include more integrated care using multi-specialty providers, a greater emphasis on public health and removing the barriers between health and social care, and physical and mental health.
The biggest issue is funding: everyone, from trade unions to thinktanks, is agreed that the NHS needs more money. By 2020-21, the NHS will need £30bn more than it receives at present, just to keep NHS spending constant. The Five Year Forward View estimates that some of that could be addressed through new ways of working, but the NHS would still need £8bn a year over the next five years to close the gap.
But will politicians deliver? The British Medical Association (BMA) has launched a No More Games campaign, arguing that for too long politicians have recycled a small amount of money from one part of the NHS to another, instead of committing to proper long-term funding.
Rob Webster, chief executive of the NHS Confederation, says it’s time for politicians to be honest about the real costs involved – and not pretend that efficiency savings will solve everything. “Change costs money, and some of the parties think you can save money by making the change happen,” he says. “But double running costs, the cost of new IT, the way you change the use of buildings, all cost money before they save money.”
Staffing is a major issue for the unions, who argue that the NHS needs both to recruit more staff and to increase pay. Barrie Brown, national officer of health for Unite, says that means addressing shortages in healthcare scientists, clinical psychologists and speech and language therapists, not just doctors and nurses. He adds that the current government is the first to ignore the recommendations of the NHS pay review body set up by Margaret Thatcher: “That has created an impact on staff morale and an attitude about how they are valued, which we haven’t seen before, and an incoming government has got to restore that.”
Both Unite and Unison support Labour’s plans for a repeal of the Health and Social Care Act – specifically a move away from the use of private providers. Christina McAnea, Unison’s head of health, says the act was “a huge waste of money and has caused untold damage to day-to-day health services” and says the NHS should be reinstated as the prime provider of care.
There is consensus that the act has proved disruptive, and that further reorganisation would be detrimental to the NHS. Dr Mark Porter, chair of the BMA council, argues that time and energy invested in restructuring the NHS has not resulted in improvements. “Structural reorganisation is not the answer. What high-performing health services do is examine how to make their services better, not spend their time re-sorting which body provides what.”
The integrated model of care outlined in Five Year Forward View – in which GPs, nurses and other health providers work in teams to provide local care – is also broadly welcomed. But Chris Ham, chief executive of the King’s Fund, says a more integrated model will need to be supported by commissioning that makes use of alliance contracts, prime provider and lead provider contracts. Care should be paid for through capitated budgets rather than through payment by results: “We need to align the payment systems so that the incentives that face providers support integrated care rather than work against integrated care.”
That integration must, argues Webster, include a recognition that physical and mental health are “two sides of the same coin”. But it extends to other areas. Caitlin Barrand, head of policy at Breakthrough Breast Cancer, says the NHS is currently dominated by silos and a lack of communication. “Critically for the common cancers, including breast cancer, we have some services that are commissioned at a national level, for example chemotherapy and radiotherapy, and some that are commissioned locally,” she says.
More localised decision-making is also a priority, and healthcare providers welcome the recent decision to allow Greater Manchester councils control over spending. Ham, however, is concerned about the “confusing and complex” arrangements created as a result of the Health and Social Care Act. “There’s a sense in which nobody is in charge at a county level or a city-wide level when it comes to getting different organisations to work together both to implement the Five Year Forward View and to deal with the growing financial and service pressures within the NHS,” he says.
These changes will need to go hand-in-hand with improved methods of measuring outcomes. Webster argues that long A&E waiting times, for example, should the responsibility of all primary and community care providers, not just hospitals. He argues: “What we need is a simplified outcomes framework that aligns across healthcare, public health and social care.”
No one disagrees that a greater emphasis on public health should also be a priority for an incoming government. Porter expresses frustration with the current government’s record on public health interventions, citing the about-turns on introducing plain packaging for cigarettes and the spat on minimum unit pricing of alcohol as “examples of things which are really good evidence-based public health interventions that are being played for electoral advantage”.
The focus on public health should include a recognition of the links between health and other policy areas such as housing and the environment, argues Barrand. “To make progress on prevention, it’s not just a job for the NHS, it’s a job across government,” she says.
Despite the consensus about the way forward for the NHS on matters such as integrated care and public health, the sticking point is whether an incoming government will commit to the funding and staffing levels required to deliver those changes. As Porter says: “What we really need is this root-and-branch determination to say what is going to happen about the resource gap that is opening up and to step back from the political games.”
