Dr Nick Mann – Written evidence (NHS0028)
No Health Service within EU or OECD countries has been shown to be better value for money in terms of cost-effectiveness and efficiency than the NHS system, taking into account quality and outcomes. If the UK has the fifth or sixth largest economy in the world, it also has a moral public duty to provide a health service funded to levels commensurate with that economic wealth.
It must be accepted by government that, if England is to continue to benefit from high quality healthcare for its population, it must commit adequate funding from taxation to the NHS in order to maintain that provision. This is not happening. To maintain sustainability, funding should at least achieve parity with average spend as %GDP compared to countries with similar economies and healthcare systems eg EU/OECD.
Current Health spending per capita, %GDP spend on Health in England, and acute care beds per 1,000 population are all the lowest of fourteen comparable OECD countries1.
If UK Govt continues its current policy of funding for the NHS to 2049, England will still have not reached the EU14 average funding levels for 20162.
The current £30bn NHS funding gap projection was modelled on the basis of flat funding for the NHS (0.85% increase per year 2015-2020) while health inflation continues at its historical level of 3% to 4% per year. The £8bn funding settlement was the absolute minimum required to close the gap, provided another £22bn of efficiency savings were found3.
The King’s Fund have dismissed productivity gains worth £22bn as unachievable. They have clearly stated that current provider deficits are not the result of provider organisation mismanagement; rather they are the consequences of a health system buckling under the pressure of demand without sufficient funding.
The claimed “£10bn extra” for the NHS 2015-2020 is in fact only £4.5bn of new money4. The other £5.5bn is money transferred from non-NHSE (NHS England) budgets and granted to NHSE instead. Although earmarked for “sustainability and transformation” infrastructure funding, the majority of this money will be used to backfill existing holes in NHS budgets caused by six years of underfunding.
The arguments for unsustainability of the NHS are false. The “ageing population” and “health tourism” have become shibboleths but are simply misrepresented. Approximately 40-60% of health inflation costs are attributable to rising technology and drug costs. The ageing population will account for less than 1% increase of GDP spending over the next forty-five years5. In fact, when the extra contribution to the economy of baby boomers - people working healthier for longer - are taken into account, the balance is a positive one for the health economy6. The additional strain of provision for the ageing population falls squarely in the social care sector, which has seen cuts to budgets of 31% since 20107. ‘Health tourism’ costs to the NHS are estimated to be around £70-300m annually8.
By controlling drug acquisition costs from pharmaceutical companies, a substantial proportion of NHS health inflation costs could be mitigated. It is important to note that, although pharmaceutical companies claim that their pricing reflects their research and development costs, many of the drugs brought to market have initially been developed by public sector research institutions and are later acquired by the private sector. The public purse thus pays twice. New treatments for Hepatitis C are a case in point; while undoubtedly cost-effective, drug pricing exceeds – by up to a factor of ten times - linkage to research and development costs9.
The immediate crisis in the NHS, and Trust deficits, did not exist in 2012. The causes of the current crisis have been static funding and staffing levels since 2009. In addition, there have been cuts to 57% of total hospital beds since 1987, including 72% cuts to beds for Mental Health10.
Although the number of FTE (Full-Time Equivalent) Consultants in England has increased by 25% since 2009, there has been almost equivalent reduction in the numbers of FTE Junior Doctors (all grades). FTE GP numbers have reduced by nearly 3,000 since 2009. The number of Nurses + Health Visitors has increased by just 2% since 2009. District Nursing FTE numbers have reduced by 48% nationally 2000-2014. Accounting for 5% population rise since 2009 and without any proportional increase in numbers compared to 2009, England has a current running deficit of 4,500 GPs, 3,000 Junior Doctors, and 7,800 Nurses + Health Visitors11.
NHSE’s 5YFV (Five Year Forward View) and current STPs (Sustainability and Transformation Plans) are predicated on cost savings by “New Models of Care” and “Care Closer to Home”. These premises include centralised models of acute provision, commissioning and support services. Models of “Integrated Care” include greater use of ‘self-care’, a downskilled primary care workforce backfilled with IT remote monitoring and remote consultations, financed by the sale of NHS estate which will entail the closure and selling off of England’s existing hospital infrastructure. There is incoherence between the visions of 5YFV and their implementation under STPs. While 5YFV’s vision of success is predicated on an upscaled primary care workforce, at least one published STP includes the reduction of the FTE GP workforce by one third by 2020 (accounting for population increase, a real terms reduction of 50% of the GP workforce by 2020)12.
In context of NHS England’s drive for major reconfiguration of services in England, it is important to note research evidence has shown that major acute sector reconfigurations do not save money13. In addition, transfer of care out of hospital and into the community may improve patient satisfaction, but it will not save money either, and may even lead to worse outcomes. The success of centralisation of specialised services for stroke, trauma and heart attacks was specific to those specialties and it was carried out with evidence-based strategic planning which was medically-led. These successes are not transferable to other medical disciplines.
It is likely that some productivity savings and quality improvement may be achieved by the RightCare programme, which has focused on evidence for reducing unwarranted regional variation in processes/outcomes of care by implementing population systems and programme budgeting, but any such savings will be very slow to evolve and almost certainly much less than the £11bn envisaged by Prof Sir Muir Gray14.
Therefore it is likely that 5YFV and STP will not save money in themselves, and any substantive savings will only be achieved by further cuts to an already overstretched existing workforce and infrastructure. Future sustainability predicated on further shifting care into the community cannot be achieved while the same plans diminish an already impoverished primary care workforce, and cuts to social care have already deprived 26% of older people of their home care packages. The NHS does not need further structural reforms and the system cannot bear further cuts to its infrastructure or workforce. The NHS needs adequate funding to provide a workforce, beds and infrastructure to a level commensurate with the UK economy, with comparable countries, and with the standard of care which citizens are entitled to expect in England.
The financial position of the NHS has deteriorated catastrophically since the inception of the Health and Social Care Act 2012. Research has shown that competition, marketisation and privatisation of health services have not improved outcomes for patients or proven to be cheaper for the NHS. Estimates of the costs of administrating the market process itself show increases from 6% to approximately 14% of the entire NHS budget, including £5bn recurrent annual costs, but not including the financial and human costs incurred by the many failed outsourced private contracts to date15. There is no credible evidence that the private sector can deliver health care to an equal or better standard for less money.
Some reduction in healthcare costs and demand may be anticipated in the longer term by prevention strategies. These are chiefly related to obesity and healthy eating, smoking, alcohol, and poverty/inequality. These factors are clearly the remit of government policy at a population level for public health and some require legislation to mitigate deleterious effects of industry-driven consumption.
Big data and informatics may improve quality of health research, provided that commercial interests in data acquisition do not over-ride privacy and confidentiality issues inherent in data sharing. Technology-driven remote monitoring and remote consultations have been shown neither to reduce healthcare demand nor costs, nor to improve outcomes for patients16,17,18. Further investment in NHS IT should therefore be restricted to that which improves data processing and connectivity between healthcare organisations and for medical research purposes.
The future sustainability of the NHS in England therefore depends on a government which is willing to commit to funding the health service commensurate with the level of quality which it expects to be provided. Future savings and cost controls need to be directed at the major sources of health inflation ie technology (against which one must balance the benefits of improvements in healthcare resulting from progress in technology) and spiralling drug costs (for which the NHS needs to maintain a strong position with respect to acquisition from the private sector).
Summary of measures for sustainability:
References: