Keep Our NHS Public – Written evidence (NHS0109)

1. Taking into account medical innovation, demographic changes, and changes in the frequency of long-term conditions, how must the health and care systems change to cope by 2030?

1.1    Legal framework and allocation of funds

• The first thing that needs to change is the wasteful competition made compulsory by the Health and Social Care Act 2012. The National Health Service Bill, due for its second reading on 4th November would reverse the 2012 Act and restore the legal responsibility of the Secretary of State for Health to provide a comprehensive health service in England. The 2012 Act was the culmination of managerial changes to the NHS which began with the introduction of general management in 1984, then the introduction of the internal market and the purchaser provider split in 1990.  Following this the use of the Private Finance Initiative to build hospitals in the late 1990s and the introduction of Independent Treatment Centres from the early years of this century, has meant that money has been wasted on non-clinical matters and repeated re-organisations which not only lose money but lose experienced staff and deplete the organizational memory. An important book about these changes is ‘The Plot against the NHS ‘(1).

The experimental ‘World Class Commissioning programme’ was examined by the Health Select Committee in 2009-10 (ref 2). They noted the increased transactional costs and ‘were appalled that four of the most senior civil servants in the Department of Health were unable to give us accurate figures of staffing levels and cost dedicated to commissioning and billing in PCTs and provider trusts’. They concluded ’If reliable figures for the costs of commissioning prove that it is uneconomic and if does not begin to improve soon, after 20 years of costly failure, the purchaser provider split may need to be abolished’. The next Health Committee under a different government did not follow this damning criticism up and all energies were directed to the white paper ‘Equity and Excellence ; Liberating the NHS’ which laid the foundations of the Health and Social Care Act 2012. With what information available it seems that administrative costs in the NHS rose from 5% in 1984 to 14% in 2003 when a lower proportion of the GDP was spent on health than currently (ref 3). The latest (conservative) estimate by the Centre for Health and the Public Interest is £4.5 billion, about 4% of the budget (ref 4) falling from a high of £8 billion in 2010.

• The second thing that needs to change is the allocation of money to the NHS which is considerably less than similar counties. This year the OECD changed the way that they calculate health spending to include some previously classed as social care expenditure but although this increases the proportion of GDP allocated to health that still leaves the UK 9th of the 12 counties with similar accounting systems. Estimates for 2015 are that Switzerland. Germany, Sweden and France will all spend over 11% of GDP whereas UK will reach 9.9% ( ref 3) With GDP about £2000 billion a year each 1% of GDP is worth 20 billion which means that if we spent the same proportion of our GDP as France does we would have over £20 billion more to spend on the NHS. In addition this funding should be guaranteed over at least a five year period to allow longer term planning to be enabled. The NHS needs at least 11% of GDP or £5,500 per person instead of the current approximately £4000.

1.2    Provision of services

• Although policy makers have been urging de-centralisation of services and ‘care closer to home’ there is remarkably little evidence to support their plans and the contention that this will be cheaper seems based on hope rather than hard evidence. What evidence there is suggests that implementing change is difficult and may well not save money (ref 5). Any major change to the structures on which our health system is based should only be made after rigorous analysis of properly designed pilot studies which should include patient evaluation of the services.
• A network of District General Hospitals (DGHs) needs to be maintained so that patients do not have to travel long distances to receive diagnosis and treatment. This is inconvenient for patients and their families and often costly and difficult if they have to rely on public transport which becomes more likely as they age. Longer journeys also contribute to air pollution and climate change.
• Each DGH should have a full range of surgical and medical specialties to ensure that patients with multiple conditions can be adequately cared for. Inter consultant referrals in hospital should be facilitated and the wasteful and time consuming business of sending patients back to their GP should be stopped. Consideration should be given to the provision of clinics for elderly people where consultants from different specialties work together so facilitating multidisciplinary working and preventing patient having to make multiples journeys to hospital. Specialist units centralised for well-evidenced clinical reasons should be continued but balanced carefully against the increase in average travelling time that follows.
• Each DGH should have access to smaller residential units where patients can be referred for rehabilitation and ongoing physiotherapy, nutritional advice, podiatry and monitoring of diabetic control. These units would be staffed by Health Care Assistants overseen by a qualified nurse on each shift , with access to a multi-disciplinary team including OT and physiotherapy, but patients would be encouraged to self care and cook for themselves and there could be facilities for gardening and outdoor exercise.
• A smaller number of tertiary hospitals for services such as stroke, major trauma, coronary care and vascular emergencies or other conditions which clinical research has shown to have better outcomes if admitted to specialist units, should continue in each sub-region. Care must be taken to ensure that the time of transfer to such a unit does not cancel out the benefit of the specialist care and research is needed to establish whether there are other conditions which would benefit from centralisation.
• The importance of good primary care facilities cannot be emphasised enough. It is the bedrock of our NHS and more money needs to be spent on supporting General Practice. Patients value the continuing care by a known doctor. We do not think that the polyclinic model or placing expensive X-Ray facilities in group practices is the way forward. Where GPs wish to arrange laboratory tests or X-ray investigations the protocols for doing these should be agreed with the DGH consultants and access should be speedy, where the DGH is accessible to the patients and venepuncture should be local.

1.3    Demographic changes

• Increases in population from a higher birthrate and immigration should be recognized in the funding formula and the lesser use of the NHS by these younger people will counterbalance the increased use due to longevity of the elderly. We need to concentrate on the determinants of health, providing good education for all, decent housing, a adequate income via employment or good pensions, facilities for exercise and a nutritious and non-diabetogenic diet. Air pollution needs to be tacked vigorously as does obesity both areas where health expenditure could be reduced if dealt with effectively. This requires action in all government departments to assess the impact of planned expenditure and a willingness to tackle food and drink companies using taxation or legal changes if necessary as has been done successfully with the tobacco industry.
• The continued negative emphasis on the cost of elderly care is misguided and we should celebrate the fact that people are living longer and many of them are healthier for longer than in previous generations, but we need to organize the specialist aspects of their care more efficiently and to be more patient friendly.

2. Resource issues, including funding, productivity, demand management and resource use. To what extent is the current funding envelope for the NHS realistic?

2.1 The NHS is underfunded and has always been although the attempt by the last Labour government to reach the European average expenditure briefly remedied this.

The effect of austerity since 2010 has led to increasing calls for increased expenditure, the latest by the Royal College of Physicians (ref 6) and the effect of years of underfunding has meant poor infrastructure. The disastrous PFI programme means that too much money is diverted to ( companies for the new hospitals which were built this century, (£2bn annually – a significant proportion of which relates to the high interest repayments.) We have now has fallen behind our European neighbours as described above (1.2). The NHS needs at least 11% of GDP. The government should accept that provision of a health service, recognized as being the most cost-efficient in the world (ref 7) is the hallmark of a civilized country and stop trying to shrink the state which damages the poorest most.  Investment in health makes sense and the economy benefits fourfold through the fiscal multiplier effect (ref 8). An increasing proportion of the NHS budget is going to private companies £2.9bn in 2013-4, £15.8bn in 2014-5 according to the NHS Support Federation(ref 9) which rely on the NHS to train medical and nursing staff, for back-up when things go wrong and do not provide expensive A&E or intensive care departments. In addition the burden of regulation and the cost of the ineffective CQC and requirements for hospitals to provide masses of data to NHS Improvement means less is spent on direct patient care. The escalating cost of NHS England where six figure salaries for posts which did not exist 10 years ago proliferate and are of questionable value and the high salaries paid to Chief Executives of Trusts mean another estimated 2bn diverted from frontline care.

Productivity of the GP workforce is unparalled but the strain of rising demand and falling resources are beginning to take their toll. Productivity is a vast subject well reviewed by the Kings Fund ref 10) so the only comment we have is that diverting money from the NHS to private companies who have not been shown to be more efficient, means less money for NHS services to improve systems and manage the patient load. It and wastes valuable managerial time preparing tenders and being involved in the unnecessary market mechanisms. The best way to manage demand for health care is to reduce the need for health care and the best way to do that is by funding public health adequately and dealing with unhealthy environmental factors as mentioned above taking into account the wider determinants of health. But for those in need of healthcare, the NHS publicly administered, funded and provided is the well-evidenced best option internationally.

2.2a  Does the wider societal value of the healthcare system exceed its monetary cost?

Yes. People are proud of the NHS and value the freedom from the fear of illness bankrupting them, They respect the democratic route of funding it from general taxation. They also accept the principle of caring for those less fortunate than themselves and the solidarity which adds to the sense of community. The NHS is seen by many as an essential part of our national identity. Educating schoolchildren on the history and best use of the NHS is the best way ensuring that society continues to understand, respect and use appropriately the health service.

2.3b. What funding model(s) would best ensure financial stability and sustainability without compromising the quality of care? Funding from general taxation with a guaranteed amount  over a five year cycle to allow planning

What financial system would help determine where money might be best spent? The work done by NICE  in evaluating the value  for money of drugs and now systems of care is a reasonable way of doing this. Ways of involving patients in the discussion should be found. If the system were adequately funded a lot of the controversy would be avoided.

2.4 c. What is the scope for changes to current funding streams such as a hypothecated health tax, sin taxes, inheritance and property taxes, new voluntary local taxes, and expansion on co-payments (with agreed exceptions)?

What we need is an adequate amount of money set aside for the NHS which as a ciivilised country with the fifth largest economy we should be able to afford.

A hypothecated tax merely labels tax receipts in a particular way and the expense of separating out money in this way does not seem justified. Adding new taxes again adds to complexity and is unnecessary. Co-payments are  a barrier for those who can least afford care and are counterproductive (ref 11)

2.5 d. Should the scope of what is free at the point of use be more tightly drawn? For instance, could certain procedures be removed from the NHS or made available on a means-tested basis, or could continuing care be made means-tested with a Dilnot-style cap?

No. All these suggestions will incur transaction costs make those least able to pay reluctant to see the doctor and interfere with the doctor patient relationship.

Dilnot’s recommendations were for social care not health care and whilst the idea of merging health and social care has merit until there is adequate funding for both this seems unwise.

3.Workforce

The Department of Health has been poor at planning and it is disgraceful that a rich country such as ours relies so heavily on doctors and nurses trained in the developing world. The introduction of health care assistants was ill-judged and they need to be professionally overseen like other health care professionals as recommended by Francis. Programmes for physician assistants are beginning but their work needs to be piloted before their use becomes widespread as although paid less than doctors they may refer more patients and end up costing the NHS more money. We think the balance of doctors, nurses and the professions allied to medicine seems about right. The UK has only 2.8 doctors per 1000 population less than the OECD national average of 3.2 of whom 28% were trained abroad. We should plan to produce enough doctors and nurses for our own needs. We have more nurses than most other countries and increasing their autonomy and responsibility in enhanced roles is a good way forward. Whilst the Government announces increased employment of doctors, it does not report this in relation to increased population and in terms of doctors/nurses/hospital beds per 1000 population. On workforce, this is an essential way to compare where we are in England over time and comparatively with European neighbours

UK citizens are keen to train in all parts of the NHS and although medical school applications have fallen recently there are still enough to fill the training places but these should be increased so that we do not need to import doctors or nurses from abroad.  Training standards are good and professionals can be trusted to adapt to changing circumstances. Retention requires proper remuneration for the work done, good working conditions including control over hours of work, opportunities for advancement including further training, and improvement in morale which has been declining under austerity. Professional staff need to be in control of training and standards and respected for their skills not bullied or subjected to repeated re-organisations and dictats from on high or from managers without adequate knowledge or training. The current impasse with the junior doctors cannot be solved by imposition of a contract rejected by a majority of those working in the NHS and is not the way to go forward. Work life balance is important for all workers and the emotional demands of working in the NHS mean preserving a good work life balance is essential in any contracts for staff to prevent burnout. It should be possible for in-service training to help staff move across roles but ‘agility’ and skill mix are words often raising suspicion that roles are to be downgraded so staff have to be involved in any major restructuring of the workforce.

The effect of the UK leaving the EU could be disastrous and the government should take steps to reassure EU staff that they can remain working in the NHS whatever happens to free movement.

5. Models of service delivery and integration

What are the practical changes required to provide the population with an integrated National Health and Care Service?

5.a Firstly there is the question of funding. The proposal by Andy Burnham in his plan to integrate Health and Social Care to have a capitation fee which covered the cost of whole person’s care for a year was a radical first step which sadly has gone no further. If health and social care were properly and publicly funded and if citizens, CCGs, Local Authorities and providers of care in the NHS could work together collaboratively, this would be the way forward. but the Sustainable Transformation Plans (STP) have been introduced in secret in a climate of massive cuts in social care and health and are of questionable legality. These 44 ‘footprints’ created by NHS England are virtual organisations where the purchaser provider split is abandoned as dysfunctional. The NHS is carrying the costs (including opportunity costs) of a shadow planning system and a market system which cost at least £3bn to implement and £4.5 billion to operate. The risk is inescapable in this present climate, that the STP plans will lead to loss of well established services and plundering of the NHS estate. The difficulties in amalgamating two large services with different cultures and funding are huge; NHS free, social care means tested. A first step would be to make social care free. For those who are well off an increase in tax paid as income increases would fund their care and would be cheaper to collect and easier to administer than imposing a cap. Whilst both the NHS and Local Authorities are underfunded it is hard to see how any group will want to relinquish part of their budget.

5.b Pilot studies which show how different services can work together should be funded and evaluated and best practice shared. Staff are keen to improve services and the care of patients and reduce bureaucracy so clear proposals are the only incentive needed to get people to participate.

5.c There has to be adequate provision of services before staff feel able to work towards integration. Innovative examples such as putting mental health teams in GP surgeries in Barnet and Islington improve the care of patients and save money so if shared can be spread throughout the NHS.

6. Prevention and public engagement

What are the practical changes required to enable the NHS to shift to a more preventative rather than acute treatment service?

We are sure the public health doctors will answer the questions in this section but it is counterproductive for the government to cut spending on public health which Marmot suggested should be at least 0.5% of the budget. As far as (d) is concerned the government should legislate to compel the food and drink industries to show greater responsibility. The example of harm reduction from tobacco consumption by combining taxation and legislation shows what can andshould be done. Obesity has reached epidemic levels. In relation to (f) reduction in poverty and planning for healthier cities and legislation to improve workplace safety and imposition of punitive fines where employers fail to do this would enable people to choose healthier options.

7. Digitisation of services, Big Data and informatics

How can new technologies be used to ensure the sustainability of the NHS?

We defer to those with more knowledge of this technical field but believe that the usefulness of digitization requires careful evaluation in pilot studies. The record of using computers in the NHS has been lamentable and costly although GPs pioneered effective systems, which need to be linked to hospital systems. This should be arranged locally by clinicians working together rather than having IT firms who impose their ideas seemingly without consultation with those who are forced to use them. An example is choose and book which replaced a perfectly good system of GPs writing to or emailing hospital consultants selected by the GP to suit the patient with a faceless bureaucratic mess where neither the GP nor the patient know who they are referred to and patients often get lost in the system. Pilot studies using new technology should be evaluated before rolling out new digital systems. The idea of putting summary information on to a memory stick which people could keep in their wallet or handbag and have updated when seeing their GP, should be explored. This would maintain patient confidentiality and have information where it is needed at minimal cost.

The importance of personal contact and the clinician patient relationship in healing is immense and cannot be provided by a smart app or internet chat. It also discriminates against those without such IT skills or access, and without adequate English language skills for communication.

In a densely populated country such as ours the use of tele-health is probably not cost effective as the equipment is expensive although less sophisticated systems such as Skype consultations and telephone home monitoring can be cheaply provided and convenient for patients.

Confidentiality of records is crucial and the risk of hacking and loss of devices has made many people reluctant to share data.

Refs

1. Player S and Leys C (2011) The Plot against the NHS Merlin Press London
2. House of Commons Health Committee (2010) Commissioning Fourth report of Session 2009-10 Volume 1 The Stationery Office London.
3. Appleby John (2016) Is the UK spending more than we thought on Health care (and less on Social Care)? Kings Fund London
4. Paton Calum (2014) At What cost? Paying the price for the market in the English NHS. Centre for Health and the Public Interest. London
5. Bardsley M, Steventon A, Smith J, Dixon J (2013) Evaluating integrated and community-based care: How do we know what works? Nuffield Trust. Available at: www.nuffieldtrust.org.uk/publications/evaluating-integrated-and-community-based- care-how-do-we-know-what-works
6. Royal College of Physicians (2016) Underfunded, Underdoctored, Overstretched. The NHS in 2016 https://www.rcplondon.ac.uk/guidelines-policy/underfunded-underdoctored-overstretched-nhs-2016 Accessed 21.9.16
7. Davis K, Stremikis K, Squires D, Schoen C. Mirror, mirror on the wall, 2014 update: how the US health care system compares internationally. New York: The Commonwealth Fund, 2014. www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror . Accessed 2014
8. Reeves et al. Does investment in the health sector promote or inhibit economic growth? Globalisation and Health. 2013 9: 43 Accessed 23.9.16 http://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-9-43
9. NHS Support Federation http://www.nhsforsale.info/contract-alert.html
10. Hugh Alderwick, Ruth Robertson, John Appleby, Phoebe Dunn and David Maguire (2015) Better Value iin the NHS. Kings Fund. London http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/better-value-nhs-Kings-Fund-July%202015.pdf) accessed 19.9.16
11. Lister John (2005) Health Policy Reform: Global Health Versus Private Profit (Management Policy and Education (2013) Libri, Faringdon

Keep our NHS Public

Keep Our NHS Public was founded in 2005 by the NHS Consultants Association, NHS Support Federation and Health Emergency and has now grown as a grass roots organisation pledged to defending the NHS with 36 KONP groups and another 46 fully affiliated groups and 49 supporting affiliated groups spread thoughout England.

Our broad aim is to Keep our NHS public, which means publicly provided and publicly accountable as well as publicly funded. We are a membership organisation and our members are drawn from all walks of life. They include many NHS workers , patients and carers with experience of the NHS.

Visit our website www.keepournhspublic.com for further details

23 September 2016