Mr Adam Chaffer – Written evidence (NHS0144)
EXECUTIVE SUMMARY
1. This written evidence draws on my experience as a Public Governor and through my research during my Masters in Law dissertation looking at the rights to resource allocation in the NHS.
2. The National Health Service (NHS) is very much a national treasure for Great Britain; it is a concept which despite our cultural, regional and national differences we can all associate with and is equally the envy of the world. No other nation has truly managed the concept of universal healthcare free to the point of use. Notwithstanding the special place the NHS is held in the mindset of the British public the organisation nationally is facing challenges which if not tackled in an expedient manner are likely to severely undermine the long term sustainability of the organisation.
3. The underpinning points are contained in the next three numbered paragraphs.
4. The Executive Agencies of the NHS (in particular NHS England and NHS Improvement) have become too powerful and run contrary to their intended purposes. This power needs to be returned to the Department of Health so that decisions can be challenged appropriately through Parliament.
5. The second point which this paper considers is the fact that Foundation Trusts do work as a sustainable delivery model. However, the commissioning and tariff structure of the NHS is causing chronic financial problems to develop which if they continue will manifest in significant shortfalls in accessing the best level of care for patients.
6. This report will finally conclude that the future of the NHS involves tough decision making which Parliament, the Department of Health, NHS England and NHS Improvement need to make but cannot do so in the current climate. It is appropriate for Parliament in the current climate to convene a Royal Commission to consider the future of the National Health Service before we reach point of no return.
INTRODUCTION
7. The National Health Service (NHS) is currently at a crossroads the decisions which the Government makes in the coming years will have a significant impact on the future existence of the organisation. In order to balance the competing needs of patients both now and in the future the Government needs to take bold and decisive steps which are made with the full engagement of Stakeholders and the general public. In light of the prevailing situation within the NHS the House of Lords Select Committee is presented with a unique opportunity to shape the future and perhaps very survival of the NHS; it is truly an opportunity not to be missed.
8. I understand that the terms of reference for this Select Committee is to investigate and consider the, ‘long term sustainability of the NHS’ and to report to the House of Lords by Friday 31 March 2017. To that end this evidence is drafted to support the Select Committees objective. Drawing on my experience which I have outlined in paragraphs 9 to 11 I shall comment on the following areas of the Select Committees work:
8.1 resource issues, including funding, productivity and demand management;
8.2 models of service delivery and integration;
8.3 prevention and public engagement; and,
8.4 in addition to the above terms of reference I will also comment on additional points of relevance to the long term sustainability of the NHS.
INTRODUCTORY COMMENTS
9. My name is Adam Chaffer I am a Trainee Solicitor in Durham. Alongside my full time role I also serve as a Public Governor on the Board of Governors at the Newcastle upon Tyne Hospital’s NHS Foundation Trust. Within this role I sit as Vice Chairman of the Business Development Working Group and an elected member of the Nominations Committee.
10. I hold a degree in Law (2012) from Northumbria University and also hold a Masters in Law (2016) with a dissertation that considered the fairness and methods of challenge to the current resource allocation model in the National Health Service.
11. From the outset can I be clear that this evidence is submitted in my professional capacity and therefore any opinions made herein are my own views and opinions and should not be taken to be representations or opinions of my employer or any other organisation which I represent.
POINT 1: THE FUTURE HEALTHCARE SYSTEM
12. Before considering how the NHS will cope in 2030 it is first important to appreciate where the NHS has come from. The NHS is built on a core precept that it meets the needs of everyone; it is free to point of delivery and based on clinical need, not the ability to pay. These core principles continue to survive to this day and remain a key cornerstone when considering future decisions making within the NHS. Another important point to appreciate is that the structure of the NHS is based within a framework set down by Parliament in successive Acts of Parliament from the National Health Service Act 1946 through to the Health & Social Care Act 2012. This framework debate and endorsed by Parliament has indecent times been eroded by the delegation of significant decision making to executive agencies.
13. Since the NHS was founded the health service as a corporate entity has undergone significant amount of structural reform following the amendments made by the Health and Social Care Act 2012.
14. At the time of writing the current model of the NHS can be broadly broken down into the following simplistic components:
i. The first tier of NHS service relates to the ‘first contact’ of the patient; normally this contact will be made to a General Practitioner, pharmacist, dentist or optician, however, emergency cases will be dealt with either at an Emergency Department or through a minor injuries ‘walk in centres’.
ii. The second tier of contact that the patient will come across is referral from the first tier (above) to a Consultant for diagnostic referral, outpatient, clinical services or surgery. Separate to this Emergency Department patients and minor injuries units can refer patients for non-elective care.
iii. The third tier concerns specialist care and long term treatment such as cancer care, cardiology and neurosciences.
iv. Running concurrently to these components (tiers one to three) there is support in an outreach capacity specifically by community nursing, social workers and other allied health professionals.
Deficiencies in the current NHS service model and the impact on the NHS by 2030
15. For secondary care; services are provided through NHS Foundation Trusts and NHS Trusts. Commissioning of these clinical services is provided by Clinical Commissioning Groups (CCG’s) and for specialised services NHS England as the NHS Commissioning Board. The commissioning model which is currently utilised is a working model to an extent. The reliance of local knowledge to steer provider services works. However, the system of commissioning services has three major flaws which inherently weaken the entire financial structure. First the system no longer practices under the principle that the money follows the patient and therefore local commissioning falls down, if the model refocuses on this point it will be greatly strengthened. Secondly, there is scope to argue that the CCG model creates conflicts of interest and is an expensive model to operate. Further there is scope to argue that the previous model of Primary Care Trusts amalgamated into units covering a large geographic area functioned without any overriding conflict of interest. If this model could be transferred into a CCG model which mirrored the Primary Care Trust success then significant improvement will be made. At the same time this proposal would greatly reduce the administrative cost and duplication of services. The commissioning of specialised services from a central point does work as this remains a niche market which requires co-ordination from a central point.
16. The decision by the Coalition Government to introduce localised commissioning is a point which should be praised, it creates a market place which drives up standards. In the previous paragraph the failings of commissioning from an operational aspect were considered. In this paragraph reference is made to the funding aspect. The tariff structure which currently exists does not work and its failure creates a direct correlation to the budget deficit within the NHS. In order to rectify this flaw the Department of Health and its executive agencies will need to undertake comprehensive reform of the tariff system. This is a point which can be easily reformed and if done expediently will greatly benefit the wider NHS.
17. A recurring theme which a future health system will need to manage is the discharge and community support for patients leaving hospital. The current system of post hospital support is not fully integrated which means there is gaps between hospitals and the community. In some parts of the NHS this is creating chronic delays which by default incurs cost and a shortage of beds for incoming patients. By reforming the system to ensure there are clear patient pathways is a workable solution. Understandably at peak times such as during the winter the lack of joined up health and social care creates pressure on the service. In time this is an issue which will become more compounded especially in the directorates of Emergency, Elderly Care and those which work on long term conditions such as cardiology.
Can the NHS become sustainable in the long term?
18. The first question that anyone approaching the question of the future NHS should ask is does the current model work in a sustainable and competitive manner and if the answer is in the negative why not. Before answering this question it is beneficial consider the rationale behind this question. Elements of the NHS clearly work well but they are let down by poorly constructed procedures which if rectified would strengthen and allow the NHS to prosper. Steps should be taken nationally to identify the elements which work well and those which do not. By identifying the element which works and those elements which are damaging the sustainability of the NHS the system can be reformed accordingly without the waste, expense, or upheaval of wholesale reform which is introduced ad hoc or without sufficient consideration.
19. Within the NHS structure there remains a significant degree of waste in terms of financial resources; if the organisation is to become sustainable then steps need to be taken to look for efficiencies in resources. At this stage it is perhaps beneficial to draw on one sizeable cause of financial inefficiency in the NHS; that of the executive agencies NHS England and more recently NHS Improvement. With respect of NHS England; the original intention of executive agencies was to act as lean support organisations ensuring that the NHS delivered. Such a support function is clearly needed to enable the NHS to develop consistently across the country and in the original construct of NHS England the idea worked. However, in reality what has developed is large bureaucratically complex organisation which pulls funding from front line services.
20. Turning to NHS Improvement, this organisation is again incurring significant financial resources but this organisation also gives cause for concern as it is unclear what the mandate of the organisation is and indeed why it has been created. Further it is fair to note that the organisation is created without Parliament having considered the matter which raises constitutional questions as to whether the organisation should exist at all.
21. In order for the future of the NHS to remain accountable to the public steps need to be taken to divert executive decision making back to the Department of Health and responsibility removed from NHS England and NHS Improvement.
POINT 2: RESOURCE ISSUES
22. One of the questions which this Select Committee is reviewing is whether the societal model of the NHS exceeds the current cost remit. The answer to this question is yes; indeed it is trite to think any other answer would be possible in the current financial environment. However, it would be more appropriate if the question was phrased to consider whether as a nation we would be prepared to continue to support the NHS even if it exceeds its cost target. This question is entirely subjective and depends on the views of the general public; as a rule of thumb the current public view appears to hold the NHS in extremely high regard and this in turn could be an indication of long term support for an organisation which is free to the point of use.
23. What this question truly highlights is something which transcends health economics; it is a question of morality and crucially what we as a country should be doing for the NHS; is balancing the books an objective or should we be striving to achieve a healthcare system which is true to Bevans principles and protects the vulnerable. This question cannot be answered by professionals, interested parties or politicians it is a question which necessitates a national conversation and debate.
24. Another resource issue concerns competition within the NHS. The competition model introduced through the Health and Social Care Act 2012 is a workable model but it needs to be matched with strict financial controls to ensure failing organisations are dealt with promptly. The competition model also works well with the independent nature of Public Benefit Corporations but the system needs to recognise that independent means independent and that in creating organisations under this concept will create some organisations who flourish under dynamic and innovative leadership. Such organisations should not be criticised but praised and there work emulated across the wider NHS. By operating in a true meritocracy the NHS will flourish but for those organisations which are underperforming the Department of Health ought to be able to provide a turn-around team comprising of experts with public backgrounds supported by professional advisors from the private sector.
25. A clear resource problem is the continued and relentless need to continue to reinvent the NHS. This causes significant financial waste if every few years the model of providing clinical services is changed; such a zealous need to reform the NHS so regularly is not a sustainable way of operating.
POINT 3: MODELS OF SERVICE DELIVERY AND INTEGRATION
26. Integrated healthcare means ensuring the patient is treated in a metaphorical flight path to recovery; from diagnosis to discharge the care plan of the patient should be planned out. In considering this model it is important to remember that for a NHS patient one size does not fit all. The care model which suits the demographic in Newcastle upon Tyne will be radically different to that in rural Norfolk. In order to tackle the relationship between hospital, general practice and community services monthly Quad Meetings should be introduced at a regional level to co-ordinate care between the hospital and community setting. By creating a forum of joined up thinking the challenges that exist
27. The practical change which the Committee have asked for direction on is simple. First the health budget set by Parliament needs to be improved. The simple fact is NHS is unsustainable on the current budget allocation and if the Government are committed to improving the NHS steps need to be taken to increase this. This may achieved through a special tax levied exclusively for the benefit of the NHS. It is likely that if such a tax was created there would be public support but there would be an expectation that improvement will be seen within the NHS.
28. This point specifically relates to hospital care. There is a current school of thought that the model of delivering NHS care needs to be improved. Such improvement naturally incurs cost and in the past two decades the amount of structural reorganisation in the NHS has reached a rate which is a clear cause for concern. Effectively the constant change of reform is creating a plaster over a gaping wound which is the problems of the NHS; at this stage in proceedings the NHS needs a period of stability rather that further reform.
POINT 4: PREVENTION AND PUBLIC ENGAGEMENT
29. Within the NHS and the wide perspective of the general public the concept of prevention is one of the best methods to ensure that the public can ensure that the NHS is in a long term sustainable position. As things stand there understandable gulf between the current attempts at prevention and what is need to ensure that the public support and partake in prevention measures.
30. On a national level there are entrenched health problems which have a profound impact on the resources and operational efficiencies of the NHS. By way of example let us consider the obesity. The effect of Obesity is creating clear pressures on the National Health Service. It is likely that without a level of preventative action these pressures will become exasperated.
31. The current model of prevention rests largely with Public Health England. Since the devolvement of public health work to Local Government there has been a marked decline in the available the expenditure to finance prevention campaigns. In order to achieve prevention as a sustainable concern within the NHS the Government needs to ring fence the current public health budget and thereafter commit to an annual rise in expenditure each year thereafter.
32. The Government through Public Health England need to empower people to improve their health and well-being by creating a framework to inspire communities. Depending on the specific needs of a geographic community the framework could include subsidised sports programmes to allow people to get fit, weight loss clinics, and healthy eating through community allotments and farms. In order to improve Public Health engagement the Government could consider creating Public Health Panels made up of ordinary people to achieve best practice within a designated community. Such an engagement approach would ensure that Public Health is relevant to each community rather than taking a ‘one size fits all approach’.
33. The introduction of the sugar tax by the last Chancellor of the Exchequer is a significant step in tackling childhood obesity. However, there is more which can be done for instance there is a general failing amongst the public to understand the causes and effects of obesity and the general need to lead healthy lifestyles.
34. Another useful example is the work undertaken in some German companies where incentives exist to empower employees to make lifestyle changes. For instance an employee may wish to take up running for health reasons; as the employee hits certain mile stones the employer rewards the employee for example with baby vouchers or department store vouchers.
POINT 5: ACHIEVING SUSTAINABILITY
35. The challenges which the NHS faces can be overcome, however, to do so will involve the Government taking divisive step which will enable the NHS to develop a long term future. Until now although reform has been made there has been a lack of progression on key points. This pivotal step would be to create a Royal Commission on the Future of the National Health Service. The benefit and indeed logic of a Royal Commission would be to temporarily elevate the question of the NHS outside bailiwick of the political arena and into a forum which can then deliberated by a panel of associated professionals in the fields of medicine, economics, social theory and the associated legal provisions around healthcare..
36. It is perfectly understandable for the Government to be cautious in commissioning such a progressive idea as a Royal Commission; not least because of the length of time they take and the cost. However, notwithstanding these concerns it is imperative that the future of the NHS is properly deliberated and steps are taken to ensure that engagement in this programme draws in medical and allied health professionals, along with politicians (in particular former Secretaries of State for Health) and the public to ensure that a broad spectrum of information and opinion is correlated.
37. Should the Government implement a Royal Commission and then after scrutiny of the findings decided to enact into law the recommendations it is vital that such reforms are given chance to develop without the fear of continued reform for the sake of reform. One of the problems with the NHS today is not that the organisation is devoid of energy but that the institution is faced with continued, sustained and systemic patterns of structural reform to its funding and management structure. The problem with these reforms, however well intended, is that with each attempt is merely a sticking plaster over the question of the future of the NHS. Continued and unchallenged reform to the NHS of this kind has the effect of eroding the identity of the NHS which the public both know and have come to rely on.
38. Turning to the term ‘sustainability’ is relevant to ensuring a long term future of the NHS. The first step the NHS needs to establish is what does the term me. Within the ambit of the private sector, ‘sustainability’ means achieving a competitive future, adding value and ensuring that employees carry the moment of the organisation with them in their work. Establishing what the term means in the NHS should not just be a matter for the executive agencies but rather a conversation with the NHS staff as a whole. Each NHS Trust and NHS Foundation Trust should have a Sustainability Strategy which establishes what the term means but also how the organisation can achieve sustainability through engagement with the private sector. Most private companies have corporate social responsibility policies which the NHS can benefit from whether within their local communities.
CONCLUSION
39. The NHS cannot continue to provide the level of service it has done unless radical change is undertaken in the funding and operational capacity of the organisation on a national level. To achieve a sustainable health service there are a number of conclusions which this paper recommends the House of Lords consider. The first is that steps need to be taken to reduce the Executive Agencies role in terms of power, control and financial turn over. Concurrent to this first point a significant proportion of the power vested in these organisations needs to be returned to Parliament to ensure that those decisions which need to made are made in a democratic manner. The second point is that the Foundation Trust model is a sustainable delivery model but the tariff system and commissioning model which underpins the NHS is not fit for purpose and inherently undermines the ability for Trusts to either break even or make a surplus which can be invested into the organisation to ensure it is a sustainable concern. Finally, the future of the NHS involves tough decision making which Parliament, the Department of Health, NHS England and NHS Improvement need to make but cannot do so in the current climate. Instead this paper concludes that the only proposed course of action is to refer the entire matter to a Royal Commission to consider the future of the National Health Service before we reach point of no return.
23 September 2016