The Royal College of Surgeons of Edinburgh – written evidence (NHS0180)

The Royal College of Surgeons of Edinburgh [RCSEd] is the oldest and largest of the UK surgical Royal Colleges, and one of the largest of all the UK medical Royal Colleges. First incorporated as the Barber Surgeons of Edinburgh in 1505, the College has been at the vanguard of surgical innovation and developments for over 500 years.

Today we are a modern, thriving, global network of medical professionals with a membership of well over 23,000 professionals who live and work in more than 100 countries around the world. Over 10,500 of these live and work in England. Our membership includes people at every stage of their career, from medical students through to trainees, consultants and those who have retired from practice.

With our interest in professional standards, the College’s primary role – and the main concern of our Fellows and Members - is to ensure the safety of our patients and provide them with the best possible care. We do this by championing the highest standards of surgical and dental practice; through our provision of courses and educational programmes, training, examinations and Continuous Professional Development; our liaison with external medical bodies; and by influencing healthcare policy across the UK.

The future healthcare system

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?

To ensure the ongoing sustainability of the NHS a number of core services need to be redesigned. It is not sustainable or desirable to prop up a system where every hospital seeks to provide every surgical service. Centres of excellence will be required to deliver the most specialist procedures and a more generalist workforce is vital in meeting acute and emergency needs as well as the vast majority of common surgical procedures.

There also needs to be a fundamental shift from treatment to prevention. Whilst surgical intervention will always be required, improving the public’s health will mean fewer people undergo surgery and those who do are more likely to experience better outcomes. This in turn will mean less time spent in hospital and a decreased chance of follow up interventions being required.

This must all be supported by a truly integrated system which supports clinicians to care for their patients as opposed to the current system which often slows, confuses and duplicates vital work. These systems must also support patients to take ownership of their own care, in their own homes, to the greatest extent possible.

Resource issues, including funding, productivity, demand management and resource use

2. To what extent is the current funding envelope for the NHS realistic?
1. Does the wider societal value of the healthcare system exceed its monetary cost?
2. What funding model(s) would best ensure financial stability and sustainability without compromising the quality of care? What financial system would help determine where money might be best spent?
3. 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)?
4. 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?

It is clear that NHS cannot continue to deliver the same level of service within the current funding envelope. Whilst there is still hope that more efficiency savings could be found, there is no credible source that claims they could meet the funding gap predicted by 2020, let alone 2030. This is compounded by the fact that many efficiency savings that could be found would require some short term investment to be realised.

The alternatives – reduction in quality, rationing, charging, insurance contributions and tax increases – have been widely discussed and the merits of each will be familiar to members of the Committee. Any approach that is taken will require full support from the public but given evidence of support for differing approaches[1] it might be advisable to widely consult on a single proposal.

In 2014 the Commonwealth Fund found that the NHS to be the best healthcare system of 11 developed countries, not least because of the efficiency and effectiveness of the system[2]. As well as further outlining the limited potential of efficiency savings, we believe that this report demonstrates the value of a tax-funded health system. Whilst support for a dedicated NHS tax[3] shouldn’t be taken for granted, we believe that an ongoing demarcated tax should be considered as part of any proposal presented to Parliament and the wider public.

We support sin taxes where they can be proven to have a disincentivising affect. Specific examples of the taxes we support can be found below, but those that can be shown to reduce the pressure on NHS services should be prioritised. Whilst the revenues raised by these taxes can be useful, the preventative nature of those that are successful will lead to much greater savings elsewhere in the system.

In addition to a dedicated NHS tax and sin taxes, a one off tax [such as the mansion tax] could be considered in order to fund the initial investment required to realise longer term efficiency savings. For example, an injection of funds would allow for the reconfiguration of a specialist surgical service into a centre of excellence[4], leaving more money and capacity for the most common procedures that will continue in the other hospitals.

Ultimately we believe that any future model should remain free at the point of need and funded through the taxation options discussed above. Any charges at the point of access can dissuade people from seeking care. This can prove to be a false economy when those with infectious diseases, for example, do not come forward, resulting in a threat to the wider public health. Also, wide spread support for the NHS is built upon an equality of access. Therefore, it is our opinion that means testing is only desirable when it comes to taxation.

Finally, we would strongly urge that simply reducing the quality of the service should not be entertained as an option. As a Royal College, our sole concern is maintaining the highest possible level of patient care. Loosening targets and accepting a lower standard of care goes against everything the NHS was created to do. Whilst there are difficult questions to answer about what the NHS can and cannot afford to do, all services that the NHS does deliver must be delivered to the highest possible standard.

Workforce

3. What are the requirements of the future workforce going to be, and how can the supply of key groups of healthcare workers such as doctors, nurses, and other healthcare professionals and staff, be optimised for the long term needs of the NHS?
1. What are the options for increasing supply, for instance through changing entry systems, overseas recruitment, internal development and progression?
2. What effect will the UK leaving the European Union have on the continued supply of healthcare workers from overseas?
3. What are the retention issues for key groups of healthcare workers and how should these be addressed?
4. How can the UK ensure its health and social care workforce is sufficiently and appropriately trained?
1. What changes, such as the use of new technologies, can be made to increase the agility of the health and social care workforce?
2. What are the cost implications of moving towards a workforce that is equipped with a more adaptable skill mix being deployed in the right place at the right time to better meet the needs of patients?
3. What investment model would most speedily enhance and stabilise the workforce?

As the UK’s largest Surgical College, with a membership drawn from across all four UK home nations, we are only too aware of the size and complexity of the issues faced in the English NHS. However we believe that a number of practical steps can be taken in the short term that will both improve workplace cultures and ultimately patient care. In particular, we are concerned about the issues around safe and effective surgical training.

First of all, it is essential that all contacts, whether for trainees or consultants, guarantee sufficient time for training and all flexibility in work plans. A workforce that is equipped with a more adaptable skill mix being deployed in the right place at the right time to better meet the needs of patients can only be created if clinicians are able to train and retrain alongside their responsibilities for service provision. Whilst the cost implications will need to be considered carefully, a model of credentialing based on patient need is vital to ensuring the sustainability of surgical provision within the NHS.

Secondly, we would support the reintroduction of the ‘apprenticeship’ model of surgical training. Both the GMC’s annual trainee survey and feedback from our own Members and our Trainees’ Committee which represents them, clearly indicate high levels of dissatisfaction with the quantity and quality of the training they receive. We believe that the NHS is far too reliant on trainees to deliver services and, where training and CPD is provided, it is often of poor educational quality. A return to a modern day apprenticeship model would not only restore the personal links between trainer and trainee but also enhance the value of the training experience. This would in turn help nurture a more effective and stable workforce, further contributing to the sustainability of the NHS.

We would also argue that a consultant’s ability to deliver excellent patient care is often hampered by the requirement placed upon them to fulfil a range of clinical, academic, educational and leadership roles. We would therefore ask that the role of consultants be simplified and streamlined, allowing them to focus on particular areas of responsibility. This would allow those consultants who are responsible for training and mentoring the next generation of practitioners to be given the time and space to do so; something which would not only benefit consultants, but trainees and patients. It would also enable those who would prefer to focus on academic research to help bring about the advances that ensure the NHS is a modern health system.

Finally we believe that nationwide structures need to be put in place to help develop the professional skills and competencies of non-medical staff. We strongly endorse the findings of the recent Nuffield Trust / NHS Employers report into this area and, as the only UK Surgical College with a Faculty of Perioperative Care which recognises the crucial role played by the whole surgical team, we would welcome the opportunity to play an active role in bringing this about. It is also vital that regressive and hierarchical workplace structures are removed to promote a more positive culture. One specific improvement would be to find a less pejorative term be found to describe ‘junior’ or ‘trainee’ doctors. These are highly skilled and highly dedicated professionals and should be recognised as such.

As a College we believe that these actions are essential if we are to retain the current NHS workforce, attract next generation of practitioners, and safeguard the NHS for patients now and in the future. We believe that these measures are essential to ensuring that everyone who works within the NHS, and all those who rely on its services, can continue to do so for many years to come.

Models of service delivery and integration

5. What are the practical changes required to provide the population with an integrated National Health and Care Service?
1. How could truly integrated budgets for the NHS and social care work and what changes would be required at national and local levels to make this work smoothly?
2. How can local organisations be incentivised to work together?
3. How can the balance between (a) hospital and community services and (b) mental and physical health and care services be improved?

The College supports proposals of better integration health and social care and moves to reduce the NHS’s general over-reliance on hospitals. We also welcome the concept of local services being configured to meet specific local needs.

However, we also believe that patients are best served in a NHS that has a national focus and offers the same standard of high quality care, regardless of where it is needed. Therefore all decisions over resources and services should meet nationally agreed clinical and patient safety standards and be as open and transparent as possible.

We welcome healthcare devolution in England and look forward to working with relevant partners in the city regions as the plans develop to ensure the highest standards of patient care are implemented.

Prevention and public engagement

6. What are the practical changes required to enable the NHS to shift to a more preventative rather than acute treatment service?
1. What are the key elements of a public health policy that would enhance a population’s health and wellbeing and increase years of good health?
2. What should be the role of the State, the individual and local and regional bodies in an enhanced prevention and public health strategy; and what are the key changes required to the present arrangements to support this?
3. Is there a mismatch between the funding and delivery of public health and prevention, compared with the amount of money spent on treatment? How can public health funding be brought more in line with the anticipated need, for instance a period of protection or ring-fencing?
4. Should the UK Government legislate for greater industry responsibility to safeguard national health, for example the sugar tax? If so how?
5. By what means can providers be incentivised to keep people healthier for longer therefore requiring a lower level of overall care?
6. What are the barriers to taking on received knowledge about healthy places to live and work?
7. How could technology play a greater role in enhancing prevention and public health?
7. What are the best ways to engage the public in talking about what they want from a health service?

NHS England's Five Year Forward View recognises the impact that smoking, alcohol abuse, obesity and inactivity are having on the NHS's finite resources. Recent public health cuts will ultimately increase the pressure on these resources at a time when investment is required to integrate health and social care. Prevention is always better than cure. With surgery being one of the more expensive forms of treatments, initiatives that ultimately reduce the demand for surgery should be supported.

As a College we work closely with a number of organisations and participate in a number of health alliances with a preventative focus. As such, we would fully endorse the submissions made to this enquiry by Action on Smoking and Health[5], the Obesity Health Alliance[6] and the Alcohol Health Alliance[7].

Digitisation of services, Big Data and informatics

8. How can new technologies be used to ensure the sustainability of the NHS?
1. What is the role of technology such as telecare and telehealth, wearable technologies and genetic and genome medicine in reducing costs and managing demand?
2. What is the role of ‘Big Data’ in reducing costs and managing demand?
3. What are the barriers to industrial roll out of new technologies and the use of ‘Big Data’?
4. How can healthcare providers be incentivised to take up new technologies?
5. Where is investment in technology and informatics most needed?

Advances in information and telecommunication technologies have presented the NHS with a number of opportunities and challenges. The scale of the service means that rolling out any one system or technology nationwide can be fraught with danger, as care.data has demonstrated. However, individual trusts utilising incompatible systems is not desirable, plus the benefits for patients and the savings that can be realised mean that changes are worth pursuing. Although we would not comment on specific systems, we are working with the Academy of Royal Medical Colleges to develop a serious of standards for any system or technology that are used with the NHS. Although these are yet to be finalised a number of them could be considered as part of this enquiry.

First of all it would be possible to reduce the amount of time wasted and stress generated by regularly re-capturing and re-entering patients’ clinical data by creating a system that enables one source of data to be accessed by all provider organisations. Whilst there will be safeguarding risks that need to be mitigated against, a digital system that is present for all clinical encounters across the system would save resource and improve the quality of care received. This system would also be able to reduce prescription duplication.

In addition, a truly digital healthcare system would enable patients to interact with their clinician without having to travel to a hospital. Whilst it is important that patients are given the choice and that it is not forced upon those it will not benefit, clinicians should be able to interact virtually with patients to undertake consultations or support self-care where appropriate. Although this wouldn’t be suitable for all patients with a number of conditions, it would go some way to relieving some of the pressure on our hospitals.

Finally, implementing a system that captures and utilises data fully across the NHS will help ensure its sustainability. Accurate data is essential for both the commissioning of clinical services, especially those specialist services which are commissioned on a nation level, and setting procurement levels to eliminate waste. Live data is essential to ensure that any negative outliers in performance are detected as early as possible in order to prevent escalation as well as ensuring that regulators are as efficient as possible. Ultimately accurate and accessible data is a crucial component of an efficient, and therefore sustainable, healthcare system.

3 October 2016