For a sustainable NHS, we need evidence more than ever

The NHS is looking increasingly beleaguered. With very little more money until after 2020, and expenditure per head falling, there will be longer waits, more cancelled operations, reductions in quality and stifling of new technologies. Social care is already deep in crisis. The extra money councils can raise in the coming two years will help, but as all commentators, councils and those providing services have said, it won’t be enough.

Robert Francis has already referred to an existential crisis in the NHS, implying that it may not survive with its core values intact. But social care has already been reshaped. The extra money may stabilise it but it is hard to see it ever getting back to what is was with an estimated 250,000 fewer people receiving care from councils in 2013/14 compared with 2009. This trend has almost certainly continued, despite the rise in numbers of elderly people. The potential now is for increasing numbers of private sector social care providers to fold, leaving some parts of the country with absent or inadequate services.

This is the backdrop to the Nuffield Trust Health Policy Summit later this week, where the key issues affecting the future of health and social care will be debated. That debate, and the future sustainability of health and social care will focus on four issues – money, workforce, technology and different models of care.

Over the long term, NHS spending has increased by about four per cent a year in real terms. This has made the service sustainable, enabling a good – if not outstanding – standard of care to be provided, to remain funded by taxation and free at the point of use. The service has also provided universal coverage – private health insurance has always been a minority sport, and even then the NHS has been first call for nearly everybody for hospital emergencies and the most serious conditions.

The NHS has lasted through ups and downs for nearly 70 years; it should last for another 70. But we are coming to a crunch. When we get to the end of the decade, and assuming no change to government spending plans, the rate of growth in real terms will have been just one per cent a year over the last ten. The usual pattern has been for a short period of catching up and significant expenditure growth followed by another lean period. The last 20 years have been no exception, with the yearly real terms average for the 10 years from 2000 hitting six per cent.  But such a pattern does patients and taxpayers a disservice – the proof is before our eyes.  A major act of political steel will be required both to regenerate the service and set a smoother path for the long-term.

Social care funding needs a re-think. None of the past government sponsored inquiries ‘(the Sutherland Commission, Wanless Review, and Dilnot Commssion, to name but three) have produced recommendations that have stood the test of implementation, with the last set broken on the anvil of austerity. Nor has there been a rise in private insurance, as was hoped-for.

It is now time to look at health and social care spending together, reflecting on past failures and recent experience, to produce a sustainable long-term arrangement and settlement.

Fixing the workforce looks, if anything, more difficult than fixing the money. Holes are appearing in medical staffing, the junior doctors’ strike has lowered their morale and that of medical students who question whether the NHS is an organisation they want to work for. The downturn in applications for nurse training is of concern but we really need to wait for the numbers actually taking up places before reaching a conclusion. Brexit may or may not compound the problem – the UK will remain an attractive place for clinical staff even after we have left the EU.

The Trust’s recent report, Reshaping the workforce, pointed to the potential for raising the skill levels of existing non-medical staff to increase capacity and create efficiencies. These opportunities are a good start, but we will also need a recruitment strategy that looks beyond Brexit, and includes social care. These are the issues that we need to grapple with, addressing the current uncertainties and problems and devising an approach that enables us to look more confidently into the future.

Technology is often cited as a way to save money (or at least reduce future cost increases), ease workforce pressures and improve quality. Whether the first two scenarios are likely to materialise is highly debatable. It seems clear to me that improvements in IT, for example, won’t and can’t help the NHS out of its financial and workforce problems by 2020. The NHS can’t afford the upfront costs or give the time for necessary culture change even if savings are possible. For the longer term, if the past is any guide, it won’t do so either. We spend more on health than we did 20 years ago in part because new technology enables more to be done for patients. That trend looks set to continue.

But, technology will put patients more in control and change the way services are provided. Video technology can bring expert advice straight into the GP surgery without the need for a traditional outpatient appointment, creating ‘virtual’ polyclinics. And for patients, why wait several weeks to see a GP when, if you have the money, you can have a video consultation that afternoon with prescription medicines available to pick up at your nearest pharmacy or delivered to your door? Such services are available now.

Whether these and other new models of care reduce costs or the rate of expenditure growth is again contentious. While transferring care outside hospital has the potential to improve quality, there is little evidence that it saves money – at least in the short to medium term. Integration of health and social care aided by the Better Care Fund seems to be faring no better, as the National Audit Office recently pointed out.

Each of these topics – money, workforce, technology and different models of care - deserves detailed scrutiny. The Nuffield Trust’s Health Policy Summit will do this, bringing a unique group of people together to take a cold hard look at the evidence. With a range of experts in the room, the Summit provides space to dissect the problems facing the sector through a new lens. Some of the widely touted answers to the problems faced by health and social care may prove illusory when forensically examined. But this is an inevitable and important step in making the NHS sustainable and providing the social care to go with it.