The NHS across the UK faces an intractable set of problems that are all too obvious to those on the health service front line. After years of rising demand for services but flat health care funding, we seem to be nearing a point where it is no longer possible to meet the public’s expectations with the money, staff and beds available. The main response has been to look at ways to change how services work, shifting the balance away from costly and intensive care provided in hospitals. The hope is that providing care earlier, in or near people’s homes, offers a way to do more with less.
The goals are highly ambitious. In England, the local Sustainability and Transformation Plans (STPs) aim to reduce forecast activity by up to 30 per cent by 2020. In Scotland, the Government plans a 10 per cent reduction in emergency bed days by next year.
The urgency of the situation and the appeal of a narrative that promises more for less create a tempting environment for wishful thinking. In our work on these issues at the Nuffield Trust we have seen a repeating theme of over-optimism that NHS leaders and staff should learn to guard against.
There can be a tendency not to recognise that the different initiatives beneath the umbrella of shifting care out of hospital vary greatly in the strength of the evidence base behind them. Our recent analysis of studies on 27 common schemes found that seven had been proved to save money, including extra clinical support in nursing homes and better care outside hospital at the end of life. But six actually had a track record of increasing costs. The more successful initiatives tended to be those that improved access to specialists outside hospital, involved patients in their own care, and targeted specific groups of patients.
One reason savings are so elusive is that expanding care outside hospital can mean uncovering previously unmet need or providing extra services that patients effectively use on top of what already exists. For example, we have raised the concern for some time that longer opening hours in general practice may encourage more people on the margin of a decision to seek care to come forward, while diluting the time GPs have to spend with patients with more complex care needs.
Meanwhile, on the hospital side of the ledger there is a tendency to assume that preventing an admission means that all the associated costs can be chalked up as savings. In reality, reducing the number of bed days by five per cent does not mean it will be possible to neatly reduce doctors and beds themselves by five per cent, let alone overheads such as administration. Costs in hospitals come in large chunks, and when activity is taken out many costs remain. Taking them out is often complex and risky.
Staff shortages also present a major obstacle. They are at their most severe in precisely those services that need to expand. There are too few GPs to fill the roles we already demand of them. In England, 21 per cent of posts for district nurses stand vacant.
Lastly, there is a need to recognise the sheer complexity of these changes and of the care needs of the patients with which they deal. Many initiatives deal with a single, long-term condition, but patients with the highest hospital use often have several. Understanding the impact of a change across the system, with data often not fully linked, is very difficult. As is identifying which patients could benefit most. It is all too easy to mistake regression to the mean – whereby the patients with the most admissions in one year naturally have less the next – for real progress.
None of this is to counsel despair. Embracing a radical agenda may still take us close enough to the vision of doing more for less to sustain the NHS into its eighth decade. But radicalism without realism carries the risk of discrediting a promising way forward – and raising the bar of public and political expectations still further above what is possible.
Edwards N (2017) 'NHS leaders must beware wishful thinking'. Nuffield Trust comment, 30 March 2017. https://www.nuffieldtrust.org.uk/news-item/nhs-leaders-must-beware-wishful-thinking