Will over-promising mean the NHS under-delivers?

Rebecca Rosen blogs on the worrying disconnect between the reality of austerity funding for the NHS and the boom expectations of the public.

Blog post

Published: 16/10/2015

The news last week that NHS trusts had run up a £930m deficit in just three months will have come as no shock to readers of this blog who work in health and social care. The national total may be even larger than expected, but everybody in and around these services has already spent a great deal of time and energy coping with these issues locally.

Yet newspapers led with the story because from the point of view of the general public, it looks much more surprising.

The implication of a service buckling under pressure must seem at odds with so many promises they have heard over the last few years: seven day services, safer nurse staffing, more funding. There is an ominous disconnect here: while NHS staff are steeped in the consequences of years of austerity funding, politicians and the media continue to push boom expectations.

On Monday, health minister Ben Gummer told Parliament the planned £22 billion of efficiencies could bridge the chasm. But the transformation needed to achieve this level of savings has some essential ingredients - many of which are in short supply.

It requires data and technology infrastructure and the ability to share and integrate health and social care information. But despite huge effort across the country progress is too often slowed by complex information governance laws and regulations.

Funding and pricing arrangements are another essential ingredient, but how can these be developed and implemented without adequate data?

And perhaps the most important ingredient of all is time for front line professionals to develop the new working practices and inter professional relationships needed to deliver care differently. This requires a shared understanding of future working patterns; new skills; and trust that others can and will cope with their new roles. These essential building blocks for transformation can't be achieved overnight, and staff need time out of their day jobs to learn the skills and build the relationships.

Which is where the current combination of austerity funding and boom expectations becomes particularly problematic. The world's first 24/7 health service sounds attractive, but GP who are participating in extended Sunday services are less likely to be available when transformation teams are developing the vision, values and relationships for new ways of working. Exhausted by burgeoning admin, extended roles and recruitment problems, it's becoming harder for primary care staff to muster the discretionary effort and emotional energy needed to cope with change

And hospitals are similarly stretched. After the Mid Staffordshire public inquiry, who could argue with increasing nursing numbers on wards? But many hospitals are diverting scarce resources from back offices to wards and reducing administrative staffing. Patients can't get through to the hospital to cancel appointments and many are now sent back to the GP for re-referral.

Administrative systems are melting down as hospitals and GP practices bat patients backward and forwards in attempts to shift cost and workload. The promise of seven day services ticks every box on responsiveness and accessibility but it costs money and spreads current resources thinner and thinner.

Having just voted as a nation for an ambitious austerity programme, we need to adjust expectations accordingly. The other large countries of Western Europe to which we like to compare our healthcare systems already spend significantly more than we do both publicly and privately. So what is to be done?

  • First, I believe the narrative of growing entitlements and growing expectations has to change unless more funds can be found. The level of health service responsiveness seen in other developed countries goes hand in hand with higher funding. We should acknowledge the extraordinary value we obtain and create a breathing space for transformation before we pursue world-beating extensions to current services.
  • Second, targets have to be rethought. Not just the 18 week waiting limits we have already seen relaxed, but others too. If we are serious about wanting transformation, there has to be a willingness to ease up on productivity in the short term. In the US, experience in the famously 'integrated' Kaiser Permanante system found that introducing a new IT system reduced clinical productivity. In England, there was no let-up in the expectations on Addenbrookes as it implemented a hugely challenging IT development. The pressure to deliver on current targets, increase responsiveness and broaden access deprives staff of the time and energy needed for transformation.
  • Third, I think we should heed the calls for transformation funding to support the level of change we needed. Vanguard sites are receiving substantial funds to support change, and this will help to back fill clinical work as staff prepare to deliver care differently. But what about other parts of the country? Without additional resources and a temporary reduction in expectations to enable staff to develop new ways of working, transformation will remain an optimistic dream.

Rebecca is a Senior Fellow in Health Policy at the Nuffield Trust and a General Practitioner in Greenwich.

Suggested citation

Rosen R (2015) ‘Will over-promising mean the NHS under-delivers?’. Nuffield Trust comment, 16 October 2015. https://www.nuffieldtrust.org.uk/news-item/will-over-promising-mean-the-nhs-under-delivers

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