Sunday 12th March 2017
Dr Philippa Whitford, Shadow SNP Westminster Group Leader for Health, a member of the Health Select Committee and Scottish National Party MP for Central Ayrshire
Despite Jeremy Hunt’s claims that NHS England was better prepared this winter than ever before, the last few weeks have demonstrated that the system is in meltdown. Perhaps spending some time in a busy A&E unit would show the Health Secretary the reality and would knock the platitudes out of him.
Winter is always a challenge for the NHS but, with a third of hospitals in England on alert and the tragedy of patients who died after being stuck on trolleys for 24-48 hours, this winter is unprecedented. The crisis did not come out of nowhere; indeed, the Secretary of State was warned that the system was struggling last summer, and the repeated mantra of £10 billion extra for the NHS has been utterly discredited.
All four National Health Services face the profound challenges of increasing demand (due to older and more complex patients) and a lack of doctors, as well as tight finances. Yet, while NHS Scotland managed to treat 96.1 per cent of A&E patients within four hours last Christmas, many hospitals in England were only able to treat 50 – 60 per cent of patients within the target. That difference is a result of the destructive policy and funding decisions by successive Governments which have undermined NHS England’s capacity and resilience.
The increased demand is not just because people are living longer (the point of medical care, after all); rather, it is because we are not ageing well. It is important to avoid preventable chronic diseases caused by lifestyle yet, bizarrely, the Conservative Government have cut funding to Public Health England, while the watered-down Obesity Strategy is a missed opportunity that will be regretted in the future.
The Secretary of State’s plan to train additional doctors is welcome but he has cut the funding to Health Education England required to train them and, unless he improves his relationship with junior doctors, more will leave the service. With many consultant and GP posts unfilled, he should abandon talk of spreading them even more thinly and work collaboratively with the profession – as has been the case in Scotland – to strengthen Out of Hours provision in key services such as A&E, maternity and radiology.
NHS England has been damaged by political experiments, ranging from Labour’s disastrous Private Finance Initiative to the Health and Social Care Act. The latter has resulted in health services in England being put through a tendering process and often outsourced to private providers. If the local NHS hospital loses the contract, it becomes less financially viable, while the outsourced service is re-organised and often scaled back. As Trusts and services are competing financially, the English NHS has become much more fragmented and harder for patients or, indeed, GPs, to navigate at a time when integration and co-operation are essential to face the challenges of an ageing population.
There has been no demonstration of any clinical benefit gained from that competitive healthcare market, and the Government has not even kept track of the additional administrative cost of the bidding and tendering process, estimated at £5 billion per year, which removes money from frontline services.
Such financial waste appears to have contributed to the dramatic collapse of Trust finances in recent years. Prior to the HSCA coming into effect in 2013, the NHS scraped through each year with about £500 million to spare, while, by last year, 80 per cent of Trusts were in the red, with the deficit reaching £2.45 billion.
Despite the UK Government’s promise of no more “top-down” re-organisation (ironically echoing their mantra in 2010), the most recent suggestion is that NHS England should organise itself into 44 “Footprints” to develop Sustainability and Transformation Plans. The principle of returning to place-based planning of an integrated service for a whole community, as we have in Scotland with our geographic Health Boards, is sound but is being totally undermined by the execution.
While the aim of STPs should be to integrate services to achieve better outcomes for patients, each has simply been given a fixed budgetary target for 2020 to work back from. Change costs money but the £2.1 billion set aside for NHS Transformation has already been sucked into covering £1.8 billion of the deficit, leaving an unrealistic £300 million to fund redesign. Many STPs are, therefore, proposing drastic cuts to acute hospital beds, A&E departments and community hospitals to, supposedly, free up funding to invest in community and primary care. That is misguided as the UK has already cut over half its beds since the 1980s and has the lowest ratio of beds (and, indeed, doctors) per population in Europe. Removing further beds, or shutting A&E units as the first step, would cause many local health services to completely collapse. Additional primary and community services, such as step-up and step-down beds, must be expanded first and any change in hospital estates should be on the basis of developing clinical services in the most appropriate place. That may require building hospitals as much as closing them.
While older patients will often require a little longer in hospital for treatment, drastic cuts to social care funding has resulted in many getting trapped in hospital even when they are ready, and, indeed, desperate, to return home. In Scotland, Joint Boards have been established between the NHS and Local Authorities to provide an integrated approach to the provision of social care and avoid bickering over who funds what. Whilst that is a recent development, it has already achieved a 9 per cent reduction in delayed discharges, compared to a rise of 30 per cent in England.
For STPs to work, they need to be properly funded, have a statutory role and make sense geographically. They must have a shared budget to avoid financial competition and to enhance co-operation and integration between the NHS and social care. The outsourcing of services to private providers must be abandoned as this caused the fragmentation in the first place.
There is no magic wand to create NHS sustainability but STPs could be the best chance for organisational stability in NHS England. They must, however, be shaped in consultation with the public and frontline staff to develop real patient-centered services, rather than Trojan horses.
The public has consistently demonstrated how highly it values the NHS and this should be reflected in Government priorities. The recent crisis shows that NHS England is on its knees and urgent action is needed. Training extra doctors and preparing the NHS to serve an older population will take at least a decade but providing sufficient funding could stabilise NHS England in the short-term. This is a matter of political will!