Tuesday, 22 June 2010

How can NHS services be improved as budgets are cut?

The Conservative Party, more than sensitive to the esteem in which the public hold the NHS, pledged to ringfence NHS spending prior to the General Election.

Since the election, the Cameron-led government has stressed that it will maintain existing budgets and "protect frontline services". This populist approach may prove to be a mistake for two reasons: firstly, exempting the NHS from budget cuts means that cuts elsewhere will be felt harder and, secondly, the government is not actually pledging to match Labour's historic spending increases and therefore any "savings" could end up feeling like cuts.

Over the last ten years, the NHS budget has, on average, increased by 7% annually. What the government has pledged to do is not to continue making such increases, but to keep the spending budget at 2009-10 levels for the next three years. Essentially, this means that NHS Trusts will be forced to find innovative ways of doing more with less at a time when an incoming government is promising improved performances within the NHS.

This week, Strategic Health Authorities (SHAs) have been advised to make significant "savings". Nationally, these "savings" amount to approximately £30billion over the coming three years. While these budgetary restictions are not aimed at frontline services, there are concerns that frontline services will be indirectly affected as Trusts struggle to continue providing the same levels of quality service while making "efficiency savings". Unions have already expressed their worry that job cuts could be an inevitable consequence of the need to make savings while patient groups are concerned that in key areas, such as dementia care and mental health, the necessary investment in service improvements may be sidelined.

Of course, this does not apply to Scotland as health is a devolved issue but it is undeniably true that difficult decisions have to be made also by the Scottish government in relation to the health budget. So the key question is this: how can services not only be maintained but improved while budgets are being slashed?

One consequence may be that NHS Trusts may be keen to increase their use of the private and independent sector. This is not something I generally support, but if we are being realistic this is an option many Trusts will be forced to consider.

However, when Trusts are facing restrictions and opportunities for further developing services and facilities are limited, some use of the independent sector may not only be necessary but more cost-effective. For example, if an NHS Trust is temporarily unable to develop a new cancer unit, or build a new theatre, it makes sense - at least in the short term - to utilise the experience and facilities of independent providers to provide key services in line with the Trust's vision.

My chief concern is that the NHS is run in the public interest and for the public benefit. I would be be worried if the current financial situation led to NHS Trusts compromising best practice for cheapest practice. The independent sector should not, in my view, be used to simply outcource services to help reduce costs. Neither should it be allowed to cherry-pick the most lucrative services, such as certain types of elective surgery. However, there is undeniably a case for working in co-operation with the independent sector to provide an increased range of services and to increase the quality of clinical care.

NHS Trusts should also be looking to reduce costs by moving towards clinically better methods of working. The Kerr Report, which applied only to Scotland but whose principles are applicable throughout the UK, advocated a move towards preventative rather than reactive treatment. As the report makes clear, early diagnosis not only has clear clinical and human benefits, but signficantly reduces costs as fewer people require hospital admissions.

Similarly, Trusts and health authorities must develop new ways of relieving pressure on Accident & Emergency services, as well as in-patient medical facilities. This requires the development of a forward looking vision incorporating improved community services, health promotion strategy and more effective after-care arrangements for patients discharged from hospital. I strongly believe that such joined-up thinking would make a significant contribution to reducing costs - and in the latter case would reduce unnecessary re-admissions.

The NHS is still overly concerned with providing reactive treatment rather than promoting preventative care. This has to change. Health improvements can actually reduce costs and, even with budgetary restrictions, the NHS can continue to improve the services it provides. It is not merely a question of finances, but one of vision and whether the government has the courage to move towards a new needs-focused, pioneering NHS which is willing to shift away from the old models of reactive treatment centred around hospitals towards a more progressive model of health care.

This will not appease those who judge the quality of NHS service by bed numbers and David Cameron is deeply aware of the need to avoid a repeat of the Hewitt years when public opinion moved firmly against the government's policies on health. However, a better NHS requires positive health reform and therefore it is disheartening that a government that has, via its deliberate appeal to populism, halted further NHS reorganisation. The government should have the bravery not just to "ringfence" and "protect" but to innovate and put forward a fresh vision for delivering healthcare.

I have no doubt that new thinking would result in a more efficient NHS which is also cost-effective. On the other hand, maintaining the status quo while cutting budgets would be disastrous for the long-term future not only of the NHS, but the country's health.

Andrew Page is a former UNISON representative


Anonymous said...

A good piece Andrew, well done. Obviously you're thinking a lot about England as well as the NHS in Scotland. The thing about providing more preventative treatments and changing the way we view the NHS is absolutely key. It is definitely "new thinking" that's needed and not just more money!

Anonymous said...

Good piece.

"the government has the courage to move towards a needs-focused, pioneering NHS which is willing to shift away from the old models of reactive treatment"

Define "needs-focused"? If someone is obese that will lead to numerous number of health concerns, it can be prevented by the person losing weight but surely the point of need is when the health concerns actually arise rather than when they are obese and the health concerns can be prevented. Surely you mean "preventative-focused".

There also needs to be a way for patients to bypass GPs. What GPs do is incredibly important but they can be wrong especially with problems in the musculoskeletal system.

Andrew said...

Hi priggy,

I wrote this piece back in June 2010 before the substance of what the government was proposing was known.

What do I mean by "needs-focused"? Quite a lot, really, it's a very broad and inclusive term. There are individual needs, which pertain to physical, mental emotional and social well-being. There are also societal and community needs, as well as the need for the NHS to be run in a more efficient and productive way. As far as I can determine, the best way to deliver for such a range of needs is to be more "preventative" in our approaches. As someone who works in mental health, I welcome the positive rhetoric on preventative care but the reality is regrettably very different.

GPs do an important role and obviously are held in particular regard by the public. But as you say, they can often be wrong - very wrong. Especially when it comes to specialist disciplines, such as mental health. I also believe that empowering the medical profession is a positive move, but more importantly patients and service users should be empowered to make decisions about their own well-being and the system should allow for the opportunity to by-pass GPs. This is why I think the Lib Dem policy of elected regional health boards is infinitely better than GP commissioning; however, if the government is determined to go down this commissioning route it should open it up to other health professionals and those from allied disciplines.

GPs are simply one vital link in the chain. As a former medical student I do not wish to see the medical professional hold such a position of power in the NHS system, especially where there are so many vested interests. The NHS must empower its users and be responsive to a range of needs - not operate in the interests of one professional group.