NHS reform: what next for the world’s best health system?
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Version 0 of 1. The National Health Service has been judged the best health system in the world. It’s certainly the issue which matters most to voters, the opinion polls tell us. But what will the NHS look like in the years to come? How will it cope in the face of an ageing population and unprecedented funding pressures? With NHS England’s own estimates suggesting there will be a cash shortfall of up to £30bn a year by 2020, making the NHS fit for the future is an urgent priority. In advance of the general election, politicians from the Conservatives, Liberal Democrats and Labour set out their competing visions for the health service at the Guardian’s health hustings debate. The event, sponsored by the Association of the British Pharmaceutical Industry (ABPI), saw some heated debate – but there was agreement from the panel on the scale of the task ahead. “The system as a whole will crash unless we confront the issues,” said Liberal Democrat MP Norman Lamb, the minister for care and support. “We get a very, very good deal from the NHS but it won’t survive another five years if we carry on as we are. There should be a non-partisan commission established after the election. We want all parties to commit to it and we want the public to engage with it, as there are some really tough choices to be made.” Shadow care minister Liz Kendall said the values of the NHS, of fairness and “solidarity in pooling resources and risks” were ones the British public held dear. “We need strong leadership into the next decade if those values and principles are to remain and I don’t think we are getting that at the moment,” she said. “We need to reset our health and care services so they are fit for the 21st century. Over the past five years the government has squandered the opportunity.” Lamb and Kendall both pledged their parties would invest more in the NHS, through higher taxes and the mansion tax respectively. But junior health minister Dr Dan Poulter MP, who still works as a hospital doctor part-time, suggested that, although there was broad consensus about the challenge, the way forward was to ensure better joined-up care and more efficiency savings. “We have managed to free up an extra £4bn during this Parliament every single year,” he said. “We need to make sure we continue to improve efficiency to free up more for frontline patient care.” The need for integration between health and social care and to bring more care into the community, rather than keeping it in acute hospitals, were big themes of the debate. According to Poulter, it will be important in the years to come to build on the Better Care Fund, the £5bn initiative to pool resources across health and social care being introduced this year. “We need to do that to support more joined-up care and to break down those silos that are sometimes in the way of delivering care,” he said. Lamb said it was “inspiring” to see the way resources were now being brought together. “This government is the first government actually doing something practical to join up health and social care,” he said. But Kendall warned that “the rug was being pulled from under the NHS’s future” by cuts to local government social care funding. “No wonder more people are ending up in hospital and stuck in hospital,” she said. “We need a big change – not to backroom services but to the way services are delivered and a fundamental shift from hospitals to community provision.” She flagged up the fact that delayed discharges, often because of a lack of support in the community for people leaving hospital, are now costing almost £300m a year, money that Labour estimates could pay for a year of home visits for 41,000 older and disabled people. “It doesn’t make sense to make huge cuts to local council care budgets that pile further pressure on the health service,” she added. But if better integration between health and social care is widely recognised as crucial to supporting an older population and those with long-term conditions, there is no such agreement about the involvement of private sector providers in the NHS. Poulter claimed the proportion of NHS spend going to the private sector had only increased from 6% to 7% under the current government, which he claimed was “hardly evidence of swingeing privatisation”. But that view was challenged by some in the audience, who asked whether the new wave of contracts, such as the ongoing bidding for £1.2bn of cancer and end-of-life services in Staffordshire, heralded the privatisation of the NHS. According to one consultant in the audience, there was a “hidden agenda” of privatisation that was “extremely wasteful and demoralising” for those working in the NHS. Lamb said it would be a mistake for the NHS to turn its back on any challenge to existing provision. “We have to be open to other providers,” he said. He particularly stressed the value of social enterprises and mutuals in service provision, where engaged staff with a stake in their organisation could drive better quality care. Kendall said there was a role for different providers, but putting every single service out to tender was wrong. Millions of pounds were being spent by NHS trusts on tendering services and dealing with the competition now enshrined in the NHS, she claimed. “The idea that there is reduced bureaucracy in the NHS is laughable,” she said. But what other ideas do our politicians have for improving the NHS in the years ahead? Better use of technology is one key area. Lamb said he had been inspired by a project in the US, where a Seattle clinic is now carrying out up to a quarter of its consultations by secure email. Poulter agreed that embracing technology could help deliver better care, particularly important in general practice, where, as questions from the audience suggested, pressures on the NHS are being keenly felt. “We have 1,000 more GPs now and we have said we need another 5,000 by 2020. We have workforce plans in place to make that happen,” he said. “Part of it is about making general practice a sustainable and attractive career. It is a very well remunerated career but that’s not everything. We need to encourage a better working environment. Technology can improve the quality of life for GPs and reduce their workload.” Training was also highlighted as a way of both boosting the recruitment and retention of GPs and improving the quality of primary care. The potential to enhance the role of other professionals in the health field and beyond was also addressed; in response to a question about pharmacists, the panel highlighted the important part they could play in supporting healthy communities. “The role of the community pharmacy is under-recognised and undervalued,” said Lamb. “As we design much more joined-up integrated out-of-hospital support, the pharmacy has to be central to that.” He added that employers can also play a role: “A healthy, happy workforce is in everyone’s interests.” But central to the future of the NHS, the debate heard, is the need for a big cultural shift. Lamb saw it as the need to move away from change being directed from Whitehall. “We need to give powers to local leaders and clinicians to deliver as they see fit,” he said. He also stressed the need to focus on prevention and on outcomes. “The system is often too paternalistic and we need to move to one that’s personal,” he said. “We need to ensure we incentivise outcomes – at the moment the system is designed to incentivise activity in acute hospitals.” Kendall stressed the need to identify and implement the drivers for change that patients want to see: “I believe, fundamentally, that it’s about putting power in people’s hands.” And in Poulter’s view, the key challenge will be “to transform services to empower people to take greater control of their healthcare.” In the run-up to the election there will be much more debate over the parties’ approaches to ensuring the health service is sustainable in the years to come. But one thing is certain: steering the NHS over the next few years will not be easy. As the debate heard, it will be a massive challenge for whoever is in power come May. On the panel Denis Campbell (Chair) Health correspondent, the Guardian Dr Dan Poulter MP Under secretary of state at the Department of Health Norman Lamb MP Minister of state at the Department of Health Liz Kendall MP Shadow minister for care and older people This content has been sponsored by the Association of the British Pharmaceutical Industry (whose brand it displays). All content is editorially independent. Contact Matt Nathan (matt.nathan@theguardian.com). For information on debates visit: theguardian.com/sponsored-content |