Chris Ham (King’s Fund CEO) ducks the real issue in the BMJ 24th October 2015: The three crises facing the NHS in England (BMJ 2015;351:h5495 ) . Short term problems are his agenda – not longer term solutions. Whilst Chris focuses on financial, patient care, and political issues, he never addresses the longer term mismanagement of manpower, the failure to encourage patient autonomy, and the breakup of the large mutual that was once the former NHS. (To be fair this breakup does not affect England much, but it is having a big effect on Wales.) He never once mentions rationing (either overt or covert) as a possible solution…. it might cost him his “gong”! The real longer term crisis is “doublethink”… and Chris is part of it. (with apologies to the BMJ for complete copy)
The NHS in England is in crisis. For now the crisis is financial, with providers in deficit by almost £1bn (€1,4bn; $1.5bn) at the end of the first quarter of this financial year.1 2 It will soon extend to patient care as waiting times—already under huge pressure—lengthen and providers look for ways to cut costs. Before long, the crisis will become political as the government decides what to do about funding in this parliament.
None of this is surprising. Regular surveys by the King’s Fund of NHS finance directors have shown growing concerns about funding and performance and increasing pessimism about the future.3 And the fund’s recent submission to the government’s spending review shows how this is already affecting patient care.4 The government can’t claim it wasn’t warned, but it has been much too slow to act.
The hard question is what to do now, with care and cost pressures set to increase as winter approaches. In the short term, it will not be possible to get budgets back into balance because NHS providers have to meet demanding targets for patient care and deliver the standards expected by the Care Quality Commission.
Meeting these standards means ensuring that there are sufficient staff to provide care of the right quality. NHS providers have relied increasingly on agency staff to do this and have paid high rates for them. The ballooning bill for agency staff largely explains the growing deficit, and it is unclear that measures taken by the government to reduce these costs will be effective.
NHS hospitals cannot go bankrupt and have to continue paying staff and creditors and treating patients. The financial crisis therefore risks becoming a crisis in patient care, with ambulances queuing outside hospitals waiting to transfer patients to busy emergency departments, patients waiting on trolleys for beds to become available, and operations being cancelled as hospitals give priority to patients admitted as emergencies.
The impending political crisis centres on the spending review and decisions on the funding of the NHS for the rest of the parliament. The government has already committed itself to allocating an additional £8bn to the NHS by 2020-21. At a time when most other public services face the prospect of further deep cuts, this affords welcome protection. However, with a growing and ageing population and rising demands for care, it is unlikely to be sufficient.
Speaking from a meeting of finance ministers in Peru last week in response to news of provider deficits this year, George Osborne reiterated that the NHS has already received extra funding and indicated that it was now down to providers to live within their means. If the government maintains this line through the spending review, ministers need to spell out the consequences for patient care and to be honest with the public about what it will mean.
This is where there are no easy choices. Ministers could relax some of the key targets for patient care, such as the four hour wait in emergency departments and the 18 week wait for tests and operations. The risk here is of the government presiding over a return to the state of the 1990s when long waiting times for treatment were a major concern for the public.
A further possibility would be to suspend implementation of new commitments such as seven day working, the government’s flagship policy for the NHS. While this would avoid a battle with the BMA over changes to doctors’ contracts, it seems an unlikely U turn in view of the personal commitment of both the prime minister and the health secretary.
Another option would be to clamp down on staffing levels, but this would be embarrassing for Jeremy Hunt, who has led the drive to improve patient safety and quality of care by ensuring there are enough staff in hospital wards and clinics. More likely is that there will be a quiet reduction in the pressure to implement safe staffing levels and leave this as a matter for local decision.
Which takes us back to the spending review, where choices have to be made about when the promised extra £8bn will be provided and the effect of the review on publicly funded social care. If the government remains committed to delivering safe, high quality care within the NHS seven days a week and with short waiting times for treatment it will have to inject additional resources sooner rather than later. It also needs to protect public funding for social care to avoid putting further pressure on an already overstretched NHS.
To do so would not be to prop up an inefficient and bloated bureaucracy, as some would claim. Spending on the NHS is modest by international standards and in this decade is much lower than in any decade since its inception. The cause of the current financial crisis is not mismanagement but insufficient funding to deliver the care the public expects.
Recognising this will not be easy for a chancellor committed to deficit reduction and to cutting public spending substantially by the end of the parliament. On the other hand, denying the reality of NHS funding would almost certainly lead to an accelerated decline in performance and public concerns about whether the NHS is safe in the government’s hands.
Where the prime minister sides in this debate will be crucial in shaping the fate of the NHS and social care. His often expressed personal debt to the NHS will be tested to the limits in the coming weeks, with many competing claims on public funding and a commitment during the election not to raise headline tax rates. The stakes could hardly be higher for the government and for patients.