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Point of no return

Patient sitting next to hospital bed 20687

A ‘fanciful’ plan to turn the NHS around was revealed last week. It promised to create the most integrated health service in the Western world and invest in urgent care, cancer treatment and general practice. Peter Blackburn reports on the dangers that lie beneath its ambitious pledges

'When I was studying for my physics O level I learned about the point beyond which a piece of elastic will fail – and when studying physiology at medical school I learned about the point at which the strain on the heart causes cardiac failure.

‘I suspect we are looking down the barrel of the same phenomenon when we talk about targets and intentions for the NHS that are so stretching, nobody thinks they are realistic.’

BMA council chair Mark Porter’s assessment of the NHS’s potentially terminal prognosis is stark – but nobody, not even this Government, can claim the warning has come from nowhere.

The BMA, along with other health bodies including the medical royal colleges, parliamentary committees, unions and ‘arms-length’ bodies, have long warned of the crisis the service faces. It is at breaking point because little action has been taken.

And the NHS England delivery plan, revealed last week, has done little to address those problems. Instead, despite many positive ambitions, the plan has simply further exposed the causes and consequences of the crisis in the health service. In short the plan promises:

  • The creation of shiny new GP hubs, rapid diagnostic cancer centres and mental health hubs – yet there is no capital for projects to be delivered
  • Massive workforce increases but ignores the recruitment and retention crisis threatening the everyday running of services; just last week the Government’s 5,000 more GPs mission was revealed to be going backwards
  • Improvements to urgent and emergency care but removes the Government target for those awaiting treatment for serious non-urgent, but extremely painful, problems such as hip replacements to be seen within 18 weeks
  • Plans for a few STPs (sustainability and transformation plans) to go forward and become real structures with genuine authority – despite these new bodies having no mention in legislation and no formal governance.

 

Head in the sand

Perhaps most worryingly of all, Dr Porter suggests, the plan, officially called Next Steps on the Five Year Forward View, confirms that this is a Government burying its head in the sand on the NHS, steadfastly ignoring all the warning signs. This is a Government distracted by exiting the EU and a poorly evidenced manifesto pledge, and one which may go down in NHS and UK history for all the wrong reasons.

Dr Porter says the delivery plan was produced with minimal involvement of external health partners, such as the BMA, contrary to how similar reports are usually developed – with negotiations potentially ‘going to the wire about the sort of promises and commitments that could be made’ within. And it shows.

‘The contents show that the NHS is not central,’ Dr Porter says. ‘The Government is acting as if it believes people won’t notice this set of accounting tricks and these adjustments of expectations.’

Perhaps we should not be surprised. The words said behind closed doors are sometimes the sharpest – but those spoken in public are often most revealing. Last week, just hours before the delivery plan was unveiled, NHS England chair Malcolm Grant told a board meeting that the plans had involved ‘quite an amount of negotiation’ with the Treasury, prime minister and Department of Health – careful civil service phrasing for what were no doubt more heated discussions.

During the same meeting he told the board, and a small scattering of journalists and members of the public, that the year ahead would be even tougher than the record-breaking difficulties of 2016/17.

And so the landscape of the delivery plan was set. This would be a rescue plan with no significant financial backing from the Government – with every promise carefully scrutinised by accountants and spin doctors and no cash coming out of the Whitehall envelope. The genuine, deep-set problem of under-funding in the NHS would not be solved. And on top of that patients needing treatment such as hip operations would be left waiting for longer.

The plan claims to provide solutions to the crisis in the NHS, including turning around the everyday struggles in general practice, improving cancer care, tackling emergency department crowding and putting extra funds into mental health.

NHS England says it reveals how the service will ‘deliver practical improvements in areas prized by patients and the public – cancer, mental health and GP access – while transforming the way that care is delivered to ease pressure on hospitals by helping frail and older people live healthier, more independent lives’.

Among its aims include pledges to save an extra 5,000 lives a year through improved cancer care, a boost to mental health beds and services, increased access to GPs – including most controversially during evenings and weekends – and a drive to tackle efficiency and waste.

At last week’s board meeting NHS England medical director Professor Bruce Keogh admitted that there had been a ‘long-standing under-funding of general practice which we’re trying to reverse’ – and the delivery plan aims to tackle that.

It reiterates the Government’s target to train 5,000 more doctors, suggests that 100 per cent of the country will be able to access GP appointments at weekends and evenings by March 2019 and outlines plans to invest in 800 infrastructure projects by 2019.

But the reality does not match the rhetoric – particularly on general practice.

BMA GPs committee deputy chair Richard Vautrey says: ‘The rhetoric is increasingly positive towards general practice and there certainly is a plan to invest. But we need more staff in the community to be able to manage more patients in the community and the real challenge is delivering the rhetoric. The workload is expanding and we need an expanding workforce – not just a replaced workforce.’

On promises of seven-day access to GPs, Dr Vautrey points to funding cuts to the prime minister’s challenge fund sites – surgeries piloting extended access – as undermining the optimistic outlook.

‘While they are maintaining some form of evening and weekend working the number of appointments and the opportunities for patients to see a GP will be significantly reduced,’ he says.

‘We need some honesty about what is happening – the Government may now be able to tick a political box that [it is] delivering seven-day services but the reality is that’s not really happening. And there’s little evidence that this should be a key priority. The Government would be much better off investing additional money on core GP services, improving the resilience and sustainability of core practice.’

Of course, as always, money is key to all of these plans – particularly in terms of the upfront capital needed to transform services in the way the report describes.

But the document contains precious little financial detail. Even NHS Improvement chief executive Jim Mackey said last week he would have ‘liked to have seen some of that detail’ included, but that the Treasury and DH needed to be ‘comfortable’ with it.

He went on to say: ‘We’re just not at that point because we’re still in the muck and bullets of it all.’

He has also said the service could look to the private sector to borrow up to £10bn needed to improve facilities and enact STPs.

While those on the front line of the NHS might well argue that the muck and bullets have been flying for some months or years, Dr Porter said the chances of seeing the sort of cash to make changes seem very unlikely.

‘The NHS has had a huge problem with capital funding in recent years, we’ve seen limited availability and it only being available if you go down the hugely wasteful PFI route,’ he Porter says.

‘We’ve seen capital costs raided to fund revenue and we know revenue is running in deficit. I would say the one thing that has shown it works in the NHS, upfront investment in buildings and resources, appears to be at the back of the queue.

‘People whose delivery of services require something new being built should be very worried about the future.’ And the financial picture could yet become even bleaker.

 

Brexit fall-out

NHS England chief executive Simon Stevens appears to have been promised some sort of cash settlement for the STP programme, or the wider NHS, in the autumn budget.

But the looming chaos of Brexit – which the BMA has lobbied so heavily to ease – could change everything.

Dr Porter says: ‘As we approach autumn the awesome and terrible costs of the Government’s decisions about how to exit the EU may suck in everything, they may dwarf all other things. We may lose a critical element of our staff, the Government may need to save up for a divorce settlement, or what is the latest – defending Gibraltar from Spain?

‘The consequences may be very troubling for health. It makes you wonder about this Government being too inflexible to deal with the reality of the day.’

The plan is clearly well intentioned and Mr Stevens knows just how tough the years ahead will be – with financial projections looking more austere than ever and demand unlikely to tail off dramatically. Mr Stevens will know the sums do not add up.

Speaking as the plan was unveiled Mr Stevens said: ‘Heading into our seventieth year, public support for the NHS is as strong as ever but so too are the pressures on our frontline staff.

‘Today we chart a course for practical care improvements for the next few years. We do not underestimate the challenges but, get these right, and patients, staff and the tax-paying public will notice the benefits.’

The reality is that if urgent action isn’t taken those challenges might just become unsurmountable and the public will certainly notice.

But it won’t be the benefits they see. Dr Porter says it will be the slide of one of the world’s most efficient and impressive healthcare systems into an offering ‘analogous to the dental service’ in England.

As Dr Porter says: ‘The Government seems to be absolutely determined to test the system to destruction – and one can only hope someone notices before that happens.’

bma.org.uk/nhsbreakingpoint

NHS England: stand and deliver

URGENT AND EMERGENCY CARE

  • The plan reiterates previously announced funding and the targets recently stated in a letter from NHS chief executive Simon Stevens and NHS Improvement chief executive Jim Mackey to all trusts. The targets include a revised four-hour emergency access target of 90 per cent to be met by September 2017. The target will return to 95 per cent by March 2018
  • £1bn allocated to social care will be used to improve delayed transfers of care – freeing up 2,000 to 3,000 hospital beds.

PRIMARY CARE

  • Pledge to roll out evening and weekend GP appointments to 50 per cent of the public by March 2018 and 100 per cent by March 2019
  • Target of extra 5,000 doctors working in general practice by 2020
  • Funding will rise by £2.4bn by 2020/21.

CANCER

  • Within two years more than 5,000 extra people a year will survive cancer as compared to now
  • Expansion of diagnostic capacity so England is meeting all eight of the cancer waiting standards. Focus will be on the 62-day referral to treatment standard ahead of the introduction of the new standard to give patients a definitive diagnosis within 28 days by 2020. By March 2018, 10 new multidisciplinary rapid diagnostic and assessment centres will be introduced, with roll-out centres in each of the 16 cancer alliances by March 2019.

MENTAL HEALTH

  • Four new mental health units for mothers and babies
  • An increase in psychological (‘talking’) therapies – 60,000 more people will get treatments for common mental health conditions by the end of 2017/18, rising to 200,000 more people getting care by 2018/19.

STPs

  • STPs are now referred to as sustainability and transformation partnerships. The plans published at the end of 2016 are referred to as ‘mark one’ proposals that still require local engagement with patients, communities and staff, with some suggestions requiring formal public consultation
  • STPs are not new statutory bodies. They supplement rather than replace the accountabilities of individual organisations. NHS England says it does not want to be overly prescriptive about organisational form.

STPs 2.0: more powers

NHS England’s plan formally continues the STP project.

The plans published at the end of 2016 are now referred to as ‘mark one’ proposals still requiring local engagement and some suggestions will require formal public consultation.

The nine STPs deemed to be the most successful by NHS leaders have been selected to be given beefed up powers and each will become some form of ‘accountable care system’.

The areas will each be given more powers over funding and local decision making – and no organisations will be allowed to get in the way of integration, the document warns.

BMA research has led national coverage of STPs in recent months revealing that the projects hid £26bn of savings and that they would need at least £9.5bn of capital to get off the ground.

BMA council deputy chair and STP lead David Wrigley says the discrepancies between STPs and the way they would be moved forward across the country seemed ‘chaotic’ and ‘messy’ and queries where the money would come from – as well as the staff to enable an integrated, community-based approach to local healthcare.

He says: ‘It looks like a Government thrashing around with no plan and no ideas.’

Speaking earlier this month Dr Wrigley said: ‘There is nothing sustainable about asking the health service to design its own future and then ignoring its needs, and there is nothing transformative about providing around 100 times less than the capital funding that these plans require.

‘This is the same Government that regularly claims the NHS is fully funded and gave us a fictitious claim of having injected £10bn into the health service.

‘It is time the Government is open and honest with the public and with those who work in our brilliant NHS – the health service cannot be forced to limp from one crisis to another with only sticking plasters to help. The NHS is in crisis and urgent action is required.’

BMA council chair Mark Porter says the process is being carried out with a worrying lack of governance – and that some areas will lose out while others succeed.

He says: ‘It’s significant that we’re going further down the road of having the controlling, deciding important organisations which are nowhere mentioned in the act that establishes the NHS and the act that establishes the current vision of the NHS.

‘Five years after the passing of the Health and Social Care Act we are incredibly in a position where people are looking around and saying act, what act? If we don’t know the statutory authority of organisations and where their powers are derived from that’s where the absence of a formal framework will hurt.’

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