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Best-laid plans?

Can the chronically underfunded NHS in England make bold investments in areas such as integration or public health, or will it be left papering over the cracks? Peter Blackburn reports

Imagine if your team had a player like Lionel Messi. Then imagine he missed half of every game because his bus ran late and he didn’t have proper boots.

Now imagine a health service which can do impossible things before breakfast – 3D-printed limbs, personalised drugs – but where desperately ill, lonely, frightened patients have to wait hours on trolleys for the most basic treatment.

The NHS is recognised as one of the fairest, most efficient healthcare systems in the world, with some quite extraordinary talent, innovation and compassion. But it is placed in ill-fitting boots – circumstances which are largely beyond its control – rising demand, a continuing lack of capital investment, shameful failures in provision of mental health and public health. Add to that a perception among staff that it is more a political football than a genuine priority. But don’t worry, the NHS has a plan.

Yes, that was meant as a cheap jab, and the emergence of another plan to end all plans from NHS England is likely to cause a collective eye-roll like an ocular Mexican wave around the health service. But while it’s folly to declare a turning point until one’s vessel actually begins to turn (assuming it’s even possible to turn it), there are reasons to examine, and engage with, what NHS England is trying to do.

The background to the plan is this: in June, prime minister Theresa May promised the NHS in England an extra £20bn a year funding by 2023. In return, NHS chief executive Simon Stevens was charged with drawing up a long-term plan to ensure how the extra investment was best spent.

To be clear, the BMA strongly believes that the funding, while welcome, is insufficient to meet the demands on the health service, and that it is needed now, not in several years’ time. But this is at least an opportunity to address what Chris Ham, the outgoing chief executive of the King’s Fund, describes as a system which is ‘fundamentally broken, whether financially or in how patients access care’.

Professor Ham, one of the UK’s most respected health economists, told a King’s Fund conference earlier this month that it would be a ‘huge missed opportunity’ if the new money was funnelled away from change and transformation into covering existing deficits.

It’s fair to say that the words ‘plan’, ‘change’ and ‘transformation’ haven’t always had the best press in the health service. But what might be different, what needs to be different, in this case is that there is a near-consensus about the path the NHS needs to take.

It is for closer collaborative working between the different parts of the NHS, and for integration of services.

This was an overwhelming finding in the survey that informs the BMA’s major new project, which aims to set out a positive vision for a more caring, supportive and collaborative healthcare system. Of the 8,000 respondents, 93 per cent wanted GPs and hospital doctors to work together more directly in a collaborative and coordinated manner. There is no disagreement in this from Mr Stevens, who told the NHS Expo in Manchester last month that he wanted to ‘put an end to entrenched, siloed working’.


Progress at risk

Addressing the fragmentation of the health service is one of the project’s main aims.

The project will set out an environment in which people across the NHS are empowered to work together more effectively while maintaining professional autonomy. It will be centred on patients, asking what clinical pathways would look like in a more collaborative system.

The concept of integration has been around for a long time, and yet progress has been limited to local initiatives, which have shown encouraging results in bringing care closer to home, managing demand and reducing emergency department admissions.

The issue is that, for decades, Government policies have worked against integration rather than for it. In England, increasing marketisation has led to artificial barriers, perverse incentives and wasteful competition. And so, what the Government has done in Parliament to undermine integration, it must undo.

As the BMA says in its response to NHS England’s consultation on the long-term plan, there is growing concern that without legislative backing, a real template for progress, or statutory authority for the new organisations and partnerships springing up, then progress will continue to be patchy and perhaps even subject to legal challenge.

This lack of a national steer – the contradictory position from the Government of keeping a market system entrenched in law but promoting the opposite in local initiatives – is slowing progress and eroding good intentions.

Another priority – and one so often neglected in previous NHS plans – is the engagement of NHS staff.

As BMA GPs committee chair Richard Vautrey puts it: ‘Ultimately, if you are involving clinicians and enabling them to make decisions about how funding is used you will get a better outcome.’

'We often see the work coming to general practice but we don’t see the funding coming to match it'

BMA consultants committee chair Rob Harwood agrees – and urged the involvement of secondary clinicians who hold the expertise in services that may be moved to the community, and will often remain involved in delivering the care.

‘There have not been many people out of secondary care that have been involved in it [the plan] up to now and that feels like a real lost opportunity.’

He adds: ‘There will be a focus on doing more stuff out of hospital. That’s part of what we are expecting, and that’s not a problem except that there’s an assumption that you stop doing things in hospital that’s just fine – but it’s got to be better and cheaper, which it might be, but you need to make sure it actually is.’

As well as ensuring quality, it’s essentially that if services move into the community, the funding follows it too. Otherwise it remains little more than a slogan.

‘We have heard this [integration] for many years,’ Dr Vautrey says. ‘It’s something often talked about but we haven’t seen that delivered in any material way – we often see the work coming to general practice but we don’t see the funding coming to match it – this is an opportunity to do that and to put the money behind the rhetoric.’

If integration is destined to play a major role in the long-term plan, which is expected to be published in November, what else can we expect?

Keep your ear to the ground in NHS meeting rooms and conferences and the answers to this question seem to be: upgraded mental health services, a focus on improving cancer treatment and outcomes, efforts to improve services in overlooked areas such as autism, a major focus on technological progress and, yes, you guessed it, a ‘radical’ investment in, and focus on, public health.


Room for manoeuvre

Heard it all before? Perhaps so – but there is reason for a little more optimism this time around. When Mr Stevens was tasked with drawing up the Five Year Forward View, this was a health service cash-strapped beyond reason, one required to make brutal and unsustainable cuts. No organisation can innovate in those circumstances, even with the NHS’s remarkable record when backs are against the wall, as they so often are.

This time around a pocket of money has been promised. Granted it’s nowhere near what most health experts know to be required, but it’s certainly more than anyone could have expected six months ago, and that is a very different scenario to the one Mr Stevens last found himself in. Here there is an opportunity to make things better – and a little more headroom to make those changes stick.

When it comes to public health – and the wider determinants of health – the problems the NHS, and society, faces are clear and have been for many years. But they seem to get lost in the here and now.

As Duncan Selbie, the founding chief executive of Public Health England, told the NHS Expo conference: ‘We keep talking about the same things, cancer rates and [emergency care] performance. But what about the future? We should be concerned about whether children are ready to learn when they start school, can they read… these are the things that determine their future.

‘The biggest determinant of outcome is not what we do in a renal clinic but the money in our pocket. The decisions we make – do we smoke, what do you eat, how is our blood pressure. Do we have exercise, how much do we drink. And the biggest determinant of all is do I have a job?’

While this requires the shamefully neglected public health services to be rescued from years of cuts to services in areas such as smoking cessation, it is also clear there is a job for the Government well beyond the confines of the NHS.

BMA public health medicine committee chair Peter English says: ‘Much of it comes down to big Government measures – how you do taxation, how you ensure a greater level of equality in society, whether you make the healthy choices the easy choices like taxing unhealthy foods, putting fiscal arrangements in place that encourage people to take exercise.’

But it seems the Government has been better at talking about public health measures than actually bringing them into being.

‘Prevention has to be a good way to spend some of your healthcare money – the difficulty is we talk the talk around it but we don’t seem to believe it,’ says Dr Harwood.


Preventive measures

One person who does believe in the importance of prevention is Amanda Doyle, a practising GP and leader of the Lancashire and South Cumbria integrated care system, and one of the people who will draw up NHS England’s plans.

She told the King’s Fund conference: ‘What we have got is an opportunity to invest where we need it most – the only time practically speaking we are going to be able to invest up front in prevention and mental health is when there is new money available – it’s vital that we recognise while we are compiling this plan that we need to get investment into those areas where it can make a difference.’

Of course, a health service that has been neglected for so long needs attention in many areas.

The BMA also expects the plan to address long-term workforce planning, capacity in secondary care – England has 6,000 fewer beds than it had in 2014-15, and this has exacerbated winter pressures – for primary care to be given a fair share of the NHS budget, and for mental health to achieve the ‘parity of esteem’ which ministers have promised.

And the NHS needs more than merely a shopping list. The BMA believes the aim should be a new kind of health service, rather than the old one with a little bit more money to paper over the cracks.

'It is vital that the Government and policy makers heed the views of all doctors who provide care at the coalface'

The BMA’s Caring, supportive, collaborative: A future vision for the NHS  project takes on fundamental issues such the culture of the NHS, moving away from one of blame towards one of learning, and the importance of a properly equipped and rewarded workforce.

BMA council chair Chaand Nagpaul says: ‘It is vital that the Government and policy makers heed the views of all doctors who provide care at the coalface; they are in the best place to know the problems the NHS faces on a daily, hourly basis. They know the scale of impoverishment in the NHS is staggering and they are working in a culture which has improved little since the publication of the Francis and Berwick reports following the tragedies in Mid-Staffordshire five years ago.’

So the Government must realise that the funding announced in the summer is the beginning, not the end, of a fair and sustainable investment in the NHS.

A step in the right direction, but nothing more, and it should be part of a wider cultural change.

It is reasonable with any money the Government spends for it to expect to know how it will be spent. But it should not expect miracles from a health service that has suffered for so long under the effects of its austerity policies.

Equally, and despite the huge effort it takes to cope with day-to-day demands, the health service needs to invest, and invest boldly. This might mean missing some targets, but sometimes it’s better to miss a target than it is to miss an opportunity.

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