New NHS plans - forward view, frightening, or fudge?

The new NHS plans published yesterday ask for £8bn - more than any of the big three parties are offering - and offer £22bn of savings. But we've heard such promises before - where will they come from?

John Lister
24 October 2014
misty wood path.jpg

Will new NHS plans get us out of the woods? Image: Nicholas Tonelli / Flickr. Some rights reserved.

Simon Stevens’ Five Year Forward View document is being reported in much of the press as a call for an £8 billion increase in NHS funding by 2020, to facilitate a raft of other policies aimed at reducing demand on hospitals and improving efficiency.

Even those suspicious of Stevens’ history in the US private medical corporation UnitedHealth, and as a Blair aide in opening the NHS up to the private sector, should be pleased to see him raise the need for more funding – asking for considerably more than any of the main parties have yet proposed.

But his cagey interview on BBC Radio’s Today programme yesterday, in which he dodged questions on the role of the private sector and PFI, didn't help allay suspicions of some of his proposals. While his plans to reorganise local services are a long way short of a full-blown blueprint for privatisation, it certainly offers the potential for private corporations seeking to leach profits from the NHS budget.

The report itself is evasively worded. It appears to focus mainly on NHS provision.

It defends - if a little tentatively - core NHS principles, saying “nothing in the analysis above suggests continuing with a comprehensive tax-funded NHS is intrinsically undoable”.

The briefings around Stevens’ proposals are significantly different from the Report itself. The £8 billion figure does not appear in the 39-page document, and nor does the accompanying figure of £22bn further “efficiency savings” (or demand reduction) that the Report says will be needed to bridge a £30 billion projected financial gap in NHS funding.

£30 billion is the widely agreed ‘gap’ between resources and demands for the NHS over the five years from 2015, if coalition spending plans to freeze funding in real terms prevail. The three main parties are living in denial.

Stevens’ report correctly points out that ‘flat funding’ along these lines ignores population growth, and could result in a reduction in real funding per head.

Stevens points to the astonishing success of the NHS in largely maintaining services despite the spending freeze since 2010, and acknowledges the sheer effort and dedication of staff that has made this possible.

But he glosses over the fact that a third of the apparent “savings” since 2010 have been at the expense of massive reduction in real terms salaries of the million NHS staff whose pay has been frozen since 2009.

It’s clear to all but Jeremy Hunt that another five years of the same cannot be delivered.

Stevens gives a brief nod to pay, suggesting “as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff”.

If this means more pay, it will require considerable new investment.

As will promises to:

·        Radically upgrade prevention and public health

·        Give “new support” to 1.4 million full time unpaid carers whose efforts keep the NHS afloat.

·        Give “resources and support” to the introduction of “radical new care delivery options” throughout England – among them new “multispecialty community providers” bringing together GPs, nurses, community health services and mental health, employ hospital consultants, run community hospitals and have admitting rights to hospital beds.

·        Give more NHS support for frail older people living in nursing homes.

·        “Invest in new options for our workforce, and raise our game on health technology”.

 But where will the money come from? Many of these are good ideas, but the price tag is never discussed.

Stevens claims that some of the investment will eventually deliver record levels of efficiency savings. But he doesn’t explain how.

Take the plan for “multispecialty community providers”. This is an even more ambitious revival of Lord Darzi’s controversial plans for “polyclinics” that were resoundingly rejected by most GPs and by local communities seven years ago. Despite government pressure only a few, expensive and unsuccessful, Darzi clinics were built – and most of them have since closed.

Now, as then, Stevens offers no serious discussion of the costs of the new modern buildings, equipment and professional staff that would be required to deliver this.

The plan potentially hugely fragments services currently provided in hospitals, with GPs employing hospital consultants in much smaller localised units serving very much smaller populations. This might sound good - but Stevens doesn’t it explain how it will do anything to reduce costs.

He does at one point suggest a “pump-priming” by “unlock[ing] assets held by NHS Property Services, surplus NHS property…”

Stevens also offers us a diametrically opposed alternative to GPs employing hospital doctors - that in some areas, Foundation Trusts in some areas could begin to run primary care, becoming “primary and acute systems”.

Stevens worryingly compares these with “Accountable Care Organisations” now developing in the US and “other countries”, often under private ownership.

He also offers “Clinical Commissioning Groups” the option of “more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services.” Stevens ignores the reality that far from being “led by GPs” as he suggests, most CCGs are largely run by managers or by Commissioning Support Units and management consultants.

And he sets out hopes that prevention and health promotion changing people’s behaviour and lifestyle to reduce the demand for hospital care.

We’ve heard most of this before.

A shift from hospitals to ‘the community’, ‘alternative settings’ or ‘closer to home’ has been set out in every plan for hospital ‘rationalisation’ in the last 20 years or more - underpinned by the assumption that more localised services would somehow be cheaper. But there’s no evidence they are. As a result, even as local acute hospitals are undermined in the teeth of local opposition, community health services remain desperately under-resourced and further fragmented by repeated outsourcing and contracting.

And few GPs - except the most entrepreneurial - want to deal with the administration required to deliver such models.

More health promotion and prevention of ill-health is obviously a good thing. But it’s hard to change ingrained behaviour. Many of the health promotion targets have been wildly unrealistic, and the resources allocated to them completely inadequate. Time and again the burden of ill health among older adults that has already resulted from previous decades of less than healthy diet and behaviour has been underestimated.

There is no quick fix. Hospital attendances and admissions have risen throughout this same period - compounded by the massive cutbacks in social care, which are set to continue under Osborne’s public spending plans.

The result: intensifying pressure on the remaining hospital services - now taking the form of huge, under-funded demand on A&E, lengthening waiting times, and more delays in discharging patients from hospital for lack of suitable support in the community. A recent report in the Times shows the decline since 2010:

·        The number of people waiting for operations has gone up by one million to 3.3million people.

·        People are now waiting on average 10% longer for treatment.

·        The numbers waiting over 18 weeks and over 26 weeks for outpatient appointments and treatment have gone up by 25%.

·        Cancer treatment targets have been missed for two successive quarters.

·        For well over a year A&E departments have been failing to hit targets for treatment within 4 hours.

·        Trolley waits for a bed have almost trebled in the last three years.

·        Last minute cancellation of operations last year hit the highest level for nine years.

·        Delayed discharge of patients fit enough to leave hospital have hit a new record level.

·        60% of patients have to wait more than 48 hours to see a GP.

Both hospitals and GPs are clearly under huge pressure. Before doing anything that could undermine them, new services have to be put in place to ensure patient care is improved. This needs money and will take time.

Some of Simon Stevens’ ideas may help - if there was money to pay for them. But - whilst the three main parties have professed their welcome for Stevens’ plan, none have pledged to increase spending by anywhere near the £8 billion above inflation he says is needed by 2020.

And it’s unclear how his plans would generate anywhere near the hugely ambitious £22 billion savings target he sets.

Given this, his plan lacks credibility.

It’s noticeable that none of Stevens’ proposals to boost efficiency takes on the costly and wasteful elephant in every CCG and Trust boardroom – the inflated transaction and overhead costs of running the NHS as a competitive market.

Instead, his plan leaves room for private sector inroads that would further destabilise struggling and indebted NHS Trusts and contribute nothing of value to patient care.

Campaigners will have to fight on for genuinely alternative plans for the NHS. We need a short term increase in funding - followed up by efficiency savings based on stripping away the wasteful bureaucracy of the market. And we need longer term plans to get the rich and big business to pay their fair share of tax towards public services we all need, but which are being starved of resources.

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