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Funding

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Article 3 of a 3 part series on the NHS. Co-authored by Dr Aisling Koning

Original illustration for Healthcare-Arena by Fran Orford

NHS in England is facing unprecedented challenges: a prolonged funding squeeze alongside a changing burden in society’s healthcare needs has put intense pressure on services and finances. As Healthcare Arena described in Part I, since its inception, the NHS has constantly been subjected to cutbacks and reorganisations by the government, who many believe are focusing more on cutting costs as opposed to investing in a business.  A key problem may be that NHS is framed as a problem needing fixing, instead of an asset (Part II).

The current dispute between politicians and junior doctors over extended working hours is a case in point, highlighting political incompetence and mismanagement of the NHS. Politicians have the audacity to claim the doctors’ primary concern is loss of earnings when they themselves preside over the scandalous waste caused by agency nurses. It is indeed likely that many more people would trust doctors more than politicians, after all, who would you trust with your health?

Funding, transparency and Education

Any business needs investment to flourish. Unfortunately, there is currently no political party with a plan to fund the NHS properly for the future. The equation is simple: if the NHS is to survive and flourish we must pay more, alongside improving efficiency and management.

Because healthcare is free at the point of delivery does not mean that it is free. However, generations have grown up with this impression and expectation. Therefore, regarding funding of the NHS, the lack of transparency on personal contributions leads to confusion for the majority. The proportion of an individual’s national insurance and general tax contribution to the NHS, pension or social care remains largely unknown; some feel that there is no personal connection with financing all three; many people are not aware that their employer also contributes toward their national insurance contribution. Health and social care are closely related and should be managed as such.

A system that allows individuals to see how much they have contributed could have a significant impact. This could be the starting point for dealing with the reality that the NHS cannot survive as a first class service in the long term without a significant increase in funding.

A core solution to properly funding the NHS, and social care in the future, lies in education. A large increase in spending and social care, funded by increased contributions by individuals that are fully aware – and proud of their contributions – could bring significant improvements in health and social care. Indeed, there may not be huge resistance to such increases, you Gov polls in April 2014 demonstrated that 48% of individuals would be happy to increase national insurance contributions if they were ring-fenced for the NHS. This would facilitate sensible discussions on the methods for increased funding, including top-up contributions schemes etc.

Without any political party proposing meaningful solutions to sustaining, let alone improving the NHS in the next decade, this funding must come from some form of taxation; the future of the NHS is dwindling. The Scottish National Party (SNP) and Labour refer to cutting trident and defence spending to reinvest in other areas including healthcare. There is a real need for reality on funding healthcare. This concept of juggling budgets is ingrained in backward political thinking and often counter-productive because it does not address the real underlying issues. There is an urgent need for reality on funding healthcare.

Continued efficiency and prudent financial management are vital but clearly cost savings alone are not enough. This should be achieved with a cooperative, fully-inclusive management policy that is transparent, instead of continual confrontation.

Variation in NHS across the UK

As described in Part I, the universal availability of healthcare underpins the core principles on which the NHS is based. In Scotland and Northern Ireland, the NHS provides both health care and social services, where as in England and Wales the NHS provides healthcare, and local councils provide the social services. However, between the UK’s four nations ­– despite similarities and shared history, there are considerable variations in areas such as health outcomes, spending, staffing and quality (1). Unequal regional access to treatment and prescription charges ­– for some but not others, undermine the principle of universal accessibility.

In Scotland, political mismanagement of the NHS has been exacerbated by devolution. This has resulted in the unnecessary creation of regional versions of UK-wide initiatives: Healthcare Improvement Scotland, the inadequate version of NHS England’s National Institute of Clinical Excellence (NICE); and their equally substandard procurement system, Healthcare Innovation Portal. Owner of Pentland Medical, Stewart Munro, commented on his own personal experience after approaching both NICE medtech and HIPP with one of his products, “I have tested both the NICE medtech programme and HIPP with one of our products. The NICE experience was professional and worth testing. The HIPP experience was clearly inferior. I would add both organisations declined to adopt the product.” He added: “NICE at least explained their decision after due consideration, in a reasonable timescale. HIPP dismissed the application after basic form filling and took a ridiculous time to respond.”

The future of the NHS

The UK’s ageing demographic, increases in non-communicable illness (like diabetes and obesity) and the requisite cost of their prevention and treatment, plus the cost of technological advances, are all new challenges facing the NHS. There is a need for a system of funding that is directly related to delivering a first class healthcare system. The NHS is capable of providing this, however without investment, continuing on the present course will lead to the terminal decline of the NHS within the next decade.

Fortunately, all is not doomed, The Five-Year Forward View was developed as a five-year plan of how to close gaps in funding and quality of care in the NHS (2, 3). It describes national, and local models to support more efficient healthcare delivery, disease prevention, models of service delivery, and integration of services. Its delivery, however, is dependent on fundamental changes in the NHS. While there has been overall consensus on the broad models, change has been slow. Now, more than ever, we need a new, systematic and comprehensive approach to supporting and implementing change to health services, from simple improvements to more radical transformation. With this in mind, the King’s Trust has set out the need for an annual £1.5bn Transformation Fund for investment in new types of care and robust implementation, aligned with more practical support (4)

Being a human endeavour, the NHS will never be perfect. It does not deserve to be treated as a pawn by incompetent, self serving, feuding political factions. The NHS is arguably our greatest national asset and many people still proudly contribute to its running with the hope of seeing it flourish.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References:

  1. http://www.nao.org.uk/wp-content/uploads/2012/06/1213192es.pdf.
  2. http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf.
  3. https://healthcare-arena.co.uk/the-nhs-goes-back-to-the-future-in-2015/.
  4. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-change-possible-a-transformation-fund-for-the-nhs-kingsfund-healthfdn-jul15.pdf.

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Image: ©mromka/iStock #57701700

Oxford dictionaries [1] give two definitions of vanguard:

  1. A group of people leading the way in new developments or ideas
  2. The foremost part of an advancing army or naval force

Either is applicable to the 29 NHS vanguard sites, all charged with developing the new care models outlined in the Five Year Forward View [2], a partnership between NHS England, the Care Quality Commission, Health Education England, Monitor, the NHS Trust Development Authority, Public Health England, and the National Institute for Health and Care Excellence. Recommendations of the Dalton review [3] were also considered.

These new care models seek to allow flexibility and creativity in care delivery with partnerships between the NHS and external agencies (for example, social care), thereby eliminating the traditional divide between primary care, community services, and hospitals, a barrier to personalised and coordinated health services [2]. Through the new care models programme, complete redesign of whole health and care systems are being considered; According to NHSE [4], this could mean:

  • Fewer trips to hospitals as cancer and dementia specialists will hold clinics in local surgeries
  • Having one point of call for family doctors, community nurses, social and mental health services
  • Access to blood tests, dialysis or even chemotherapy closer to home.

It will also join up the often confusing array of A & E, GP out of hours, minor injuries clinics, ambulance services and 111, thus patients will know where to get urgent help easily and effectively, seven days a week [4].

The models fall into seven categories:

  • Multi-specialty Community Providers (MCPs): federations, networks and super partnerships will be developed to enable general practices to operate on the scale required to deliver a wider range of services. Such services would include those provided by some specialists alongside other professionals [5]
  • Primary and Acute Care Systems (PACS): single organisations to provide NHS list-based GP and hospital services, together with mental health and community care services’ [1]
  • Urgent and emergency care networks: more appropriate use of primary care, community mental health teams, ambulance services and community pharmacists and other specialist emergency centres
  • Viable smaller hospitals: new organisational models will be explored.
  • Specialised care
  • Modern maternity services
  • Enhanced health in care homes

The initial 29 Vanguard sites are exploring multi-specialty community provider (MCPs) models, aiming to move specialist care out of hospitals into the community, integrated primary and acute care systems (PACS) – joining up GP, hospital, community and mental health services, and models of enhanced health in care homes, offering older people better, joined up health, care and rehabilitation services. More recently, a further eight sites which will explore the urgent and emergency care model have been announced.

The concept of the FYFW and the associated new care models have been largely hailed as a good thing. The King’s Fund however, urges caution as funding is required to implement new care models (after the initial pump-priming of Vanguard sites by the DH); this funding is likely to come from substantial improvements in productivity rather than from government [5].

Fortuitously, the same document offers suggestions on how to implement the new care models; presumably these will complement the recently published DH support package [6], as these merely refer to payment options for MCPs and PACS (capitation fees). This package has been developed with the NHS Vanguard sites, based on their experiences to date. The support package covers:

  • Designing new care models – working to develop a local model of care, maximising the greatest impact and value for patients
  • Evaluation and metrics – understanding the impact the changes are having on patients, staff and the wider population
  • Integrated commissioning and provision – breaking down any barriers which prevent their local health system from developing integrated commissioning
  • Empowering patients and communities – enhancing the way in which Vanguards work with patients, local people and communities to develop services
  • Harnessing technology – rethinking how care is delivered, and helping organisations to share patient information
  • Workforce redesign – developing a modern, flexible workforce organised around patients and local populations;
  • Local leadership and delivery – developing leadership capability, learning from international experts
  • Communications and engagement – demonstrating best practice in the staff, patient and local population engagement

Conclusion

Vanguard sites are in their early infancy. However, the lessons they are learning are being shared across the NHS, so that when the models are rolled-out across England, other organisations will not be working from a ‘standing start’. However, historically, change in the NHS has been difficult to sustain, even where they is a strong will on the part of individuals and organisations for such change.

We can only watch and wait.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Oxford University Press. Oxford Dictionaries. 2015. http://www.oxforddictionaries.com/definition/english/vanguard Accessed August 2015
  2. NHS England. NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England, Trust Development Authority. NHS five year forward view. London: NHS England. 2014 Available at: www.england.nhs.uk/ourwork/futurenhs/
  3. Dalton D. Examining new options and opportunities for providers of NHS care. The Dalton Review. 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384126/Dalton_Review.pdf Accessed August 2015
  4. NHS England. New care models – vanguard sites. http://www.england.nhs.uk/ourwork/futurenhs/5yfv-ch3/new-care-models/ Accessed August 2015
  5. Ham C, Murray R. Implementing the NHS five year forward view: aligning policies with the plan. King’s Fund, 2015. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/implementing-the-nhs-five-year-forward-view-kingsfund-feb15.pdf Accessed August 2015
  6. NHS England et al. THE FORWARD VIEW INTO ACTION: New Care Models: update and initial support. 2015. http://www.england.nhs.uk/wp-content/uploads/2015/07/ncm-support-package.pdf Accessed August 2015

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