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House of Lords committee calls for independent Office for Health and Care Sustainability

The sustainability of the NHS is at risk with the government pursuing a “a culture of short-termism”.

That’s the conclusion of the House of Lords Select Committee, which has slammed the short-sightedness of successive governments for failing to plan effectively for the long-term future of the health service and adult social care.

The Committee makes it clear that a tax-funded, free-at-the-point-of-use NHS is the most efficient way of delivering health care and should remain in place now and in the future.

But, for that principle to remain, however, many aspects of the way the NHS delivers healthcare will have to change.

It recommends that a new, independent Office for Health and Care Sustainability should be established to look at health and care needs for the next 15-20 years and report to Parliament on the impact of changing demographic needs, the workforce and skills mix in the NHS and the stability of health and social care funding relative to demand.

A political consensus on the future of the health and care system is “not only desirable, it is achievable” according to the Committee and they call on the Government to initiate cross-party talks and a meaningful “national conversation”.

The Committee says that in the past funding has been “too volatile and poorly co-ordinated between health and social care”.

This has resulted in poor value for money and resources being allocated in ways which don’t meet patient needs.

In the future health funding will need to increase at least in line with growth in GDP, and NHS financial settlements should be agreed for an entire Parliament to enable effective planning.

Pressures in social care now pose a significant threat to the stability of the NHS so the Government needs to embark on a far more ambitious three-year programme to stabilise publicly-funded social care.

The Committee asserts that, beyond 2020, a key principle of the long-term settlement for social care should be that funding increases reflect changing need and are, “as a minimum, aligned with the rate of increase for NHS funding.”

The report says that the failure to implement a comprehensive long-term strategy to secure the appropriately skilled, well-trained and committed workforce that the health and care system will need is, the “biggest internal threat to the sustainability of the NHS.”

The report highlights the problems of over-burdensome regulation, unnecessary bureaucracy, a prolonged period of pay restraint, low levels of morale and retention problems.

The Committee points out that service transformation is at “the heart of securing the long-term future of the health and care systems.”

They argue that the model of primary care will need to change, secondary care will need to be reshaped and specialised services consolidated further. A renewed drive to realise integrated health and social care is badly needed.

The Committee makes 34 recommendations for change including:

  • The health and social care systems are interdependent but poorly-coordinated. To allow money and resources to be used more effectively the budgetary responsibility for adult social care at a national level should be transferred to a new Department of Health and Care.
  • The traditional small business model of GP services is no longer fit for purpose. NHS England should engage with GPs to examine alternative models including direct employment.
  • Policy is now increasingly focused on integrated, placed-based care and so NHS England and NHS Improvement should be merged to create a new body with simplified regulatory functions and strong local government representation.
  • There is an indisputable link between a prolonged period of pay restraint, over-burdensome regulation and unnecessary bureaucracy and low levels of morale and workforce retention. The Government should commission an independent review to examine the impact of pay on morale and retention of health and care staff.
  • There is a worrying lack of a credible strategy to encourage uptake of technology and innovation in the NHS. The Government should do more to incentivise the take-up of new approaches and make clear that there will be funding and service delivery consequences for those who repeatedly fail to engage.
  • Cuts to funding for the public health budget are short-sighted and counter-productive. National and local public health budgets should be ring-fenced for at least the next ten years. We also need a new nationwide campaign to highlight the dangers of obesity.
  • The Government should be clear with the public that access to the NHS involves patient responsibilities as well as patient rights. The NHS Constitution should be redrafted to emphasise this.

Commenting, Lord Patel, Chairman of the Committee, cross bench peer and eminent obstetrician said: “The Department of Health at both the political and official level is failing to think beyond the next few years. There is a shocking lack of long-term strategic planning in the NHS. This short sightedness stems from the political importance of the NHS and the temptation for politicians to reach for short-term fixes not long-term solutions.

“To solve this we need a new body that is independent of government and is able to identify clearly the healthcare needs of a changing and ageing population and the staffing and funding the NHS will require to meet those needs. This new Office for Health and Care Sustainability should be a trusted, independent voice as the Office for Budget Responsibility has become on economic forecasting and on public finance matters. It will need to look ahead and plan for 15-20 years into the future.

“We also need to recognise the NHS will need more money. NHS spending will need to rise at least as fast as GDP for 10 years after 2020. One area where more spending will be required is on pay for lower paid staff. We are in an increasingly competitive international market for health professionals and a decade of pay constraint in the NHS has damaged morale and made it difficult to train and recruit the staff we need.

“We have heard much about the need to integrate health and social care and we think the best way to do that is make the Department of Health responsible for both health and adult social care budgets. We also think it is time to look at the way care is delivered. This may well involve changing the model where GPs are self-employed small businesses.  Delivering health care fit for the 21st century requires improvement in primary care to relieve pressure on hospitals. That change should be delivered by GPs.”

Additional reaction:

RCP President Jane Dacre said:

“We are very pleased to welcome today’s findings by the Lords Select Committee and agree with the view that for too long successive governments have failed to plan for the long-term future of the NHS.

“The report’s focus on transformation and call for a long term strategy on how we care for a changing population are essential and agrees with much of our own ‘Future Hospital’ work. If we are to improve the care for patients we treat, as clinicians, in collaboration with patients, we need to reshape the secondary and specialist care we provide.

“However, as we highlighted in our recent report Underfunded, Underdoctored and Overstretched, our hospitals and NHS staff are only just coping and we cannot underestimate either the time or effort needed to make these fundamental changes. Therefore, the recommendation to increase funding for the NHS before 2020 is welcome.

“We would also agree with the long term ambition to move the NHS from an ‘illness’ service to a ‘wellness’ service, but as we outlined in our own evidence the current failure to protect and enhance the public health budget is at best short-sighted and at worst counter-productive.”

Dr Mark Porter, BMA council chair, said:

“This report highlights what we have been saying – that the NHS desperately needs a long-term strategy to deal with the funding and staffing problems threatening the delivery of high-quality care. For too long successive governments have based health policy on short-term measures that do not benefit patients or staff in the long term. This is especially evident in cuts to funding for public health which this report identifies as short-sighted and counter-productive. The NHS is at breaking point and this can only be relieved through increasing investment based on a realistic assessment of what is needed to meet the health and social care needs of current and future generations. We need politicians of all parties to come together to agree a long-term approach and put an end to political game-playing with the NHS.

“The committee is right to identify the serious and ongoing problems in recruiting and retaining NHS staff, and the morale damage of years of ongoing pay restraint. Only last week, doctors got yet another real-terms cut in pay despite working harder than ever before. At a time when GPs are unable to keep up with the number of patients coming through the surgery door and hospital doctors are working under impossible conditions, our government should heed the committee’s recommendation and allocate the investment needed to match the promises made.

“It is important that general practice continues to evolve to meet the changing demands of patients, especially those who need more intensive, complex and flexible care in the community. Many GP practices are, with the BMA’s support and leadership, exploring new ways of working, including forming federations or networks to pool resources and plan care for their local populations. A “one size fits all” model won’t do this. General practice’s great strength is its flexibility, and smaller practices can work just as well as larger units in providing services that their patients want. The biggest threat to smaller practices is not their organisational form, but the pressure that all parts of the NHS are under from rising demand, unnecessary bureaucracy, stagnating budgets and staff shortages. It is this wider challenge that the government must urgently address.

“We spend less on healthcare than other leading European economies and the NHS cannot continue to do more, with less. We need to end the chronic underfunding of our health service and address inadequate staffing and funding for the health and social care system as a whole.”

Professor Derek Bell, President of the Royal College of Physicians of Edinburgh, said:

“Today’s report is wide ranging, addressing the key issues which affect our NHS now and will continue to do so in the coming years.  These include a lack of resources, workforce challenges and the need to improve the prevention agenda. This College continues to call for the Government to set up a working group involving the Royal Colleges, healthcare practitioners, patients, the public, and politicians as a matter of urgency to find solutions to alleviate the pressures faced across the NHS in England.

“Undoubtedly there will need to be changes to ensure a sustainable healthcare system by 2030. A partial solution is significantly greater financial investment into healthcare. However, even if this were forthcoming, it would still not be enough without greater system changes.

“The Committee is correct to conclude that short- termism exists in the NHS and in social care. Longer funding cycles are needed to avoid this to avoid this, and any end of year effects. Many attempts to reform the NHS, particularly in the community, have resulted in excessive efforts to re-group, re-package and re-design services which consume time, effort and funds only for a new cycle of reform to begin a few years later. There is an over-emphasis on appearing to reform rather than sustaining and improving existing services for the long term.

“The stated ambition to reduce reliance on the acute hospital sector should not be pursued to the detriment of the quality of patient care. We must not allow patient safety to be compromised by the implementation of this approach without clear, established evidence that the care of patients outside acute hospitals will be as safe and effective as hospital care. We support shifting care closer to home but not at the expense of quality.

“The report notes the value of the workforce and the importance of strengthening workforce planning, and we welcome the recommendation that this be tackled as a matter of urgency. A similar exercise is already underway in Scotland. We also look forward to hearing more about proposals to change the training and education of the health and social care workforce. This College is committed to ensuring that medical training and education is the best it can be as this ultimately leads to better and safer patient care.

“The College has worked to improve public health for nearly 350 years, and we concur with the Committee’s conclusion that failure to protect and enhance public health spending is short-sighted and counterproductive. The costs of obesity to both the NHS and patients are high, both financially and in terms of preventing avoidable diseases such as cancer and type 2 diabetes. While we would support the Committee’s recommendation to implement a nationwide campaign on the issue, other policies such as reducing pack sizes and implementing taxes must also be considered in the short term.”

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