The period between Christmas and the January credit card bill can be one of nervous denial, but we eventually face up to our excesses and pay for them, in the gym or in the bank.
The NHS is in a different situation. The financial outlook is dire, but if there ever was any extravagance in the 25 years I have worked in the health service, I must have been off that day.
No, the NHS is struggling just to keep pace. A growing and ageing population, public health problems like obesity, and constant advances in treatment and technology are all contributing to push NHS costs well above general inflation.
The increases in costs may be inevitable – the Health Select Committee has estimated demand will grow at 4% per year – but the corresponding budget increases are not. In June, the Chancellor gave the NHS in England a rise of just 0.1% above general inflation between 2014-2015 and 2015-2016 – more than most public services but significantly less than the costs facing the health system. The allocations in Scotland, Wales and Northern Ireland are also tight.
The numbers overall are so bad that if the NHS were a country, it would barely have a credit rating at all. The Nuffield Trust has estimated that if the NHS budget continues only to keep pace with general inflation, there will be a shortfall of between £44 billion and £54 billion in England by 2021-2022, unless there are productivity gains.
But even with a 4% productivity gain every year, the funding gap would still grow to as much as £34 billion. It would take savage cuts to even begin to find this much money out of further ‘efficiency’ savings.
And efforts to generate savings to date don’t encourage optimism. We are now part way through the Nicholson challenge – the initial drive to find up to £20 billion recurrent of savings in England over the four years up to 2015. In the first year of the challenge, more than half of the £5.8 billion savings achieved were from reducing tariff payments to providers or cutting staff pay through freezes. The Commons Health Select Committee subsequently warned the government that neither were a ’sustainable form of efficiency gain’.
The National Audit Office said the NHS had made the ‘easiest’ savings first. They were certainly not easy for the doctors and other healthcare staff who were made to bear the brunt. And it was not easy for the patients and staff every time a vacancy is not filled, a ward is closed, or a clinic is cancelled.
However, it is beginning to be more widely recognised that more fundamental change is required. Though, not necessarily, the kind of change most of us would want. A senior NHS leader warned recently at a policy gathering that efficiency savings would not be enough in the years ahead, and that the NHS would have to ‘take out capacity’. That translates as cutting services to patients.
What are the alternatives? There have been some thoughtful and brave efforts to reconfigure services in ways that maintain or improve quality while also increasing efficiency, much of it thought up and led by clinicians. The transformation of stroke services in London is one such brilliant but rare example.
But such strategic approaches require clear and credible leadership to be successful. A major problem, in England at least, in that in a post-Health and Social Care Act world no-one really knows who is in charge. Too often, service change decisions are driven by a mishmash of political and financial imperatives, alienating the local communities that the services are meant to serve.
This is underlined by the government’s recent heavy-handed approach to facilitating service change – with legislation currently passing through Parliament that would give trust special administrators, appointed to run failing trusts, the powers to make changes to neighbouring trusts without consulting patients, clinicians or other providers.
So, what does that mean for our profession? Can we not bring evidence instead of prejudice to the problem?
The negotiations over changes to GP contracts in England for 2014-2015 show that a more strategic approach can deliver for patients and doctors while also improving efficiency. Our negotiators reversed the adverse impact of this year’s contract changes, which brought in unnecessary targets and excessive paperwork, and agreed changes that will enable GPs to deliver more personalised care for vulnerable patients to help them stay out of hospital.
The GP contract negotiations show it is possible to achieve efficiencies and still improve care, rather than having one or the other, or randomly knocking chunks out of the health service budget.
And that’s the point. The solutions are harder to find given the dire financial outlook, but if doctors are given the chance to find them, we can. And we must.
The year ahead will be shaped in many ways by the outcome of contract negotiations for junior doctors across the UK and consultants in England and Northern Ireland currently underway. Within the same cost envelope, we need to find a way of enabling doctors to provide the highest quality care while ensuring fair remuneration, meaningful development opportunities and a healthy work and life balance.
As part of this, we are looking at how best to tackle the ‘calendar lottery’ so that our patients can receive the same high standards of NHS care seven days a week. There are many barriers to overcome, but our recent position paper on seven-day services showed we are willing to take a lead.
One barrier that we need to get rid of as soon as possible is a perception in the media and elsewhere that doctors are part of the problem. We know that a huge proportion of consultants already provide emergency cover out-of-hours and some are regularly present, and as part of our work on negotiating a new consultant contract, we are finding out its full extent.
But the public needs to know this too. You will remember what happened when politicians made inaccurate and demoralising comments blaming GPs for the pressures on emergency care, and we must be alert to these kinds of attacks on our professionalism and integrity, and fight them with facts.
We also have to tackle bureaucracy. All too often, it saps our energy worse than a winter virus. In a survey we published in the summer, two-thirds of doctors said they had wanted to make changes but were held back by red tape or a lack of capacity or support. A similar proportion felt less empowered than they did the previous year.
At a special event we held to draw out the views of juniors and consultants – we have more planned this year – doctors said managers often seemed there mainly to enforce targets and find savings, and that they felt many managers regarded them as irritants in that process. We can no longer afford to have two tribes, because two tribes bring half the benefit to patients.
It is more than just a question of mutual respect. It’s also a willingness to step out of traditional roles and recognise that the financial constraints within which the NHS works are not just an issue for managers, and that good patient outcomes are so much more than a ‘clinical issue’.
It can all sound very aspirational. It is, but look what happens when it is missing. At Mid Staffs, where a managerial obsession with achieving foundation status became more important than anything else, where disengaged and disillusioned clinical staff did not speak out loudly enough, and patient care suffered terribly.
The problems at NHS Lanarkshire were not on the same scale, and an inspection report published earlier this month said clinicians and managers were working hard to do the right thing. But that report contained a very worrying detail – that staff did not always report risks to the delivery of patient care because they believed that management would not take action.
Both cases, although very different, show that giving up can be harmful.
Clearly it is time to put medical professionalism back at the heart of the NHS, and in 2014 we will be starting a major campaign to put modern professional values – like integrity, evidence-based practice, and patient-centeredness – to the fore.
The campaign will aim to empower and support doctors, who want to lead services and shape change. It acknowledges that doctors often feel change is forced upon them, and they want the freedom to make services better for patients.
This will drive our contract negotiations and help doctors take the lead in major issues like seven-day services.
We will also promote the value of the profession, a value that is not always reflected accurately by government or the media. Part of this will be about showing the extraordinary things that doctors do in their ordinary working lives. They happen so often that even we do not always notice them, and we certainly don’t do enough to promote them.
And the campaign will also aim to shape NHS reform so that medical professionalism is liberated. This means that not only will doctors be willing to lead and improve, but the system enables them to do so.
We look to learn from best practice in the health service and outside it, and how those who raise concerns can be supported and protected.
Our work on professionalism is new and urgently needed, but the values that underpin it – integrity, compassion, altruism – can be found all around us, and have always been there in the medical profession. Indeed, while everything else in medicine has changed, they are what connects us with doctors who practised hundreds, even thousands, of years ago, often in harder times than now.
Our aim is to encourage professionalism to flourish, by ensuring the NHS is built around it. In the contracts we negotiate, in the open and engaged way in which we offer to work in partnership to reform services, and most of all in enabling integrity and compassion to be at the heart of what we do, I want this to be a good year for professionalism, and a great one for patient care.