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Four options for reviving the NHS Four options for reviving the NHS
(6 months later)
The NHS has come under intense scrutiny in recent weeks as the media and public question its management capability and standards of care, and patients and carers call for greater transparency about how their services are run. This storm of criticism has made it very clear that we need to rebuild public confidence in the NHS. We need to make it a service that is much more open and accountable, one that listens to patients and gives them a central role in how their services are delivered.The NHS has come under intense scrutiny in recent weeks as the media and public question its management capability and standards of care, and patients and carers call for greater transparency about how their services are run. This storm of criticism has made it very clear that we need to rebuild public confidence in the NHS. We need to make it a service that is much more open and accountable, one that listens to patients and gives them a central role in how their services are delivered.
Getting this right means talking honestly with people about the challenges facing their NHS and the best course of action. It means being transparent about variations in standards of care and outcomes around the country, and differences to the cost of care. If NHS leaders do not engage people about the challenges facing the service, we will have no mandate for change.Getting this right means talking honestly with people about the challenges facing their NHS and the best course of action. It means being transparent about variations in standards of care and outcomes around the country, and differences to the cost of care. If NHS leaders do not engage people about the challenges facing the service, we will have no mandate for change.
The NHS has reached the point where its financial predicament is on a scale we have never seen before. We have been slow to change the NHS into a truly modern and efficient service, and are now beginning to see the consequences. We are wrestling with a flat budget while demand for services is increasing above the rate of inflation. We have an ageing population, increasing technology costs and are seeing the major impact that lifestyle choices are having on our services.The NHS has reached the point where its financial predicament is on a scale we have never seen before. We have been slow to change the NHS into a truly modern and efficient service, and are now beginning to see the consequences. We are wrestling with a flat budget while demand for services is increasing above the rate of inflation. We have an ageing population, increasing technology costs and are seeing the major impact that lifestyle choices are having on our services.
Despite a two-year pay freeze, pay costs – often as much as 70% of an NHS organisation's budget – are not falling as fast as they might have done, due largely to incremental salary growth. Over the past decade, the government has met these costs by increasing funding from taxes. But we no longer have the luxury of time or additional money on our side.Despite a two-year pay freeze, pay costs – often as much as 70% of an NHS organisation's budget – are not falling as fast as they might have done, due largely to incremental salary growth. Over the past decade, the government has met these costs by increasing funding from taxes. But we no longer have the luxury of time or additional money on our side.
Finances and quality of care go hand-in-hand. Once financial problems in an organisation emerge, NHS trusts can quickly get caught in a spiral of decline. Recruitment of doctors and nurses becomes more difficult, leaving trusts with expensive short-term staffing. Organisations struggle to attract good senior managers, leaving them reliant on expensive interim directors, and there is usually significant change at board level. We have seen the tragic consequences of what this can lead to at Mid Staffs.Finances and quality of care go hand-in-hand. Once financial problems in an organisation emerge, NHS trusts can quickly get caught in a spiral of decline. Recruitment of doctors and nurses becomes more difficult, leaving trusts with expensive short-term staffing. Organisations struggle to attract good senior managers, leaving them reliant on expensive interim directors, and there is usually significant change at board level. We have seen the tragic consequences of what this can lead to at Mid Staffs.
The NHS Confederation has published a report looking at the financial pressures on the NHS and four choices we face. These are choices, not solutions. None are pain-free and some may prove too difficult to swallow. But I believe that the public will be better able to understand and engage in a national debate if we are open about what needs to happen and why.The NHS Confederation has published a report looking at the financial pressures on the NHS and four choices we face. These are choices, not solutions. None are pain-free and some may prove too difficult to swallow. But I believe that the public will be better able to understand and engage in a national debate if we are open about what needs to happen and why.
The first choice – doing nothing – means running services in the same way we have done until now. This increases the likelihood of more organisations going into the red with a knock-on impact on quality of care. Financial "plugs" may solve the solution in the short term, but they don't address the root causes and take away resources from other NHS organisations.The first choice – doing nothing – means running services in the same way we have done until now. This increases the likelihood of more organisations going into the red with a knock-on impact on quality of care. Financial "plugs" may solve the solution in the short term, but they don't address the root causes and take away resources from other NHS organisations.
The second choice – spending more – involves some publicly divisive proposals. The NHS has enjoyed a decade of spending increases and some people question why it should continue to do so at the expense of other public services. Of course, the government could mitigate this by raising taxes or increasing the range of services that patients are charged to use. But these options can be difficult politically and carry risks. Do we risk people going untreated or having their symptoms undiagnosed if they cannot afford costs? Or choosing to buy cheaper unregistered medicines online if prescription charges increase?The second choice – spending more – involves some publicly divisive proposals. The NHS has enjoyed a decade of spending increases and some people question why it should continue to do so at the expense of other public services. Of course, the government could mitigate this by raising taxes or increasing the range of services that patients are charged to use. But these options can be difficult politically and carry risks. Do we risk people going untreated or having their symptoms undiagnosed if they cannot afford costs? Or choosing to buy cheaper unregistered medicines online if prescription charges increase?
The third choice – doing more for less – is attractive, and the NHS has performed well so far to achieve a sizeable chunk of the £20bn it has been asked to save. But the initial savings are starting to slow and NHS leaders are questioning just how sustainable this strategy is in the longer term. Many chief executives have told us that early savings have been achieved by targeting the "low-hanging fruit". They believe it will be far more difficult to save more substantial amounts without a negative impact on services.The third choice – doing more for less – is attractive, and the NHS has performed well so far to achieve a sizeable chunk of the £20bn it has been asked to save. But the initial savings are starting to slow and NHS leaders are questioning just how sustainable this strategy is in the longer term. Many chief executives have told us that early savings have been achieved by targeting the "low-hanging fruit". They believe it will be far more difficult to save more substantial amounts without a negative impact on services.
The fourth option – doing things differently – involves transforming services to meet modern health needs and reduce variation in the standards of local services. Put bluntly, it means fewer hospital beds and fewer hospital-based jobs. But that need not be as painful as it sounds. Evidence shows we can improve care if we concentrate some specialist services in bigger centres and offer new forms of care out of hospital where it is in patients' best interests. But such changes can prove controversial with the public, making it difficult to communicate the case for change, even when there is a good clinical case for doing so.The fourth option – doing things differently – involves transforming services to meet modern health needs and reduce variation in the standards of local services. Put bluntly, it means fewer hospital beds and fewer hospital-based jobs. But that need not be as painful as it sounds. Evidence shows we can improve care if we concentrate some specialist services in bigger centres and offer new forms of care out of hospital where it is in patients' best interests. But such changes can prove controversial with the public, making it difficult to communicate the case for change, even when there is a good clinical case for doing so.
Personally, I believe we need to look beyond the short- and medium-term suggestions and consider more radical solutions that will improve care and allow us to manage the resources we have on a sustainable basis.Personally, I believe we need to look beyond the short- and medium-term suggestions and consider more radical solutions that will improve care and allow us to manage the resources we have on a sustainable basis.
NHS leaders need to be honest with the public – we can no longer kick the tough choices into the long grass. If we delay, we risk harming the care we provide and worse still, destabilising the future of our health service.NHS leaders need to be honest with the public – we can no longer kick the tough choices into the long grass. If we delay, we risk harming the care we provide and worse still, destabilising the future of our health service.
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