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Niall Dickson: The NHS is not an island

Source: NHE July/August 2018

Our national health service appreciates the extra money, but it can’t solve all its problems alone, says Niall Dickson, chief executive of the NHS Confederation.

The NHS is subject to key moments in its history when its future direction is determined: the battle with the medical profession around its birth, the 1974 reorganisation in England, the introduction of general management in the late 1980s, the 1990 reforms when the purchaser-provider split arrived, the NHS Plan, with a reintroduction of the market and the implementation of the Wanless report from 2001, and of course the lamentable 2012 reforms – about which almost no-one has a good word to say.

The decision to announce a long-term plan (10 years) and a medium-term settlement (five years) for the NHS in England must rank alongside any on that list. It is important because there is at last recognition not only that the health service needs a significant cash injection if it is to have any hope of meeting demand, but also because it provides a degree of stability and certainty going forward. The graph line of NHS funding history is more akin to the Himalayas than a calm sea – a period of sustained extra funding may be better than feast and famine.

But we need to be under no illusion that the extra resources will end the current pressures. A 3.4% increase every year is barely enough to keep the service on its current path. It would not be enough to transform services. Worse, as ever with the Treasury you have to look closely behind the headline figure – the 3.4% rise is for the NHS England budget. This excludes public health, training budgets, and the plan for capital. In other words, it is not 3.4% of the whole, but 3.4% of a part of the NHS spend.

Two further complications: it will have to include the cost of the pay deal for Agenda for Change staff and any increases coming for doctors and other senior staff. So before ministers and others rush off to spend it three times over, we need a large dose of realism.

Secondly, there is nothing yet for social care, which remains in a parlous state. Providers operate in a precarious market where, to remain viable, they are relying on cross-subsiding one resident with another, or a rise in the property market.

The interdependence of health and care is now well understood, yet we seem incapable of creating the incentives and funding to make them work effectively together. This is not just about dealing with delayed transfers of care, however important they are. It is about funding and establishing new models of care that will support people in their own homes and communities with a range of primary, community and social care interventions.

Yet speech after speech treats the NHS as if it were an island that can solve its problems alone.

Not all is lost. Setting aside the chancellor’s ominous throwaway remark that there is now nothing left in the cupboard, we do have a new health and social care secretary, we have the promise of social care reform, and we have the offer for the service to help shape the longer-term plan.

We must continue to press for a joint funding settlement – like health, social care will need at least 3.9% a year for the next decade to keep its head above water.

And all this does not mean that money is the answer to everything. We will need to answer the efficiency challenge – tackling unwarranted variation, reconfiguring services to improve quality and drive down costs, embracing technology, integrating frontline teams, and focusing relentlessly on mitigating the rise in demand with new interventions that treat and support people in the right place, at the right time. But delivering this when all the immediate effort is just on keeping the service going is exceptionally difficult.

The message is the same: from the boardroom to the ward, from the commissioner to the surgery, in hospitals and the community, we need some respite from the relentless pressures. Without this, and without a joint plan which sees the centre supporting transformation throughout the country, the eighth decade of this amazing institution will have to continue to operate with one hand tied behind its back.


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