Simon Stevens, CEO, NHS England – Speech to NHS Providers, Birmingham, November 8th – in full
THE NHS APPROACHING 70 – PROGRESS AND PROSPECTS
We meet today with the NHS in full mobilisation for the winter ahead.
Flu vaccinations are in full swing, and we’re ahead of where we were last year in terms of the uptake of flu vaccines for older people, staff, and for the first time we’re making available NHS funding so that care home staff can also get the vaccinations they need.
Major changes are in place of this winter in respect of the support that GPs will be providing: GPs in A&E streaming; increasing the proportion of 111 calls handled by clinicians from 22% last year to over 36% now; appointments available evenings and weekends over the busiest times.
Detailed plans for struggling hospitals being overseen by Pauline Philip, our national emergency care director. And a new National Clinical Escalation Panel, that Sir Bruce Keogh will be chairing, that will identify the nature of the national response that will be required based on different demand conditions.
The operational priority for the next several weeks is of course ensuring that we have got as many hospital beds available now as we can, and that requires further progress both on the NHS-related ‘delayed transfers of care’, as well as those from social care. And I’m pleased to say that over the last few weeks all councils bar one have now agreed their contribution to the delayed transfer reduction that we want to see ahead of winter.
But today I also want to talk frankly about our wider prospects.
THE NHS AT 70
Next year of course is the 70th anniversary of the NHS.
The question is: will we mark that anniversary proud of our past, confident of our future, and ambitious for the improvements that we know are ahead? Improvements of the sort that Jeremy has quite rightly just set out.
Or: will we shuffle into the new year recovering from winter with zombie NHS arguments risen from the dead? Right on cue for Halloween here was a comment in one of the Sunday newspapers a fortnight ago: “The NHS is beyond fixing. The sorry truth is that whatever is done to the NHS…nothing will ever really work.”
History shows, medical advances show, our patients’ experiences all show that is patently untrue.
Sure, the NHS isn’t perfect – show me a health system that is. Working in the NHS – I started working 29 years ago – I’ve also had the benefit of working in many other countries health systems, so I’ve seen them, I know.
Is there a need to redesign care in the era of empowered patients, chronic health conditions and new technologies? Yes, and we are. As this week’s Economist magazine says: “Almost unnoticed, the NHS is starting to change at its core.”
But there’s no contradiction in three things being true at once. First all the international comparisons show that we’re an incredibly efficient health service. But second like every other country we’ve still got waste, that we’re going after relentlessly. And third, even as we do so, we’re still going to need more funding.
The GIRFT programme, Rightcare, model hospitals, the new care models, are all now having an impact, we’ve driving efficiency hard.
NHS productivity – as the Kings Fund, Health Foundation and the Nuffield Trust show this morning – has been increasing faster than the rest of the UK economy.
Here’s how the Institute for Fiscal Studies illustrates the point – slide. Hospital staffing has increased, but the number of patients being looked after has increased faster. GP numbers over the last seven years have actually fallen but their workload has risen. The good news is we’re now seeing a big increase in the number of new doctors willing to qualify as GPs, but we’re seeing real pressures in the GP retirement rate and that speaks to the big workforce reforms I will talk about in a moment.
The NHS has been driving an increasingly rigorous bargain with drug companies and other suppliers, and I’ll be saying more about that tomorrow. For the first time we’ve introduced an affordability check on NICE appraisals, and later this month we’re going to be deciding on potentially controversial limits on over-the-counter medicines.
GPs have taken unprecedented action to manage elective demand, actually cutting new referrals so far this year. And by the way, even if NHS Improvement’s unpublished report on theatre productivity was implemented and hospitals did an extra 280,000 operations for free, remember that’s less than two week’s worth of overall operations that the NHS performs each year – certainly worthwhile but no silver bullet.
Turning to emergency care, as you’d expect with a growing and aging population, we’ve more people needing urgent and emergency services. But it’s important to get that in context. Actually the NHS is doing an increasingly effective job at moderating ‘front door’ emergency demand growth.
– Trusts are reporting that, major A&E – Type 1 A&E – attendances across England are up by under 1% year-to-date, as GPs, local commissioning groups, and a reformed 111 provide better alternatives.
– Non-elective admissions are up by 2.2% year to date – but four fifths of that increase is for zero day lengths of stay.
– And 10% fewer people are being admitted to hospital as emergencies than would have been five years ago, thanks to better support at home.
– What’s more, 37% of the extra emergency admissions the NHS is coping with are because hospitals have got better at treating the very sickest patients, who thank goodness now survive and live to use further hospital care in due course
– Even more encouragingly, emergency hospitalisations per person in our most ‘integrated’ geographies are now growing at under half the rate of the rest of the country. Where it’s being implemented the Five Year Forward View recipe is working. Where GPs, community services and hospitals are working most closely together – in the Vanguards and Accountable Care Systems – fresh data for the first quarter of this year shows we’re seeing a continuation of the positive trends that we reported at the end of March.
So, do we have capacity constraints, do we have a delayed discharge problem – especially given the pressures on community and social care? Certainly.
And does it confirm the necessity of redesigning care to better join up services? Yes.
But by the standards of our own recent history, by comparison with other western countries, and in the light of our own population’s needs, do we have a problem with runaway and unaffordable demand? We do not.
We have a care fragmentation problem and a funding problem.
Now some may say: aren’t we spending at the European average? Well, only if you think that bundling-in austerity-shrunken Greek and Portuguese health spending should help shape the benchmark for Britain. If instead you think modern Britain should look more like Germany or France or Sweden then we’re underfunding our health services by £20-30 billion a year
I want to be clear: the Government has rightly supported the NHS through difficult times. It protected the NHS budget immediately after the financial crash, and has funded modest growth ever since.
But that growth rate is set to nose dive next year and the year after. As I have told Parliament on many occasions: “for the next three years we did not get the funding the NHS had requested”, so “2018 – which happens to be the 70th anniversary of the NHS – is poised to be the toughest financial year.”
The Care Quality Commission and the National Audit Office have both expressed their concerns. As have the Royal College of Physicians, the Royal College of Surgeons, the Royal College of General Practitioners, the Royal College of Nursing, and many others.
Of course NHS funding isn’t decided by the doctors and nurses who know the service best. Nor by the patients whose lives depend on them.
In our publicly funded health service, it’s the chancellor of the exchequer who rightly decides the NHS budget.
But in a democratically accountable NHS, the public have a right to know what those choices would mean.
Today I set out NHS England’s independent assessment.
It is that the budget for the NHS next year is well short of what is currently needed to look after our patients and their families at their time of greatest need. After seven years of understandable but unprecedented constraint, on the current budget outlook the NHS can no longer do everything that is being asked of it.
That judgement is confirmed today by the Kings Fund, the Nuffield Trust and the Health Foundation. They independently size next year’s funding gap at £4 billion. They show there’s nothing out of the ordinary about needing such a sum. In their words, it would just be a return to the average increases of the first 63 years of the NHS’ history, as against the exceptional choking back of funding growth of the past seven years.
Our duty of candour requires us now to explain the consequences of our decisions, to help inform the difficult choices that will be made for the year ahead.
It boils down to this.
On the current budget, far from growing the number of nurses and other frontline staff, in many parts of the country next year hospitals, community health services and GPs are more likely to be retrenching and retreating.
On the current funding outlook, it is going to be increasingly hard to expand mental health services or improve cancer care. Services the public need and rightly want.
And crucially, on the current funding outlook the NHS waiting list will grow to 5 million people by 2021. That’s an extra million people on the waiting list. One in ten of us waiting for an operation. The highest number ever.
Of necessity, the NHS this year has reluctantly had to temporarily limit the annual increase in waiting list operations to protect funding for A&E, mental health service and GP care. To decide that that should now be a permanent decision would be to turn back a decade of progress. A decade in which we’ve cut the wait for an NHS operation from over 18 months to under 18 weeks. It’d mean the government having to publicly legally abolish patients’ national waiting times guarantee.
No-one disputes that these are choices that a chancellor could make. That’s democracy.
But democracy also produced the Brexit referendum. The NHS wasn’t on the ballot paper, but it was on the Battle Bus. Vote Leave for a better funded health service – £350 million a week.
Here’s what the Campaign Director of Vote Leave said in January this year:
“Pundits and MPs kept saying ‘Why isn’t Vote Leave arguing about the economy and living standards?’ They did not realise that for millions of people, £350m/NHS was about the economy and living standards – that’s why it was so effective. It was clearly the most effective argument not only with the crucial swing fifth but with almost every demographic. Would we have won without the £350m/NHS? All our research and the close result strongly suggests No. Some people now claim this was cynical and we never intended to spend more on the NHS. Wrong.”
Rather than criticising these commitments to the NHS – promises entered into by cabinet ministers and by MPs – the public will doubtless want to see them honoured.
By the end of the next financial year for the NHS – March 2019 – the United Kingdom will have left the European Union.
Trust in democratic politics will not be strengthened if anyone now tries to argue:
‘You voted Brexit, partly for a better funded health service.
But precisely because of Brexit, you now can’t have one.’
A modern NHS is itself part of the practical answer to the deep social concerns that gave rise to Brexit.
At a time of national division: an NHS that brings us together. An institution that tops the list of what people say makes them proudest to be British. Ahead of the army, the monarchy or the BBC. Unifying young and old, town and country, the struggling and the better off.
At a time of economic dislocation, when many communities in this country are exposed to the chill winds of globalisation, an NHS where care is available not tied to whether you’ve got a job or your wealth. An NHS which is often the largest employer in many of these towns across the country. An NHS where we don’t load the cost of healthcare onto the cost of our jobs and exports is not only the right social choice, it’s the right economic choice for this country.
FUTURE-PROOFING THE NHS
But let me also say that as we turn to next year and the years ahead, it’s not just a question of ‘keeping the show on the road’, we also need to continue and accelerate the fundamental changes we’re embarked on. To ‘future proof’ the health service for future generations ahead.
The history of the NHS is not a history of stasis. It is a history of change. Of treatment advance. Of shifts in care delivery. Of new ways of engaging with patients and the public.
We have some enormous challenges that we need to square up to, and face in to, looking out over the next 5 and 10 years.
We need to reinvent the district general hospital, the model of hospital care that has served our communities since at least 1962 and the hospital plan for England. We are doing so through: networking hospitals; through hospitals with their neighbours sharing services; but in some parts of the country where that is not always possible we are going to need to fundamentally reinvent the medical staffing model – the way in which urgent care is provided – and challenge the inexorable sub-specialisation that we have seen develop in many of the medical specialities.
We are now embarked upon the most profound changes in general practice not only since 1948 but since 1911. We are seeing a reinvention of the clinical model, the career model and the business model of what general practice looks like – while retaining list basis care and the trust and continuity for those patients for whom it matters so much.
We are also doing what most other industrialised countries are doing – which is recognising the clinical and the financial logic for integrated care, rather than fragmented competition. We are driving that through the ACSs, and we are seeing the benefits where that is deployed. And we will be setting out further steps on that journey over the course of the next 2 months.
We have a big conversation to have as a country about how we support innovation and how we support patients around health and prevention.
And as we have just heard from Jeremy – and this has been subject of debate at this conference so far – we need to fundamentally rethink what the NHS is as this country’s largest employer.Yes, we need to reform aspects of our pay system. We need to become a more flexible employer, recognising that the ‘first world war’ model of recruiting successive waves of bright and brilliant 22 year olds, then with burnout and churn, is unsustainable. Expectations on the part of the people that look after our patients are inevitably changing. We have been insufficiently flexible in responding to those big generational shifts.
So we look into the next year and beyond not with a sense of complacency, and nor simply with the aspiration to ‘keep the show on the road’. We do so with a sense of ambition and possibility.
69 years ago this country was facing a war-weariness, an economy in disarray, the end of empire, a nation negotiating its place in the world, a need for massive house building. At that point, this country stepped-up, and took a bold and optimistic view. Not only on a whole range of social topics, but about the need for and the benefits from a National Health Service.
Faced with similar challenges today, there is absolutely no reason for thinking that – looking out to our 70th anniversary – that should not, once again, be the choice this country takes.