The Health Foundation’s Dr Jennifer Dixon reflects on the myriad challenges facing the NHS as the pioneering healthcare service turns 70.
The NHS was founded in 1948 on the principle that healthcare should be free, for everyone, at the point of use. 70 years on, like most healthcare systems, it is under increasing pressure to deliver more and better care with constrained growth in resources.
The prime minister’s announcement of a £20.5bn (~€23bn) yearly funding boost – in real terms – by 2023/24 was thus a welcome one, but detractors point out that the investment falls short of the 3.7% average increase the NHS has been used to, and claim it will not go far enough to deliver the improvements and modernisation the NHS needs to keep pace with the challenges it faces.
Here, Dr Jennifer Dixon, the chief executive of independent charity the Health Foundation, shares her concerns with Health Europa and looks ahead to the next 70 years of the NHS.
Where can the recent funding commitment be most effectively spent to produce the best outcomes for patients?
There are two ways of looking at this. To improve outcomes in particular disease areas – and there are clearly some, if you look at comparative statistics from the OECD, for example, where we lag behind what you’d expect or are average at best, cancer survival being one example, heart disease mortality another – it would certainly be of value to devote the new resources to boosting staff, kit, drugs and equipment in those areas and to draw up a well-articulated plan of action which includes milestones to deliver against.
A complementary approach would be to ask something more profound, which is how does a system such as the NHS, which is almost totally publicly funded, improve itself across the board in an ongoing way outside of any specific push on particular disease areas or patient groups? How can we increase productivity? How can we motivate staff to improve quality?
That approach requires a really coherent strategy on quality but also quality improvement and productivity, which is more generic than just simply going after a particular disease area. For that, you need to have the right staff, and you need to make sure that they’re equipped with change and QI skills, that they’re operating in an environment where the management is sound, that there are good operating processes, and that the leadership and culture of the organisation is conducive to staff making changes, experimenting and taking risks. You also need to make sure that the incentives in the system aren’t perverse, that they’re lined up to enable staff to make change and not the opposite.
For example, to improve the care of people with cancer, you need to think about not just treating cancer well at diagnosis but also how to achieve earlier diagnosis, or even reduce the risk of cancer in the first place – how do you incentivise that effectively? And you might also work out how staff could better increase the throughput of patients through the system so that they’re seen faster and more effectively and don’t fall through the cracks.
Unfortunately, that latter approach is often neglected. The NHS is funded by the taxpayer and politicians are accountable and responsible for that, which makes it a very politicised system. Politicians understandably want to see short-term outcomes; they want to see cancer care improving and survival rates going up. But short-term interests can sometimes mitigate against the need to invest in the kind of long-term capacity building that I’ve been talking about. But because politicians don’t always have deep enough knowledge about the system to address that, it is often absent in reform plans.
Are you optimistic that that long-term vision will be included in the upcoming ten-year plan for the NHS?
The signs are hopeful. As I’ve said, a lot of the reform plans in the past have been a combination of actions on specific elements such as cancer or mental health and assessments of high-level policy tools – incentives, targets etc. – that will be used to try to improve the system in certain areas. But they often completely fail to consider how you can work with the system at its grassroots to achieve change and improvement.
In other words, policymakers tend to favour ‘vertical targeted programmes’. But in the NHS change is also mediated by local institutions (e.g. hospitals) and cultures (such as in professional groups). Understanding what they need and supporting them – for example by strengthening management, leadership and clinical capacity – is critical to producing the kind of everyday improvements that are needed. This type of support should feature in NHS investment plans, and certainly a ten-year plan.
Does the NHS do enough to support staff at the front line in driving change?
In the last few years the NHS has received roughly a third of what it’s used to in terms of average annual growth in funding, which has put staff under considerable pressure. Nevertheless, my organisation has, over the last ten years, given around £200m to the NHS to support clinical teams to make improvements. What we’ve found, overwhelmingly, is great enthusiasm and willingness to do this among staff – and a relief, actually, when they are taught the skills needed to make the changes that they’ve been wanting to for years. For example, the Flow Coaching Academy in Sheffield NHS Trust has coached teams in many hospitals to improve flow of patients through the hospital.
As a result, there have been seen some terrific improvements: the average length of stay for older people has been shaved right back, halved actually, in some parts of the country, in a very resource-constrained environment, and sepsis rates have improved dramatically, as well. Those are eye-wateringly good results, and they’ve been achieved just by supporting staff and giving them the skills and permission needed to implement change.
How far does the omission of social care and public health in the recent funding commitment suggest a dialling back of the emphasis on these areas in the Five Year Forward View?
Vital aspects of funding – social care as well as capital, public health and training of staff – have been left out of the recent funding announcement. But they are absolutely crucial for the future. In ten years, the number of people admitted to hospital as an emergency and with five or more conditions has risen from one in ten to one in three, and there are over 150,000 hospital beds days blocked at any one time – at least some of which is due to a lack of social support. There have been a number of national inquiries and green papers on this, but successive governments have ducked action.
My understanding, however, is that these omissions are not permanent and will be considered in the spending review, which will take place in 2019. In the meantime, locally, there is progress in health and social care services working better together to offer a better service for patients.
How can the NHS effectively confront the workforce shortage it faces?
We’re in a very challenging situation at the moment, with full-time vacancies across the NHS running at about 10%. One answer is obviously to plan better for the number of staff we train in the UK. According to Health Education England, by 2033 we will need another 190,000 staff across the NHS. If current trends continue, we’ll only have an extra 72,000. This is a long-term issue that we need to start working on now.
The second answer is to improve the retention of staff. The number of GPs coming into the NHS has gone up, but a lot of them are retiring early or leaving for other reasons, so we must look closely at retention incentives.
The third answer lies in international recruitment, which is obviously an issue because of Brexit. Roughly half of the NHS staff who weren’t trained in the UK were trained in the EU, but the number of new workers coming from EU countries has now fallen and surveys show EU citizens working in the NHS increasingly indicating their intention to leave until they have clarity about what their options are. That is a deep worry. Thankfully, certain immigration rules (the Tier 2 visa cap) for doctors and nurses have been relaxed, which means those from outside the EU can come to work here, which suggests some recognition of the challenge we’re under.
Really, though, we need to start growing our domestic trained workforce and treating them well enough so that they don’t leave at 55 but consider a career up until 65 and beyond. In the longer term, we also need to start thinking about technology, because in the future that will begin to substitute not for whole groups of clinical staff but for certain tasks that staff do. We need staff to begin embracing that agenda, which, if the technology is too bluntly introduced, they won’t.
Much has been made of the potential of technology to streamline healthcare services. Is this being seen as too much of a panacea?
The waves of new technology that are coming are certainly going to be exciting, not just for the NHS but for all health systems internationally. At the moment, however, the evidence that I’ve seen suggests that these technologies are quality enhancing but at the same time cost enhancing, so the idea that they may help to contribute to the sustainability of the NHS is questionable.
The question, then, is whether the NHS itself can better identify, pilot and assess an increasing number of technologies. Some technologies boast high-solution claims. So the NHS needs to be much smarter at piloting technologies in a way that enables us to learn about how best they diffuse in the system. At the moment, studies show that too many new innovations take years to diffuse.
In my experience, a lot of people in leadership are oriented towards technology; they think that if the technology is good they can simply roll it out. But that isn’t the case, because most of healthcare isn’t technical and staff and patients aren’t robots. Technology needs to be ‘live tested’ to find out if it actually is beneficial, for which patients and under what circumstances. And how it is introduced to staff is critical too.
That kind of thoughtfulness is never part of the testing of technology, but it needs to be, because without it the technology might be introduced in one area but it will never spread. We simply can’t have mandated technology being rolled out across the system; that’s a recipe for staff resistance.
On the occasion of the NHS’s 70th birthday, how would you assess its performance and what are your hopes for its future?
The idea of an NHS that is free at the point of use and available on the basis of need is a deeply civilised one and an ideal which continues to motivate successive generations of people and huge amounts of talent to work for it. In that respect the NHS is a beacon to the world. What we can absolutely be proud of is that we, of all the countries in the Commonwealth Fund survey, have the lowest financial barriers to healthcare – people in Britain don’t skip care because of cost.
Nonetheless, we can’t escape the challenges ahead. Internationally, the NHS is extremely efficient in terms of its administration costs, but the OECD’s analysis shows that it has middling funding and middling performance.
Healthcare costs are outstripping GDP growth by some margin in every country, and the UK isn’t any different. The question for the future is whether the NHS can sustain itself by becoming more productive. Fortunately, we are a great system for experimentation. Lots of countries are looking to us because all sorts of innovations are being introduced at a pace here that they simply can’t be in Germany or Switzerland, for example, because their health systems are much more stable and don’t move as fast.
Ultimately, we’d like to see the NHS buck the trend and achieve better than middling quality despite the middling funding. And we do have all the ingredients for success:
- Talented and motivated staff;
- A national healthcare system;
- Excellent data and research infrastructure; and
- Solid public and political support.
About the Health Foundation
The Health Foundation is an independent charity committed to bringing about better health and healthcare for people in the UK. By collaborating with those delivering healthcare, giving grants to those working at the front line, and carrying out research and policy analysis, the Health Foundation is playing a leading role in improving health service delivery, informing health policymaking, and fostering a healthier UK population.
Dr Jennifer Dixon
The Health Foundation
This article will appear in issue 6 of Health Europa Quarterly, which will be published in August.