NHS reform is inevitable. Manifestos might not spell it out to the letter, but this is a truth recognised by every major party. As the biggest public service, with a £110 billion budget and employing 1.3 million people, getting value for money from the NHS is the only sustainable option. Simon Stevens at a Reform conference this week was uncompromising on this point: “Anyone who believes we can spend our way to success needs to get their reading glasses on.”
The next government should therefore be deeply concerned by the news that the NHS is not moving far or fast enough. Take the much needed shift away from a system where all roads lead to the hospital. It is to be praised that the number of hospital beds has fallen by 5% over the Parliament. Yet spending on hospitals continues to rise as a proportion of the total budget. The use of alternatives to hospital A&E departments, such as walk-in centres, has flat-lined after a period of growth. Indeed a third of walk in centres have been closed over the last five years.
NHS hospitals must become much more efficient. The Health Select Committee has warned that savings this Parliament have been through national pay freezes and squeezes on prices, not through changes to the way services operate. The average hospital is still 10% less productive than the best performing. Hospital deficits are expected to reach more than £800 million in the next few weeks.
With half the budget spent on staffing, a more efficient NHS must mean a smaller workforce. At the beginning of the Parliament, the NHS White Paper acknowledged that “as a result of record debt”, a smaller workforce was “a hard truth which any government would have to recognise.” But while staff numbers fell in the first half of the Parliament, in 2012-13 this reversed. In the wake of high profile inquiries into failings of care, such as that at Mid Staffordshire NHS Foundation Trust, the number of staff has become increasingly synonymous with quality of care. New figures show the NHS workforce is now the largest it’s ever been, rising by 1.7% in the last year alone. In any public service what matters must not be the number of staff, but how effectively they are deployed.
The NHS will have to deliver care in new ways that are more responsive to patients. Across the public sector, the coalition sought to harness competition and choice as levers for more responsive and efficient services. The reality has been very different. The share of the NHS budget spent on private companies, charities and other organisations has risen from 8.5% to just 9.1%. Instead of allowing private providers to compete with the NHS, there been just one new entrant into the provider market (Hinchingbrooke). The number of patients offered choice of hospital treatment has fallen from 49% to 38% – hardly “no decision about me, without me”.
All political parties have called for a more integrated NHS, meaning better co-ordination of care for the elderly between hospitals and residential or nursing care. That co-ordination has significantly worsened. The numbers of days lost to delayed transfers out of hospitals has risen by almost two-thirds.
Changing the pace of reform will require tough choices, at times politically unpalatable. Expensive hospital estate will need change. Local A&Es will have to close. The rising number of staff and the growing wage bill will have to be challenged. Contracts that free doctors from work at the weekend and out of hours will have to change. NHS England has warned that the next Government must find £22 billion extra to spend on the NHS if it does not become much more efficient. Already two thirds of hospital are in deficit and A&E waiting times are at a record high. If this is the alternative for the new government, NHS reform is surely good politics.