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It’s no secret that funding and demand pressures pose a significant threat to the NHS, but what needs to change to secure its survival? Rachel Carter reports.
Three months after the National Health Service was born on 5 July 1948, health minister Aneurin (Nye) Bevan called it ‘one very great revolution’.
In an address to a conference of the Executive Councils Association later that year, Bevan spoke of a service that offered free healthcare to everyone, and that would improve ‘a great deal’ over time.
But 70 years on, Bevan’s towering achievement is cash-starved and buckling under the pressure of an aging population with more complex health issues. It seems nothing short of a revolution can ensure this much-celebrated institution survives.
‘Invest in transformation’
The NHS is valued by many because of what it represents: the idea that free healthcare is a human right. Its three founding principles – to meet the needs of everyone, to be free at the point of delivery and be based on clinical needs and not income – have remained at the heart of the service.
But things have changed, not least the availability of funds. Between 1948 and 2010, government spending on health increased by an average of 4% each year. In the past eight years, that average has dropped to around 1.2%.
In 2013, NHS England estimated that it faced a funding gap of £30bn by 2020. The following year it pledged to save £22bn before that date, which even its chief executive, Simon Stevens, admitted was ‘ambitious’. In 2015/16, hospitals in England racked up a record £2.45bn deficit. This figure dropped to £791m the following year, but that increased to £960m in 2017/18, it has been announced.
In a report published in May, the Institute for Fiscal Studies estimated that health spending will have to increase by an average 3.3% a year for the next 15years to maintain the service at its current level. If this is met through tax increases UK households might have to pay up to £2,000 a year more.
Maisie Borrows, senior researcher at independent think-tank Reform, says its work has detected some public appetite for a ‘very slight’ increase in income tax, but adds that any extra money will need to be invested in transforming service delivery.
‘The issue we’ve had with the NHS is that when additional money is given to it, more often than not it goes to the day-today running of the hospital rather than investing in transformation and that side of the agenda,’ she says.
‘We obviously have the challenge around funding and the fact that the NHS is very cash-strapped, but at the same time, the model isn’t fi t for purpose anymore.’
‘Local solutions to local problems’
As Ms Borrows points out, this is partly due to the ‘increased consumer expectation’ being placed on the NHS – the publics want a 24-hour, easy-to-access healthcare system – but there’s also the issue of a growing ageing population.
The demographic of the population has changed significantly since 1948 – people are living longer and often with multiple long-term conditions. Recent NHS figures show there were half a million more people over 75 in 2017 than in 2010 – a figure that is predicted to increase by a further two million in 2027.
Ms Borrows supports the idea that the NHS should move towards a community and primary care-based model of delivering healthcare – as is broadly set out in the NHS Five Year Forward View – because this is what the population needs.
‘More money should be invested in the acute and primary sector – whether that’s developing the workforce, the buildings in which care is delivered, or the technology to better meet people’s needs,’ she adds.
‘If we can develop more of a localised approach where local public services, including social care, can work together to improve health outcomes, I think that would be a far better model than what we’re seeing now.’
‘Maintaining primary care’
This view is echoed by Aneez Esmail, professor of general practice at the University of Manchester. He describes primary care as the ‘jewel in the crown of the NHS’, but says a key challenge now is how to embed it into the heart of system.
‘I don’t think it was planned this way – but when the NHS was created, primary care was almost an afterthought, and we are living with the consequences of that,’ he says. ‘So the challenge now is how do we maintain a primary care system where people can see a generalist physician who understands them in the context of their society, community and family?’
The answer could be better integration with secondary care and a fairer funding settlement, professor Esmail says. But he believes it’s also about tackling the declining numbers of GPs.
The shortage of GPs is just another problem faced by the NHS. In 2016, the Government pledged 5,000 more GPs by 2020, but Imperial College London research has since warned this is far short of the numbers actually needed, estimating a workforce deficit of 12,000 GPs by the end of the decade.
Professor Esmail says that when he graduated in 1982, half of his university year became GPs – but now it’s the other way around, with students more likely to follow a specialist route.
‘I think we need to have a training system that is geared towards making general practice the first destination of choice for graduates,’ he says.
Ms Borrows suggests local areas should be given control over how many doctors they train each year, rather than this being done by a central body. ‘Each local area has a different need,’ she says, ‘so giving them the flexibility to attract doctors but also retain staff would be a powerful move.’
‘Just a black hole’
Another key challenge for the health service is shifting to a preventative model. The NHS Five Year Forward View states that earlier warnings to take prevention seriously have been ignored, resulting in a sharp increase of avoidable illness.
The document called for a ‘radical upgrade’ in prevention and public health. Dr Kailash Chand, a retired GP and honorary vice-president of the British Medical Association, says that over the past 70 years ‘we have created a national illness service’, that diagnoses and treats patients rather than address the root causes.
‘I have practised for almost 40 years and I can safely say that 70-80% of people who walk into a GP surgery are essentially victims of their own problems,’ he says.
‘Diet, lifestyle, alcohol and smoking – these all lead to problems such as diabetes, heart disease, obesity and stroke, and we haven’t done anything to [solve] that.’
Dr Chand argues that the lack of investment in public health is largely to blame, and this has contributed to the NHS becoming ‘just a black hole. In the 2015 Autumn Statement, the Government announced plans to slash public health budgets by 9.6% over five years.
This led to cuts to GP services, including smoking cessation, sexual health and weight management treatments. By 2020, councils will lose another £170m.
Professor Esmail agrees that if there are funding problems, the Government often cuts public health. What it really comes down to is ‘the language of priorities’, he adds.
‘The role of the Government is to identify priorities, recognise that those priorities should determine what receives funding and stick to that,’ he says.
‘Take Denmark as an example – in the 1960s, the country made the decision to prioritise the bike over the car. It was a 20-year strategy, but now everyone cycles.’
‘Bold and brave’
The NHS has, however, often been used as a ‘political football’ and, as Dr Chand points out, the political battle over private vs publicly-funded services has brought ‘all manner of conflicts, restructuring and whatever else’ – the reforms by health secretary Andrew Lansley in the 2012 Health and Social Care Act perhaps being the most extreme example.
‘I always say we should take politics out of the NHS, but it is a very important part of the whole concept – even in 1948 there were two opposing views,’ Dr Chand says.
Responding to the health service crisis, Prime Minister Theresa May pledged to bring forward a long-term funding plan for the NHS to coincide with its 70th birthday.
The Department of Health and Social Care is pushing ahead with plans to upgrade all sustainability and transformation partnerships to integrated care systems, to drive up the quality of local health and care services.
But is it enough? Ms Borrows believes that for the NHS to survive there needs to be a ‘total rethink’ of what the service actually is and what its business model should be.
‘The NHS is going to require bold, transformative reforms if it is going to carry on offering free healthcare at the point of delivery,’ she says. ‘The Government has an integral part to play, so we need it to be brave and commit to those reforms.’
Dr Chand says that for him it’s less about reform, and more about a revolution – looking into the ‘fundamental errors’ that have led the NHS to its current state.
‘I’ve always believed that access to healthcare is a fundamental human right and, in my view, Bevan translated that ideal into reality in 1948.’
‘We have to preserve that concept and maintain the gift given to us by our ancestors, so it is available for future generations.’
Rachel Carter is a freelance reporter