There may be trouble, ahead…

nao snip for blog post

The National Audit Office, warning on untested, untimetabled, but very expensive changes to health and social care.

The Guardian recently published a big interview with Sir David Nicholson, the chief executive of NHS England, who is due to retire at the end of the month. In it, Sir David says that the NHS is “unsustainable” in its current form, and that some major reorganisation will be needed to make it safe and sustainable for the future.

In itself, this is unremarkable. Sir David has been warning since 2008 that there will be a gap between the flat funding that the health service is likely to receive for the foreseeable future, and the growing demand that is being put on it by an ageing population living with a growing burden of chronic disease.

He has been urging the health service to make ‘quality, innovation, productivity and prevention’ savings to stop the gap reaching £20 billion by 2015; and £30 billion by 2020.

To date, all the indications are that the NHS is on track, but only because it has held down management costs and wages. Big changes – reorganising services, bringing in new ways of working, making more use of technology – have not really been tried.

NHS England outlined three new ‘models’ of working for hospitals, community and primary care services in December; and it is these that Sir David reiterates in his interview.

Understandably, the Guardian dwells on one of the models – a big reorganisation of hospital services being pushed by NHS England’s medical director, Sir Bruce Keogh. This would see specialist and full-scale A&E services delivered from far fewer centres; but it’s questionable whether they can be introduced, given what Sir David calls “the public’s attachment to bricks and mortar.”

NHS leaders tend to find local campaigns to ‘save’ A&E, maternity, and surgical services very irritating, and frequently complain that MPs and local papers stop ‘essential’ changes by backing them. After all, they claim, as Sir David does in his interview, that bricks are not services, and the future lies in teams “working seamlessly together to care for patients in, and espeically out, of hospitals, concentrating on helping them to stay well.”

However, the evidence base for the kind of changes proposed is surprisingly thin. Although advocates for change routinely cite the case of Fabrice Muamba – the footballer who collapsed on the pitch, and was taken to one of London’s specialised heart centres – as evidence that ‘reconfiguration’ is a good thing, it’s hard to find a good, well referenced study that makes the case on a more than individual level (particularly outside London).

Meanwhile, it’s even harder to find a case study demonstrating that change has really made services more efficient; never mind cheaper. This seems to be worrying the National Audit Office, which issued an under-reported study on adult social care last week.

The bulk of the report detailed the ongoing collapse of council services for disabled adults and elderly people who need help shopping, washing, eating, or just getting out of bed on their own, and the strain this is putting on other parts of the health and social care system.

But it also warned that the second of the new models of care propounded by NHS England, a move towards ‘integraged’ community health and social care, is being hampered by “a lack of evidence on what works” and uncertain timescales.

The NAO points out that even if things can be found that do work, neither the Department of Health nor the Department for Communities and Local Government in fact knows “how quickly savings can be achieved across health and care through transforming services and greater integration.”

This makes the push for change – and the £2 billion being siphoned out of the NHS this year to top-up the £3.8 billion Better Care Fund that is supposed to pump-prime them – something of a leap of faith.

Or, as the NAO puts it: “As the changes take effect, central and local government risk not knowing if: services are deteriorating to unacceptable levels; needs are not being met; care quality is improving; and public funding is achieving value for money.” 

Or, as the chair of the Public Accounts Committee, Margaret Hodge, puts it: “The fact the departments do not know how much longer the entire care system can cope under the mounting pressure makes for a worrying picture.” 

The PAC will be holding a hearing on the report on 26 March, which should make for interesting listening. Hodge has a reputation for asking public officials some very difficult questions. Hopefully, she’ll give Sir David or his colleagues less of an easy ride on change than his exit interviewers have done to date.

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