House of Lords Select Committee on the Long-term Sustainability of the NHS
Monday, 3 October, 2016

The Select Committee on the Long-term Sustainability of the NHS of the House of Lords, chaired by Lord Patel, is conducting an inquiry into the sustainability issues facing the NHS and the impact they will have over the next 15–20 years. The Committee invites interested individuals and organisations to submit evidence.

Written evidence is sought by Friday 23 September 2016. The submissions will guide the Committee’s deliberations in oral evidence sessions which will be held later this year and inform the Committee’s final conclusions and recommendations.

Public hearings began in early July and will continue until late December. The Committee aims to report to the House with recommendations by March 2017. The report will receive a response from the UK Government and will be debated in the House.

Background

The terms of reference for the inquiry as set by the House of Lords are “to consider the longterm sustainability of the NHS” and to report back to the House by Friday 31 March 2017.  The sustainability of the NHS is a topic of significant political and public interest. There remains a continuing level of support for a national health service which is free at the point of use.

Yet the demographics of both England and the UK are changing rapidly. There are estimated to be 51% more people aged 65 and over in England in 2030 compared to 2010. Moreover, 101% more people in England will be aged 85 and over in 2030 compared to 2010. People with three or more long-term conditions in England will increase by over 50% by 2018 compared to 2008.

These demographic changes directly affect healthcare expenditure, potentially putting financial stability and sustainability at risk. In 2015/16 NHS providers ended in deficit for the second year running.

Alongside this, the pace of change in healthcare is dramatic. Developments in drugs and medical technology mean that treatment and prevention are becoming more personalised, opening the door for more targeted treatment of diseases.

The Committee will be looking at UK Government policy and practice. It will consider whether their strategies and planning are sufficiently long-term, and what might usefully be done in practical terms to guarantee the sustainability of the NHS. The Committee will focus its inquiry on five main themes:

  • resource issues, including funding, productivity and demand management;
  • workforce, especially supply, retention and skills;
  • models of service delivery and integration
  • prevention and public engagement; and
  • digitisation of services, Big Data and informatics.

The Committee will attempt to identify the main problems in each of these areas and explore potential solutions.

The Committee is keen to take evidence from as diverse and as wide a range of stakeholders as possible, from a variety of sectors. This includes, but is not limited to: NHS Trusts and Foundation Trusts; patient organisations and charities; Royal Colleges; academics; local

authorities; consultancies; civil society and non-governmental organisations; organisations working in the EU and other international bodies. We would like to hear from as many organisations and people working in these sectors as possible.

The Committee’s inquiry will focus on the long-term sustainability of the NHS in relation to the five areas identified above. Submissions which do not address one or more of these issues, or which focus on the past, current, or short-term situation, may not be accepted as evidence.

House of Lords Select Committee on the Long-term Sustainability of the NHS – Response from the Royal College of Physicians of Edinburgh

The future healthcare system

1. Taking into account medical innovation, demographic changes, and changes in the frequency of long-term conditions, how must the health and care systems change to cope by 2030?

There undoubtedly will need to be significant changes to ensure a sustainable healthcare system by 2030. A partial solution is significantly greater financial investment into healthcare. However this may be unrealistic; and even if it were forthcoming, without greater system changes it would probably still not be enough. 

The frequency of almost all chronic or long term illnesses increase with advancing age, and many co-exist in older people.  The latter makes the course of the illnesses more complex, and increases sharply the demands and costs of both the investigations and management in those patients.  Given the ageing population, increasing training and experience in all aspects of the care of the complex frail older population will be vital.

We have witnessed a welcome and unprecedented revolution in medical knowledge and technologies allowing for the better diagnosis and treatment of illnesses.  These treatments have grown in complexity and understandably in cost. Not only are we able to cure many intercurrent illnesses, but we are able to sustain longevity despite the presence of treatable, but not curable, illnesses which constitute the bulk of long term conditions. We are able to post-pone death and prolong the period of ill health that requires sustainable expenditure - which is expanding in parallel with the expansion of the vulnerable population.

The NHS spends a huge amount of money on treatment of patients in the last few months of life when often high quality care would be more appropriate and kind. We need to recognise impending death much better.

There should be realism about what the NHS can offer, and further discussion around the roles played by both family and the state in providing care. There is currently a lack of balance between the demands on social services and their ability to deliver, which is one of the major reasons for the high pressures on hospital beds in the UK.

Many attempts to reform the NHS, particularly in the community, have resulted in excessive efforts to re-group, re-package and re-design services which consume time, effort and funds only for a new cycle of reform to begin a few years later. There is an over-emphasis on appearing to reform rather than sustaining and improving existing services.

Finally, improving the morale of the healthcare workforce which has decreased massively over the last 10 years is a vital part of the future healthcare system. The efficiency of having a well-motivated, well rewarded workforce is important, as huge pressures exist in hospital settings.

 Resource issues, including funding, productivity, demand management and resource use

2. To what extent is the current funding envelope for the NHS realistic?

It is clear that financial resources are not sustainable and are not realistic. The Committee may wish to consider which measures might be introduced to prevent possible misuse of a system that is deemed to be ‘free’. Cross party solutions should be considered with each new Health Minister not obliged to re-organise for political purposes.

It is likely that there will be a greater push towards centralisation of specialist services to preserve resource in staffing, backed up by local hospitals with more outreach into the community using virtual wards, telemedicine, e-consultations etc. Ideally there would be a switch to enhanced community care – however, there is currently no evidence that switching resources from secondary to primary care has reduced demand for hospital services. Bed numbers in the UK are already low compared to EU averages.

Social care is also key to resource issues and the focus should be on highlighting its successes in supporting vulnerable people rather than concentrating on fraudulent practices. Failures in providing social care impact on the healthcare budget when patients are not able to be discharged from hospital because they lack a care package.

a. Does the wider societal value of the healthcare system exceed its monetary cost?

This is difficult to quantify. It is clear that the public hugely value the NHS as a concept, and with the correct funding, management and support it can still deliver care in the way that it has previously rather than some of the drives towards complex provision of costly fragmented care.

b. What funding model(s) would best ensure financial stability and sustainability without compromising the quality of care? What financial system would help determine where money might be best spent?

By considering the NHS as an organisation itself rather than multiple competing providers moving funding around a system. This could still leave the greater organisation free to innovate and generate profit; but the service overall should be funded by general taxation at an appropriate level.

A cross-party or independent social and healthcare taxation commission could be considered to advise Government on this issue.

c. What is the scope for changes to current funding streams such as a hypothecated health tax, sin taxes, inheritance and property taxes, new voluntary local taxes, and expansion on co-payments (with agreed exceptions)?

Unhealthy food should be made more expensive with healthier lifestyles encouraged and rewarded through making healthy foods affordable and improving opportunities for active and public transport.

d. Should the scope of what is free at the point of use be more tightly drawn? For instance, could certain procedures be removed from the NHS or made available on a means-tested basis, or could continuing care be made means-tested with a Dilnot-style cap?

There are huge ethical arguments about some aspects of this but there are some procedures (eg some aspects of cosmetic surgery) provided by the NHS that could be handled differently. There is already some variation across the UK that could be regarded as unfair (eg prescription charges).

Workforce

3. What are the requirements of the future workforce going to be, and how can the supply of key groups of healthcare workers such as doctors, nurses, and other healthcare professionals and staff, be optimised for the long term needs of the NHS?

It seems likely there will be a relatively small number of highly trained professionals in the future, supported by healthcare assistants. There are also roles for hospital apprentices and hospital volunteers who can perform many and varied support tasks.

a. What are the options for increasing supply, for instance through changing entry systems, overseas recruitment, internal development and progression?

Our current entry systems have proved to be effective at recruiting the best candidates for the health professions, and have allowed us to maintain high standards of individuals admitted to the Universities and Colleges. More places could also be made available across the healthcare and allied professions.

Rigorous selection programmes of certification examinations and assessments of linguistic and professional standards of overseas graduates should remain in place to ensure standards are not compromised.

Consideration should be given to developing and further recruiting into the newly created option of physician assistants who would provide a stable subsidiary work-force that can work to supplement the doctors and not replace them within prescribed specialties and roles.

b. What effect will the UK leaving the European Union have on the continued supply of healthcare workers from overseas?

The UK imports more healthcare professionals from the EU than it exports so there is a potential risk here. Should a points based system be introduced for immigration there would be the opportunity to prioritise healthcare workers.

In applying rules of worker selection the UK will be able to ensure professionals have an adequate command of the English language, and meet the same high standards applied to UK graduates and workers.

c. What are the retention issues for key groups of healthcare workers and how should these be addressed?

Retention issues are caused by the downward spiral of shortages and low morale. This can only be broken by getting staff numbers up to standard quotas. There is also a role for better hospital management with the correct interpersonal and leadership skills. 

There could be a national drive to attract young people into the Health Service, for example as is done with campaigns to join the armed services. Family friendly working patterns need to be supported, along with recognition of professionalism rather than a production line approach.

Some issues are national and others more localised and there is no comprehensive joined up plan of deployment of personnel, rather this is tackled at local or specialty level.

Where positions are not filled, there is a resulting increase in pressure on those in post in these areas to deliver what would have been expected from full complement of teams. These increased pressures can cause a decline in both the quality of work provided and in the morale of the workforce. This is driving senior GP’s to early retirements and younger doctors in both the hospitals and the community to emigrate mainly to Australia/New Zealand and to Canada. When the current medical trainee workforce reach their consultant posts this is likely to be even worse given the recent contract dispute.

4. How can the UK ensure its health and social care workforce is sufficiently and appropriately trained?

Through better strategic planning, closer ties to Universities, and agility in introducing new roles such as the Physician Assistant and Advanced Nurse Practitioner - many universities now offer such courses. 

There is a role for enhanced simulation and fast tracking in view of the present crisis.

a. What changes, such as the use of new technologies, can be made to increase the agility of the health and social care workforce?

Training programmes are already making good use where appropriate of the new technologies and simulation training.

b. What are the cost implications of moving towards a workforce that is equipped with a more adaptable skill mix being deployed in the right place at the right time to better meet the needs of patients?

There have been a number of discussions recently regarding the potential to shorten medical training, although there is also a case for extending training given the increased burden on the workforce. Adaptable skill mix is all very well, but this should not be at the expense of expert specialism.

There will be costs at two levels:

  1. the cost of the extra-training of the existing work force to do other previously not done tasks;

  2. the cost of recruiting more of those to back fill the tasks that they will not be doing because of their extended roles.No one can do extra without having to drop some of what they are currently doing.

Workers who take on more and new tasks and who receive extra-training will view themselves as more qualified and would inevitably expect a rise in their remuneration.

Multi-tasking is a potentially fulfilling extension of the roles for those who are being asked to do them, but it cannot be regarded as the ‘cheap method’ of avoiding the reality of the need to spend more.

c. What investment model would most speedily enhance and stabilise the workforce?

Long term steady investment is needed to train new workers and meet the demand appropriately; this can also help boost workforce morale. Short term, immigration will potentially have to be part of considerations.

Models of service delivery and integration

5. What are the practical changes required to provide the population with an integrated National Health and Care Service?

a. How could truly integrated budgets for the NHS and social care work and what

changes would be required at national and local levels to make this work smoothly?

By removing boundaries and having joint organisations covering both aspects as already being tried in parts of the UK.   This may involve ensuring some ring fencing or protection of social care budgets due to the increasing demands they are under.

b. How can local organisations be incentivised to work together?

Local organisations could be penalized for delays in providing services for patients who need them, that significantly delay the patients’ discharge from hospital. Provision of cheaper, viable alternatives to hospital beds when hospitalization is no longer required is a potential method of avoiding penalties invoked against the social services when the provision of care package is delayed for patients who need to be discharged from hospital.

c. How can the balance between (a) hospital and community services and (b) mental and physical health and care services be improved?

(a) Could consider an integrated model where single health boards are responsible for community and hospital care which could remove local protectionism and increase understanding. Having roles which work across both settings may also help.

(b) These could be improved through combined work between the Liaison Psychiatrists and the doctors and nurses providing physical health services. This requires funding of further posts for the Liaison Psychiatry services (doctors and nurses) and close working relationships with those working on physical health (through multi-disciplinary team working) which helps with smoothing any difficulties in the provision of care in either direction.

Prevention and public engagement

6. What are the practical changes required to enable the NHS to shift to a more preventative rather than acute treatment service?

a. What are the key elements of a public health policy that would enhance a population’s health and wellbeing and increase years of good health?

Public health policies that enhance a population’s health and wellbeing and increase years of good health are based on measures that are simple to implement, characterized by lower cost, and have profound impact on people’s health that is sustained in the long term. One example of such a policy is the smoking ban in public places.

There are many potential preventative interventions that could be designed to maximize the impact on health and reduce spending, for example the prevention of osteoporosis in the population that is ageing.

b. What should be the role of the State, the individual and local and regional bodies in an enhanced prevention and public health strategy; and what are the key changes required to the present arrangements to support this?

The State’s responsibility lies mainly in enacting laws and enabling their implementation through funding or budgeting and enforcing penalties. Local and regional bodies have responsibility for implementing policies and encouraging those individuals who are in positions of power to educate the public and encourage their adherence to these policies.

It is important to highlight the importance of supporting research that investigates the role of interventions at societal level and to investigate the cost-effectiveness of these interventions.

c. Is there a mismatch between the funding and delivery of public health and prevention, compared with the amount of money spent on treatment? How can public health funding be brought more in line with the anticipated need, for instance a period of protection or ring-fencing?

With the demonstration of the cost effectiveness of the interventions in public health, one could then expect the government and the funding bodies to honour the funding commitments to public policy.

d. Should the UK Government legislate for greater industry responsibility to safeguard national health, for example the sugar tax? If so how?

Potentially, and expanding the role of bodies such as NICE could help the UK Government in choosing the interventions that need to be enacted in law because of their public health impact.

The Government should be prepared to legislate whether it be on sugar, alcohol or smoking, in order to protect public health.

e. By what means can providers be incentivised to keep people healthier for longer therefore requiring a lower level of overall care?

This could be through establishing quality standards parameters that need to be implemented for these providers to be given good assessment status compared to their peers, or to link achieving those good quality standards to income of the provider.

f. What are the barriers to taking on received knowledge about healthy places to live and work?

There is a good argument for centralisation of public health and ensuring education of the nation, including within schools.

g. How could technology play a greater role in enhancing prevention and public health?

Technology and improved technology can be used to detect pollution, purify water supplies from bacteria, and detect illnesses prior to symptoms developing. Examples of the latter include plans to detect impaired left ventricles prior to demonstration of heart failure symptoms, detecting hypercholesterolaemia and treatment thereof prior to the establishment of coronary artery disease, and treatment of patients with positive calcium coronary score in the absence of symptoms of angina.

7. What are the best ways to engage the public in talking about what they want from a health service?

There is a place for honest public debate and conversation about what the NHS can offer, with educational and publicity programmes encouraged through various channels including digital.

Digitisation of services, Big Data and informatics

8. How can new technologies be used to ensure the sustainability of the NHS?

a. What is the role of technology such as telecare and telehealth, wearable technologies and genetic and genome medicine in reducing costs and managing demand?

There is no doubt that some new technologies are helpful in some aspects of healthcare. However, the wholesale adoption of these because of their being trendy is to be discouraged. Like all interventions technologies need to be subjected to the same levels of evidence as those for pharmacological ones. We need to encourage studies demonstrating cost effectiveness and health benefits of these technologies before they are adopted.

b. What is the role of ‘Big Data’ in reducing costs and managing demand?

The main role is to minimize duplication and provide health workers with access to all the information available on the patient and thus avoiding un-necessary expenditure.

c. What are the barriers to industrial roll out of new technologies and the use of ‘Big Data’?

The cost of these remains prohibitive and previous attempts to automate have previously failed to attain the projected aims and escalated in their costs beyond the budget. In addition, these need to be restricted to technologies proved to be effective, helpful and cost-efficient.

d. How can healthcare providers be incentivised to take up new technologies?

By demonstrating the benefits of such provision to the health of the patients and the efficiency of the services provided (including cutting costs).

e. Where is investment in technology and informatics most needed?

In the acute hospital sector, to access test results and the link between primary and secondary care.