1 December 2016

It’s time the NHS stopped panicking and started planning

By Nick Bosanquet

As yet another budget statement comes and goes, political debate over the NHS is still fixated with the funding issue. People think the only solution is to throw ever larger sums of cash at the system and hope for the best.

But even with the extra £10 billion – which is what the Government has “promised” and not as much as the many people are asking  for – the ultimate reality would still be the same. The population is getting older and more expensive and we simply don’t have any more money to spend on the NHS.

But there is an alternative. We could make better use of all resources – both private and public – across the UK. With careful collaboration, the private sector can help the NHS to fill the gaps in its healthcare provision.

Take social care, for example. It’s one of the flashpoints in the health debate as demographic changes mean that more and more people need looking after. Yet again there are calls for more public money to be injected as alarmist reporting in the media, especially by the BBC, tends to obscure the fact that most service users are being well cared for.

The country has already experienced a large private-sector investment in residential and nursing home care. And a recent CQC survey showed that 65-70 per cent of care homes were rated as good—compared to 30 per cent of acute hospitals. Nearly all residents are now in en suite rooms – it is a far cry from the dormitories of the past. There is room for improvement, of course but when did we last see a programme that told us about the good care homes?

This isn’t just about residential care, though. There are now 100,000 carers providing a service to a million people in their own homes. No other developed country has anything like this level of service, brought into existence by private companies and voluntary organisations.

If the number of long-term residential care places had risen at the same rate as population was ageing, social services would have had to pay for 50,000 more places for elderly patients. The thriving home care service, however, has given many of these people the choice and opportunity to stay in their own home. Of course there are still many problems but the glass is half full.

The sensible thing would be for our public servants to seek to nurture longer term collaboration with private investors, to allow for proper investment and broader skills development. But it seems NHS leaders and politicians are unable to think further ahead than the next winter crisis.

And so the NHS only ever really approaches the private sector in panic mode when the serious central heating problems start. With this winter’s crisis about to bite, hospitals are already being told to take drastic measures to clear beds in anticipation of an influx.

Hospitals currently have alarmingly little – if any – space when it comes to beds. So local Trusts are being asked to use last-minute, high-cost private providers to plug the service gaps and shift patients through the hospital at a faster rate.

The trouble is, many frail elderly patients cannot be safely discharged after three or four days recuperation. The problem of bed blocking – and NHS Trusts have just recorded the highest level of occupancy ever in the run-up to winter – is not just about slowness by local governments but also because there are genuine problems with early discharge.

So how can we speed things up?

Frailty units, such as the one pioneered by Leicester Trust, which provide “safe, compassionate care for elderly, frail people”, are a good place to start. The dedicated care they can provide to geriatric patients drastically reduces discharge time.

But we also need to provide better convalescent support after discharge so that these elderly patients can regain confidence. The private sector could help by improving the links between hospitals and nursing homes.

Some space in nursing homes, for example, could be dedicated to offering longer term re-ablement, and rehab programmes could draw on support from nurses, physiotherapists and occupational therapists usually based in hospitals.

Commissioning, meanwhile, should focus on developing strong providers who can offer different levels of service. At present, the focus is on delivering the maximum number of hours for the minimum cost – an approach which threatens quality and deters providers.

Instead, the NHS should consider how it can carefully  calibrate and fund different levels of home care – from occasional help to more comprehensive support for people with serious health problems. A successful strategy would have a dramatic effect on the take-up of hospital beds.

There is also scope for collaboration in elective treatment. The private sector could help to develop a new wave of treatment centres for orthopaedic operations.

A promising start was made by the NHS with the Epsom treatment centre which carries out 3,000 operations a year. Conducting all orthopaedic surgery in the same location has brought massive cost and treatment benefits and, like the dedicated elderly units, significantly reduced discharge time for patients. And yet there has been no follow up. Many theatres are still on mixed use where emergencies have to take precedence over elective care.

It’s time for the NHS to stop panicking and start planning. Back in 1948 the NHS did have a near monopoly of care covering long-term support, hospital and GP services: but these days are long gone. With no magic money tree to fund it, the NHS has got to shake off its provider monopoly mindset and start driving to get the best possible deal for patients.

Intelligent collaboration with the private sector is the only way forward.

Nick Bosanquet is Emeritus Professor of Health Policy Imperial College; he was Special Advisor to the Health Select Committee 2001-10.