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The Long-term Sustainability of the NHS and Adult Social Care: Select Committee on the Long-term Sustainability of the NHS

House of Lords: Report of Session 2016–17

A culture of short-termism and an Office for Health and Care Sustainability

A culture of short-termism seems to prevail in the NHS and adult social care. The short-sightedness of successive governments is reflected in a Department of Health that is unable or unwilling to think beyond the next few years. The Department of Health, over a number of years, has failed in this regard. Almost everyone involved in the health service and social care system seems to be absorbed by the day-to-day struggles, leaving the future to ‘take care of itself’. A new political consensus on the future of the health and care system is desperately needed and this should emerge as a result of Government-initiated cross-party talks and a robust national conversation.

To build on this consensus, we recommend the establishment of an Office for Health and Care Sustainability. It should play no part in the operation of the health and care systems, or make decisions, but should be given the independence to speak freely about issues relating to its remit. It should look 15–20 years ahead and report to Parliament, initially focusing on: (1) the monitoring of and publication of authoritative data relating to changing demographic trends, disease profiles and the expected pace of change relating to future service demand; (2) the workforce and skills mix implications of these changes; and (3) the stability of health and adult social care funding allocations relative to that demand, including the alignment between health and adult social care funding. The body should be established in statute before the end of this Parliament.

Transforming services

Service transformation is at the heart of securing the long-term future of the health and care systems. It is dependent on long-term planning, broad consultation, appropriate systems of governance and local accountability. The model of primary care will need to change, secondary care will need to be reshaped and specialised services consolidated further. Importantly, a renewed drive to realise integrated health and social care is badly needed. However, the statutory framework is frustrating this agenda and in order for real progress to be made reform is needed to reduce fragmentation and the regulatory burden. Service transformation will be key to delivering a more integrated health and social care system and although there are some positive examples in some areas, there is more to be done. With policy now increasingly focused on integrated, place-based care we see no case for the continued existence of two separate national bodies and recommend that NHS England and NHS Improvement are merged to create a new body with streamlined and simplified regulatory functions. This merged body should include strong representation from local government.

Realistic and consistent funding for health and adult social care

We are clear that a tax-funded, free-at-the-point-of-use NHS should remain in place as the most appropriate model for the delivery of sustainable health
services. In coming years this will require a shift in government priorities or increases in taxation. We are also clear that health spending beyond 2020 needs to increase at least in line with growth in GDP in real-terms. We heard that publicly-funded adult social care is in crisis. The additional funding for social care announced in the 2017 Budget is welcome and means funding for social care will increase by more than 2% a year for the next three years. This is more than the increase for NHS funding. However it is clearly insufficient to make up for many years of underfunding and the rapid rise in pressures on the system. The Government needs to provide further funding between now and 2020. Beyond 2020 a key principle of the long-term settlement for social care should be that funding increases reflect changing need and are, as a minimum, aligned with the rate of increase for NHS funding.

Funding for health and adult social care over the past 25 years has been too volatile and poorly co-ordinated between the two systems, and this should
be addressed as a matter of priority. We recommend that the budgetary responsibility for adult social care at a national level should be transferred to the Department of Health which should be renamed the ‘Department of Health and Care’. This should allow money and other resources to be marshalled
within a unified policy setting at national level. We acknowledge the difficulties with integrating budgets at a local level but this is achievable. The Government should undertake a review and bring forward changes in order to make this happen.

We support a funding system for social care that enables those who can afford it to pay for the care they need but with the costs falling on individuals capped in the manner proposed by the Dilnot Commission. We also call on the Government to implement as quickly as practicable, and no later than the first session of the next Parliament, new mechanisms to make it easier for people to save and pay for their own care. The Government should, in the development of its forthcoming green paper on the future of social care, give serious consideration to the introduction of an insurance-based scheme which would start in middle age to cover care costs.

The absence of long-term workforce planning

We are concerned by the absence of any comprehensive national long-term strategy to secure the appropriately skilled, well-trained and committed workforce that the health and care system will need over the next 10–15 years. In our view this represents the biggest internal threat to the sustainability of the NHS. Health Education England has been unable to deliver. It needs to be substantially strengthened and transformed into a new single, integrated strategic workforce planning body for health and social care which should always look ten years ahead, on a rolling basis. This will enable it to produce and implement a joined-up place-based national strategy for the health and social care workforce, which utilises a greater proportion of the domestic labour market. Health Education England’s independence should be guaranteed, it should be supported by a protected budget and it should be given greater budgetary freedom. It will need enhanced skills and a board that includes representation from all parts of the health and care system.

The evidence was clear that too little attention has been paid to training the existing workforce and a radical reform of many training courses for medical recruits is desperately needed. Health Education England should take the lead on changing the culture of conservatism which prevails among those who educate and train the health and social care workforce. It should convene a forum of the Royal Colleges, the General Medical Council, the Nursing and Midwifery Council, higher education institutions, other education providers, social care providers and local government representatives to investigate how medical and social care education and ongoing training courses can be reformed and streamlined. We also heard repeatedly of the linkage between over-burdensome regulation, unnecessary bureaucracy, a prolonged period of pay restraint, low levels of morale and retention problems. We call on the Government to bring forward legislation to urgently reform the system regulators and the system of regulation for health and social care professionals.

Innovation, technology and productivity

Currently, leaders in the NHS seem to be incapable of driving the much needed change in levels of productivity, uptake of innovation, effective use of data and the adoption of new technologies. Understandably, too much management and clinical attention is focussed on the here and now and there are too few incentives to look ahead to the longer term. It is not clear who is ultimately responsible for driving innovation and ensuring consistency in the assessment and the adoption of new technological approaches. The Government should make it clear that the adoption of innovation and technology, after appropriate appraisal, across the NHS is a priority and it should decide who is ultimately responsible for this overall agenda. It should also identify the bodies and areas within the NHS which are falling behind in the innovation and technology agenda and make it clear that there will be funding and service delivery consequences for those who repeatedly fail to engage.

Unwarranted levels of variations in patient outcomes are unacceptably undermining the effectiveness and efficiency of the NHS and there is no plan to bring about a greater consistency in levels of performance. The Government should require a newly unified NHS England and NHS Improvement to work with commissioners to achieve greater levels of consistency in NHS efficiency and performance at a local level. There is an immediate opportunity in the implementation of Sustainability and Transformation Plans to take this forward. Greater levels of investment and service responsibility should be given to those who improve the most.

Public health, prevention and patient responsibility

We are of the firm opinion that continued cuts to the public health budget are not only short-sighted but counter-productive. There is a grave risk that the burden of disease will increase if these cuts continue, a trend which is bound to result in a greater strain on all services. The Government should restore the funds which have been cut in recent years and maintain ring-fenced national and local public health budgets for at least the next 10 years. Governments should not cite unwillingness to behave as a ‘nanny state’ as an excuse for inaction on the major public health issues, including obesity. Importantly, the Government should be clear with the public that access to the NHS involves patient responsibilities as well as patient rights. The NHS Constitution should be redrafted and relaunched with a greater emphasis on these often overlooked individual responsibilities. The Government should also redouble its efforts to educate the public about the true costs to the NHS of poor lifestyle choices.

Time and resource constraints meant that we were not able to look at each and every issue in as much detail as they deserved. Nevertheless, we hope that our conclusions and recommendations, which can be found at the end of the report, will provide a starting point for others who continue to work to secure the longterm sustainability of both the NHS and adult social care.