Time for the NHS to be weaned off the boom or bust funding cycle
Not enough beds. Or where there are beds, patients lying on them in corridors. How did the NHS find itself in this situation? Of course an ageing population, problems with social care, increased patient demands, variable management and wastefulness all play a part. They always have. But fundamentally, the answer is based on two statistics – on which the NHS actually prides itself: the number of staffed hospital beds and the length of time a patient stays in a bed.
For decades, these two figures have been regarded as good measures of the efficiency of our National Health Service. But they are figures that say very little about real patient care.
For in winter time this model – having the maximum number of beds which you hope patients will stay in for the shortest time – breaks down. Because then there can never be enough beds to deal with spikes in the flu and norovirus-related influx.
The statistics that really lie at the core of health system efficiency are how many people you can keep out of hospital in the first place, and how well those who are admitted are cared for after discharge. It is unsafe, for example, to neglect illness until emergency care is required. But then, if it is required, it also unsafe to discharge patients from hospital without ensuring that they will receive appropriate care elsewhere.
These two faults lie at the heart of every NHS winter crisis, and extra funding has always been a sticking plaster, not a cure.
The year after the 2008 financial crash the NHS chief executive set out his “Nicholson Challenge”, to ensure that the NHS could adapt to the new future for public spending by finding better ways of working, as fiscal prudence returned with a vengeance
‘The behaviour of NHS leaders is that of an addict: give me one last fix, give it now, and tomorrow I will change’
after several years of extraordinary expenditure growth.
Five years later NHS leaders pledged in their “Five Year Forward View” that “the NHS will take decisive steps to break down the barriers in how care is provided”. It is clear that the barriers are still intact. It is easy to blame this on a lack of funds in local authority social services, but even within the NHS there is yet to be any significant shift of resources away from hospitals, to GPS and other services in the community and at home.
The failure of so many NHS staff to be vaccinated against flu shows how weak is the NHS’S preventative culture. Ironically, the worse a winter crisis gets, the more likely it is the NHS will receive another cash injection and the less likely culture change becomes. Indeed, the behaviour of NHS leaders is that of an addict: give me one last fix, give it now, and tomorrow I will change. The patience of other public services wears ever more thin every time this demand is made and the promised change not delivered.
A low rate of GDP growth for the foreseeable future means that the NHS must be weaned off the bust-boom funding cycle. The booms enable it to shun innovation, as it waits for the next bailout. In the mid-eighties Nick Bosanquet produced analysis for the House of Commons Health Committee that showed that the NHS required low, but consistent, funding increases. Bosanquet became known in health policy circles as “Mr Two Percent”.
But his analysis is, and has always been, true. Budget rises that are too high boost NHS costs rather than productivity; too low and the service struggles in winter.
The most sensible approach would be to put health (and social care) funding growth on a statutory basis similar to the Bank of England’s inflation target. It would then be possible to have a sensible discussion about how these funds might be raised. It would also help governments avoid the temptation to keep encouraging a recidivist addict.