Jim Callaghan may not have actually said “Crisis? What crisis?” in 1979, but the then prime minister’s words have gone down in history as the clearest example of a politician not in touch with the severity of the issues facing the country. Last week has seen a similar debate about the state of our accident and emergency services.
Seen from the position of chair of King’s College Hospital, there is no question that the pressures are real and serious. Constant and relentless effort is required to keep essential services running. That we have managed to do so is down to the extraordinary efforts of senior and frontline staff. Even with this, the picture is one of enormous fragility, not just at my trust but across the whole of the NHS.
The story at King’s is reflected in the grim national figures on A&E waiting times, trolley waits and “black alerts” released last week. Of course, the picture varies from area to area. But the underlying story is of a service under more pressure than it has been for a decade.
It is hard to think of anything that matters more to people than the health and wellbeing of themselves and their family. Given this, can we really be happy with our health and care services staggering from year to year, wondering whether they will manage to make it safely through the winter?
The reasons for our current predicament are well understood. This is a “crisis” that was not only predictable but was predicted. The hard bit here is not knowing what to do, but having the will to do it.
First and foremost of the issues we need to tackle is funding. The NHS is not a “bottomless pit” as some have suggested, but increasing demand and continuing advances in healthcare mean that it needs additional funding year on year of around 4% above inflation. Whenever it has not had this for any sustained period of time, it has run into trouble.
The funding problems of social care are, if anything, more severe. Half of local government funding goes on adult and children’s care. Local authorities have done remarkably well in delivering spending reductions while preserving services in recent years, but it is inevitable that they will have to take money out of their care budgets in order to balance their overall budgets. In the end we all want clean streets and good leisure services as well.
It is very hard to improve your swimming technique if you are struggling to keep your head above water
There is, of course, scope to improve the way services are delivered. As the work of Lord Carter has shown, some hospitals are more efficient than others. We know at King’s that there is room for improvement. But sustained progress will only come if we can stabilise the financial position. It is very hard to improve your swimming technique if you are struggling to keep your head above water.
Additional funding now, together with a concerted move to eliminate the deficits that NHS trusts are currently carrying, is essential. This would stop the incessant tug of war that currently goes on between different parts of the NHS as they desperately try to balance their own part of the system. The energy and focus could then go on delivering real improvements in productivity and more consistent service quality.
Last week was dominated by a debate between the prime minister and NHS England chief Simon Stevens over whether the NHS has in fact been given more money than it actually asked for. In reality, the funding agreed in the Five Year Forward View was the art of the politically possible at a time when big reductions were being agreed in other government departments.
It assumed efficiency savings of £22bn – higher than has ever been achieved by the NHS or indeed any other major health economy – and significantly underestimated the scale of the structural deficits that already existed in hospital trusts. Crucially, it was reliant on sustained funding of social care.
Stevens was both right and courageous to set out the true picture as he saw it, even if it has been at some cost to his personal relationship with No 10. This is his job. It is clear to anyone who works in the NHS that we cannot carry on as we are. He has a duty to say so. The prime minister had to make some tough decisions to deliver savings when she was home secretary. So did Philip Hammond when he was at defence. It is, perhaps, not surprising that they believe standing firm now on NHS funding is the right approach. In my view this would be a profound mistake. The NHS is different, and needs to be recognised as such.
The debate on funding is not just a matter for the government or the NHS. As a country we need to make some hard choices. We can help ourselves by being fitter and more active, but in the end – if we want the security of having the best health and care services available to us – we will have to pay for them. A cross-party health and care commission could begin that debate with the public.
Beyond funding, we need to put back together a service that has been chronically fragmented by the reorganisations of successive governments. This does not need, God forbid, to be another top-down reorganisation, but a concerted move to allow health and care organisations to come together at local level. Combining hospitals, GPs and community services and moving away from the current artificial division between purchasers and providers would improve care and reduce costs. In some places this change has already started. It needs much more support.
A proper investment plan is needed in the buildings and equipment of the NHS. The private finance initiative brought substantial new investment, albeit at a very high cost. This has now gone, but nothing has been put forward to replace it. Much of the NHS estate urgently needs investment, and many of the buildings built under PFI will soon need refurbishing.
As well as investing in the infrastructure of the NHS, we also need to invest in the people who work for it. In all the different parts of the public sector that I have worked in, I have never come across people with such talent and dedication. People are passionate about what they do. And yet we have contrived to create a situation in crucial areas, such as nursing, where we struggle to recruit and retain the trained staff that we need.
These are the basic building blocks of an NHS recovery plan. There is no doubt much more that could and should be done, but without these essential steps we are unlikely to succeed.
The NHS has a lot that it can justly be proud about. At King’s, we achieve consistently good health outcomes and have seen major advances in areas such as trauma, haematology and neurosciences. We are confident that over time we can become both m ore efficient and deliver better services.
But like all other parts of the NHS we are now at a crossroads. Without a new approach, these advances will be put at risk. The hardest thing for governments to do is to listen and act on inconvenient advice. It is also the most important.
Sir Bob Kerslake is the chair of King’s College Hospital NHS foundation trust
It is clear to anyone in the NHS that we cannot carry on as we are | Bob Kerslake
