While services show signs of distress, the next Parliament will pose even greater challenges. The new government will have to simultaneously stabilise performance and radically improve efficiency. Unless this happens, NHS England has warned that the government will have to find £22bn extra to spend on the NHS.
Some have claimed that the deterioration in performance is due to the coalition’s reforms to the NHS. In truth, it has arisen because of a lack of reform. Five years ago, ministers set out a brave new vision to deliver better care at lower cost. Care would be shifted out of hospitals and away from A&E. New providers would compete with the NHS to deliver the best services. The NHS would be accountable to the patient, not to politicians. These are the right kind of ideas. Indeed, many are included in the NHS’s own plan for reform published last October. They have, however, proven tough to deliver.
Since 1948, the default option has been to treat patients in hospitals. A better value health system would mean taking money away from hospitals, downgrading local A&Es, and shifting resources to other parts of the health service. Attempts to do so, however, are met with outrage. The coalition should be praised that the number of hospital beds has fallen by 5 per cent since 2010. But spending on hospitals continues to rise as a proportion of the total budget, while spending on GPs and community care has fallen or increased much more slowly. The use of alternatives to A&E, such as walk-in-centres, has stalled.
With half the budget spent on staff, a more efficient NHS will require a smaller workforce. While staff numbers fell in the first half of the Parliament, in 2013 this reversed. The NHS workforce is now the largest it has ever been, a key reason for rising hospital deficits. The reflex reaction to failings of care has been to employ more staff, but this will have to be challenged. In any public service – or business – what matters is not the number of staff but how effectively they are deployed.
The stalling of competition and choice is at odds with the need to deliver care in new ways that are more responsive to patients. The share of the NHS budget spent on private companies and charities has risen only marginally – from 8.5 per cent to 9.1 per cent. While the coalition’s reforms created the means for greater competition, in 2013-14 only 6 per cent of contracts were put out to tender. The number of patients offered choice of hospital treatment has fallen from 49 per cent to 38 per cent.
Difficult changes to the health service are inevitable in the next Parliament. Unless it wants to see deficits continue to rise and performance continue to fall, the government must build new momentum for NHS reform.