Tag Archives: Five Year Forward View

HEE budget slashed – turning NHS crisis into a catastrophe

Sunil BhanotSunil Bhanot is a GP partner in Hampshire, trainer, appraiser and member of RCGP Council.

Our NHS is about to lurch from crisis to catastrophe. Our capacity to change and cope with increasing demand is going to be undermined. Health Education England’s budget is being slashed by 30% from next month. I fear that this will have a significant impact on GP training and the transformation of the whole NHS workforce in moving towards a sustainable health care service.

It is only recently that this massive reduction in funding has been confirmed, planning has begun and it is becoming apparent that there is increasing central pressure from HM Treasury for it to be implemented by the end of the next financial year. HEE staff around the country have received emails asking them to consider voluntary redundancy and reply by 6th March.

As it is becoming common place in our NHS, professional and public consultation has again been neglected. The worst day in the lives of many leading educators has been smothered by the secrecy of contractual obligations so that they have to deny even the possibility that there may be negative implications of the cuts. It is this very lack of transparency and honesty that puts at risk patient safety, the quality of care that we are able to provide and trust in everything that we do in our NHS.

Talking to many leading educational colleagues from around the country, they are shaken to the core but are unable to share their significant concerns and have to try to exude external confidence and calm and keep smiling. This is no way to treat hard-working, dedicated and committed HEE staff who are passionate about our NHS ethos.

Educational colleagues are shaken to the core but are unable to share their significant concerns.

On its website, HEE states that it exists for one reason only, “to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours”. While the CQC talks of an NHS “burning platform” which is not fit for the future and the King’s Fund about the “credibility” of the STPs, we are about to destroy any potential for regeneration. I suggest that a 30% cut in the HEE budget will harm all our efforts to deliver the promise of progress.

The “Five Year Forward View” and the Sustainability and Transformation Plans require a workforce that has enhanced training, is flexible, efficient and effective and remains motivated to continue to learn and develop, focusing on improving the quality of patient care. This needs investment in education, training and professional development not just the articulation of hopes and aspirations followed by a kick in the teeth. There is immense pressure to increase the number of doctors, nurses and allied professionals in our NHS especially with Brexit. The challenge to develop different ways of working and retain our workforce is equally daunting. And I doubt that the Chancellor will mention the cuts in next week’s Budget statement.

I am asking for an open and honest conversation, decent engagement with the profession and the public, on the challenges and opportunities to transform our NHS with our limited resources for learning and teaching. I’m asking the RCGP, other Royal Colleges, GPC and the BMA to share our concerns with HEE, our Health Secretary, HM Treasury and the Prime Minister. We need to work with Simon Stevens, Chief Executive of NHS England to explore an alternative way forward.

I am not looking for sympathy and warm words, but I am asking for a pause and some time to consider the truthful and real implications. And, therefore, please RCGP and BMA, publish and share the responses that you get.

Acute primary care in an integrated NHS

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

The tsunami of chronic disease management – the ageing population, rocketing rates of non-communicable diseases, and increasing complexity – have dominated much of the debate about the future of general practice and of the NHS. The crucial function of general practitioners in making accurate, timely diagnoses in patients presenting with acute symptoms is easily overlooked, yet is at the very core of primary care. The implications of this for mending the fractures in the system and for the design of integrated models of care came home to me in the course of three conferences over the last couple of weeks.

The first was a European meeting on screening for colorectal cancer, held in the Czech Republic, involving European Commission and Parliament policy-makers, as well as clinicians and epidemiologists. The focus was on increasing the momentum in member states of the EU to develop and extend screening programmes for colon cancer, which is an enormous health problem in Europe. However, the flip side of this debate is the fact that the huge majority of bowel cancers are diagnosed outside screening programs, either in patients presenting in general practice with suspicious symptoms or, in a substantial minority, in emergency hospital admissions for the complications of advanced disease.

The next was a conference summarising the achievements of the Discovery programme, a large, NIHR and charity funded research programme of research aimed at collecting evidence to support early cancer diagnosis in general practice (http://discovery-programme.org). One of many important messages for primary care was the need to be prepared to investigate patients with potential cancer symptoms much more promptly than we do at present, and the consequent requirement for better investigative services that can be readily accessed by general practitioners. Discovery investigators presented new data to show that many of the “typical” symptoms associated with cancer presentations are, in fact, much less common than more general,  often vague, complaints, such as fatigue and “feeling different”. They have also demonstrated that patients presented with vignettes of possible cancer scenarios are much more willing to undergo investigations at an earlier stage than previously recognised.

The third meeting was the Annual Conference of the South London Faculty of the RCGP which took as this year’s theme “Early diagnosis in general practice”. I presented some recently-published data, including the important recent BMJ Open paper from Peter Rose and a number of European colleagues which shows that GPs in England, Wales and Northern Ireland are much less likely to request investigations for potentially worrying symptoms then their general practice colleagues in most of the eight other European countries taking part in the study. Given the relatively poor cancer outcomes in the UK (and, for some reason, in Denmark), this is an important finding, adding weight to the need for speed and accuracy in investigations for suspected cancer.

Taken together, these studies and observations are powerful ammunition for the commissioning of better access to investigations, and for careful review of two-week wait criteria. They do, I think, mean more than this, and have major implications for the kind of integration between primary and secondary care that should develop within the NHS in the near to medium term future. In his Five Year Forward View, Simon Stevens, the NHS Chief Executive, describes two possible models of integration – the so-called Multi-speciality Community Provider (MCP) model and the Primary and Acute Care Systems (PACS) model. The first of these is a more horizontal integrative approach to community-based services, including of course general practice, whilst in the PACS model there is scope for a single provider organisation to deliver both primary and secondary care services, with no pre-defined requirement for this to be general practice-led or hospital-led.

The RCGP has, understandably, focused on developing the MCP model, which is probably more likely to keep general practice in the “driving seat”, and meets the five College criteria for an acceptable approach to integration. However, it seems to me that much might be gained by looking more positively at the PACS model, within which investigative pathways for patients with potentially serious conditions – and this of course doesn’t just apply to cancer, but to a host of potentially serious clinical problems – could be developed jointly between generalists and specialists. This approach could, I believe, lead to the creation of much less delay and misunderstanding by removing many of the barriers to speedy diagnosis and swift intervention that presently exist at the primary: secondary care interface. It would be simplistic to suggest that the MCP model is better suited to chronic disease management and the PACS to acute presentations and treatment, but that may not be far from the truth.

It is also possible to see other potential advantages of the PACS system, in locations where it would provide the most clinical benefit. A single employing organisation could provide economies of scale that the small-business model of general practice simply cannot achieve. Making use of joint infrastructures, including finance, HR, and procurement is likely to have significant cost benefits. Beyond this, the possibility that primary care specialists might be employed under similar contractual arrangements to hospital specialists, with benefits for continuing professional development,  career structure and work force planning, and with potential positive spin-offs for recruitment and retention, should not be underestimated or discounted.

When Simon Stevens spoke on the BBC’s, Andrew Marr show recently, he was candid in saying that general practice has suffered from 10 years of under-investment. The RCGP has done a terrific job in making this argument and articulating a strong case for substantially increased investment in the infrastructure and in the general practice workforce. Whilst the burden of an elderly, co-morbid and increasingly dependent population is undoubtedly making general practice creak at the seams, it will be important in the future – in the very near future, given the shortage of doctors wishing to become general practitioners – to look at how other professions can support the central role of GPs in delivering primary medical care. It will also be crucial for general practice to forge alliances with other parts of the health service and, when this is in the best interests of patient care, to collaborate, as well as lead, in new systems of integrated care likely to provide the best clinical outcomes.

The elephant in the room: how are we going to fund the NHS?

BJGP JonesProfessor Roger Jones is editor of the British Journal of General Practice.

Last weekend The Times published a leading article which described the financial straitjacket in which the NHS finds itself, and suggested that the additional funding required to keep the service going should be found from sources outside general taxation. I wrote a letter supporting this view, pointing out that other healthcare systems, with perfectly respectable health outcomes, some better than ours, work on a combination or some variation of co-payment and insurance mechanisms. none of which, importantly, equate to privatisation.

I described this discussion as an elephant in the room – something that no one really wants to talk about and certainly won’t talk about in the run-up to the general election. I concluded by saying that I hoped the next government has the courage and gumption to bring into the open a discussion that everyone knows needs to take place, and which must take place if we are to preserve a national health service.

Extra money is going to be needed because the NHS is going to become increasingly expensive and there is going to be ever greater competition for money among government departments. A few years ago John Appleby, the chief economist at the Kings Fund, described three funding scenarios for the NHS – tepid, cold and arctic – and these three funding futures are reflected in Simon Stevens’ Five Year Forward View. Note that none of them are “comfortable” or “balmy”. It doesn’t require much detective work to read between some of the lines of this document to discern a lack of absolute certainty of the affordability of a publicly funded health system in the future. New models of integrated care may or may not turn out to be more cost-effective, but the NHS does not have a strong record on cost containment.

In my response to the Times leader I used the phrase “Those more able to pay for healthcare simply pay more”, and I don’t think that this is a bad mantra for the future of health funding in this country. It is consistent with social justice and I understand that there is some opinion poll evidence that it would not be an unpopular direction of travel for more affluent citizens. I think we have to tread carefully around the “free at the point of need” slogan – the NHS was never free – and we certainly would not wish to introduce a system in which health care providers need to see the colour of your money before treating you. It has been often said that the decency of a society can be judged by the way that it treats its most vulnerable and needy citizens. Requiring that the more fortunate members of our society make a greater contribution to the costs of health care could help to ensure that their less fortunate fellows continue to receive the care that they need.