Following a winter of media headlines that portrayed the NHS and social care as buckling under the strain of rising demand and difficulties in accessing services and support; last week’s Budget ended the speculation on how much additional funding would be available. While the inclusion of some immediate interventions aimed at lifting the NHS and social care out of their current predicament was welcomed, as the dust settles concerns are emerging from many quarters that the budget doesn’t go far or wide enough. This week’s blog explores the main budget proposals and what this means for social care and the NHS.
Key proposals for social care
The Chancellor’s March budget included three specific proposals for social care and the NHS. Chief among these was the promise of an additional £2 billion for councils across England to spend on adult social care over the next three years, half of which to be made available in 2017-18.1 While this is a welcome injection of much needed funds, the £1 billion in 2017-18 is only half of what expert commentators have said is needed. Indeed, the health service’s own figures suggest that social care needs a minimum of £2 billion next year, as the National Living Wage alone adds around £900m to the cost of social care in 2017-18.2 It also comes close to the amount that has been removed from councils’ adult social care funding over the past five years, resulting in some 25 per cent of vulnerable people previously eligible for social service support, no longer receiving support.3
In his announcement the Chancellor stated that councils will need to work with their local NHS to determine how best to use the funding to reduce delayed transfers of care. He calls on councils to make sure that best practice frameworks are implemented more consistently across the country. Considering that the £5.3 billion Better Care Fund has so far failed to address the problem of increased hospital activity and delayed discharges;4 it remains difficult to see, how these laudable requirements can be fulfilled.
The Chancellor, in anticipation of the above concerns, promised a green paper on options for the future funding of adult social care. However, there have already been at least four independent reviews of social care funding over the last 20 years, none of which have led to sustainable or even actionable solutions. Importantly, just under three years ago there was much excitement and support for the proposals in the Barker review.5 This recommended a new settlement for health and social care and a single budget to put both on a sustainable footing for the future, requiring reforms to existing benefits paid to older people, an increases in national insurance and changes to taxation.6 It is hard to imagine what alternative proposals a new green paper will come up with.
Key proposals for the NHS
The Chancellor announced an additional £100 million of capital investment for Accident and Emergency (A&E) departments across England, to help them create the physical capacity and invest in measures to manage demand and the triaging of patients to the most appropriate areas of care. The headline grabbing announcement was the suggestion to have more on-site GP facilities to treat less-sick patients. However, putting more GPs in A&E while helping to triage less sick patients more quickly is unlikely to reduce admissions and may instead attract more patients to hospitals.7 Furthermore, as our recent report Primary Care: today and tomorrow pointed out, there is a crisis in general practice with an insufficient number of GPs to meet the demands for care in the community; so where these GPs will come from is unclear.8 Moreover, given a key ambition of the Five Year Forward View (FYFV) is for more care closer to home, is this proposal an indication that a key plank of the FYFV has been abandoned? Perhaps this funding could have had more impact if it had been used to support the transformation of primary care?
These question do not in any way under-play the crisis that we are seeing in our hospitals, so clearly demonstrated by the King’s Fund’s latest quarterly monitoring report of NHS performance. Its survey of NHS finance directors, found that 80 per cent of those who responded, identified higher numbers of patients with severe illnesses and complex health needs as a key reason for the unprecedented pressures facing our A&E units. Moreover, while 70 per cent cited delays in discharging patients from hospital, only 27 per cent pointed to poor access to GPs as a key factor.9
Given the above, it is hard to ignore the fact that the money could be better spent by investing in primary care systems and processes. For me, adopting some of the solutions evidenced in Part 3 and 4 of our Primary Care: today and tomorrow report could significantly reduce unnecessary A&E attendances, particularly by investing in services supported by digital health technology. For example:
- deploying technology to optimise access (e.g. on-line consultations and electronic prescriptions) and enable clinicians to stratify patients’ needs and deal with them quickly, safely and effectively; including directing them to the most appropriate expertise, when and where needed
- providing GPs with Point of Care testing so they can diagnose more accurately and quickly. The technology is available but its use in UK primary care settings is very low investing in technology to monitor and engage patients and their carers in supported self-management
- adopting telehealth, which could improve the management of people with chronic long –term conditions and reduce the need for hospital admissions; see for yourselves the evidence from the Airedale and Partners Enhanced Health in Care Homes Vanguard.10,11
Finally, the Budget also committed £325 million over the next three years to support local proposals for NHS capital investment. Again, a much needed injection, especially if the Vanguards programme and Sustainability and Transformation Plans are to have a chance of succeeding. However, this year alone capital budgets were reduced by £1.2 billion to plug the gap in acute trusts’ running costs.12
There is increasing evidence that a wholesale transformation of health and social care delivery is urgently needed. For the NHS, the social care system and the thousands who rely on both services every day, there is currently a significant mismatch in the levels of investment identified and the 2017 Budget proposals. Unless new ways of working are adopted, especially in the deployment of technology and in engaging and supporting patients; it is hard to see how this mismatch can ever be addressed.
11 https://www.nuffieldtrust.org.uk/news-item/lessons-from-a-vanguard-one-year-in; and https://www.kingsfund.org.uk/sites/files/kf/media/Bridget%20Fletcher%20pres.pdf