6 November 2015
Nigel Edwards, Chief Executive, Nuffield Trust

Nigel Edwards

Chief Executive
Nuffield Trust
Richard Taunt, Director of Policy, The Health Foundation

Richard Taunt

Director of Policy
The Health Foundation

Just over a year ago the Five Year Forward View (NHS England and others, 2014) set out how the NHS must adapt over the remainder of the decade to meet future need. At its heart was a welcome recognition that, in the long term, ‘business as usual’ for the NHS would not provide patients with the comprehensive and high-quality service they expect.

It is increasingly clear that the health service is in financial trouble, with almost four in five trusts ending the first quarter of this financial year in deficit.

One year on and the NHS is still under intense pressure. Despite pledges of extra money, it is increasingly clear that the health service is in financial trouble, with almost four in five trusts ending the first quarter of this financial year in deficit. And despite the important focus on the need to monitor and improve care quality, a recent Care Quality Commission (CQC) report stated that patient safety remained their biggest concern across all health and care services (Care Quality Commission, 2015a).

In the midst of all this doom and gloom it can be difficult to assess how the NHS really is doing in providing patients with high-quality care. Our QualityWatch programme aims to help policy-makers and healthcare leaders make sense of quality across health and social care. Drawing on analysis of over 300 indicators of care quality – from waiting times to staffing levels – and several in-depth studies, we track how health and social care are performing at a time of huge challenge.

Each year we synthesise our analysis into an annual statement on care quality. In 2013 we highlighted some areas of concern, such as urgent care, but our verdict was that high-quality care was being sustained overall. Last year our assessment was less positive: while we acknowledged that things were still better than a decade ago, we pointed to several areas where historical gains in quality were starting to go into reverse, from waiting times for planned treatment, to access to mental health services.

This year, our annual statement focuses on three areas we consider to be critical to a high-performing health system: how easily patients can access care; how engaged and motivated the workforce is; and how well we look after the health of children and young people.

It is clear that there are still many areas of excellent care – from the UK’s high vaccination and screening rates, to reductions in unplanned admissions for children in England. 

Taken in combination with the past year of QualityWatch analysis, it is clear that there are still many areas of excellent care – from the UK’s high vaccination and screening rates, to reductions in unplanned admissions for children in England. Given the pressures it faces, the ability of the NHS to maintain and improve quality in such areas is to be celebrated, and is a testament to the efforts of staff across the country.

But this year there are clear signals that in some important areas quality is declining. The NHS has been unable to reverse the trends of deteriorating access to hospital, mental health and social care services, and has simultaneously suffered from growing staff disengagement and vacancy rates. On some key waiting times, for example, performance has deteriorated to the levels that were being achieved in the late 2000s.

Beyond these ‘known knowns’, QualityWatch also highlights our ‘known unknowns’ about the state of quality. Put simply, we lack the answers to many of the questions most fundamental to understanding the impact of financial austerity on quality. We do not know the impact on the health and wellbeing of individuals as a result of 400,000 fewer people receiving publicly funded social care. We know exceptionally little about patient safety in primary care, the point at which most people interact with the health service. We have virtually no data about the quality of services for children and adolescents with mental health problems. These data gaps are concerning – as is the lack of a plan in addressing them.

We know exceptionally little about patient safety in primary care, the point at which most people interact with the health service. 

Given the areas of concern we highlight in this report, and the wider political and economic context in which the health service operates, a key question arises: what do we expect to happen next?

The Five Year Forward View proposes solutions to many of the challenges facing the NHS – from making clear the need for further funding, to outlining the ways in which NHS services need to adapt for the future. But in most cases these will not address the immediate challenges facing the NHS. The conditions for addressing the current financial challenge, maintaining quality and improving services do not appear to be in place. People working in the NHS want to deliver high-quality care, but they are increasingly battling against the odds to do so.

There needs to be greater realism about the level of quality the NHS can provide within the resources available to it. Currently policy for the NHS is focusing on additions to what the NHS can offer, for example seven-day working, or NHS England’s strategy on cancer treatment. However, the NHS is struggling to preserve the quality of some existing services – let alone new ones. In the light of increasing demand for healthcare, policy-makers must focus on how to maintain and improve quality of care across all services and care settings, not just on new announcements. There is not yet a convincing plan for how the NHS will achieve the extremely challenging efficiency savings of at least £22 billion needed to prevent the £30 billion projected funding gap by 2020. With waiting times and staffing issues so closely linked to funding, it is likely that care quality will continue to decline in relation to these two areas. And on top of the tight and worsening financial position of the NHS, there will be further financial pressures as social care, staff training, public health and other related non-ringfenced budgets are subjected to further cuts.

The problem with complex systems under high levels of stress is that they can suffer sudden and catastrophic collapse – often without a lot of warning. 

Furthermore, overall management of the NHS as a system seems to be in some disarray. Many within government believe that the NHS simply needs to become more efficient in order to save money. Since staff costs account for the biggest chunk of the NHS budget, the concerning result of a significant tightening of spending is likely to be fewer staff. Meanwhile contradictory guidance from regulators on staffing levels and the requirement to balance the books is creating confusion for those within the NHS. This may be one of the reasons why the health service is losing top leaders – just at the point when their contribution is most vital.

Given these multiple areas of concern, one would expect there to be a stronger sense of urgency from those in charge – whether that is the secretary of state, the heads of various regulatory bodies, or those responsible for managing and commissioning services. Greater clarity from regulators and ministers over their approach to dealing with the problem of diminishing finances is urgently needed. Likewise, a more coherent approach to managing low morale in the workforce – an issue highlighted starkly in this report – might begin to alleviate concerns internally within the health service.

The warning lights on care quality that we observed last year now glow even more brightly. So far we have seen a gradual decline in some elements of quality. The problem with complex systems under high levels of stress is that they can suffer sudden and catastrophic collapse – often without a lot of warning. There have been examples of this in the past – for example at Stafford Hospital.

It is very difficult to predict whether crises in the quality or availability of services are likely to become more common – or even routine – or whether the gradual decline we are tracking through QualityWatch will continue. One thing that is clear is that patients cannot expect the speed at which they access care to improve anytime soon.

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