4The Spending Review and Government aspirations for the future of the NHS and social care
87.The previous chapter set out some of the difficulties facing the NHS in achieving the savings it needs to make during the Spending Review period. This chapter considers a number of major initiatives and key policy changes which will have a significant impact on the financial position of the NHS and social care, both in the next few years and in the longer term.
88.Some of these initiatives were set out in the Five Year Forward View, where NHS England said that “there is now quite broad consensus on what a better future should be” for the Service. In particular, the Five Year Forward View listed a number of specific ways in which demand for expensive hospital services could be reduced, while at the same time improving services to patients. Among the initiatives mentioned in the Five Year Forward View are these:
- A “radical upgrade” in prevention and public health
- Patients to be given greater control of their own care, including the option of shared budgets combining health and social care.
- “Decisive steps” to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, and between health and social care. In some areas this integration would be associated with full devolution of the management of health and social services.
89.The Five Year Forward View makes clear the importance of these initiatives for the future of the NHS. The document “makes the case for a more activist prevention and public health agenda: greater support for patients, carers and community organisations; and new models of primary and out-of-hospital care”, continuing “While the positive effects of these [measures] will take some years to show themselves in moderating the rising demands on hospitals, over the medium term the results could be substantial.” However, the Five Year Forward View cautions that the “net impact” of these measures will “also partly depend on the availability of social care services over the next five years.”116
90.This chapter asks whether, in view of the financial situation, these and other aspirations for the NHS and social care in England appear to be realistic.
Funding for public health
91.The Five Year Forward View emphasised the importance of major improvements in prevention and public health, stating that “The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”117
92.The document also made clear that NHS England sees prevention as key to financial stability as well as better health: “Twelve years ago Derek Wanless’s health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded—and the NHS is on the hook for the consequences.”118
93.The Government told us that it “remains fully committed to improving the health of the people of England … Local authorities will receive over £16 billion to spend on public health over the next five years. This is in addition to what the NHS will continue to spend on vaccinations, screening and other preventative interventions—including the world’s first national diabetes prevention programme.”119 However, despite the warnings of the Five Year Forward View, spending on the public health grant to local authorities in England fell in 2015–16 with an in-year cut of £200 million. It is due to be cut further over the next five years, with the cuts being “significantly front-loaded”, according to the Health Foundation. Real terms reductions in the first four years from 2015-16 (-3.8%, -4.2%, -4.4%, - 4.6%) are followed by a lower reduction in 2020–21 of -2.2%. The Health Foundation calculates that this amounts to a real terms reduction from £3.47bn in 2015–16 to just over £3bn in 2020–21.120
94.Public Health England recalled that 2013 reforms to the public health system “recognised these wider drivers of good health and wellbeing” with the statutory duty to improve the health of the population being given to upper tier local authorities—the metropolitan and non-metropolitan authorities and the Greater London A ring-fenced grant is provided by the Secretary of State for Health to those authorities. Directors of Public Health and their teams transferred from primary care trusts to local government. The transition was completed in October 2015 with the transfer of responsibility for public health services for children aged under 5 to local authorities. The NHS continues to play a role in public health, including in commissioning and delivering immunisation and screening programmes.121
95.The three health think tanks have not identified any cuts to the 2016–17 budget for public health services within NHS England’s remit, such as immunisation and screening programmes. However, they say, “complex changes to what this budget covers—such as the transfer of child public health duties to local government—make it difficult to be exact about the net effect.”122
96.In an interview in October 2015, Mr Stevens of NHS England set out five “tests” of whether the spending review settlement would meet the needs of the NHS; one was action in relation to public health.123 That test echoed a comment made in oral evidence to us in July 2015. Referring to the in-year cut of £200m in the public health grant to local authorities which was effected in 2015–16, Mr Stevens suggested that further reductions in funding for public health “would not be a smart approach”.124 Giving evidence to this inquiry in May 2016, Mr Stevens was asked whether his view of reductions in public health spending had changed since July 2015. His understated reply—“Overall, it is not helpful”—speaks volumes.125
97.Public Health England accepted that “No reduction in the public health grant is ever welcome” but, they say, the Spending Review “did not fundamentally derail the system.”126 When asked in oral evidence whether the planned spending would be enough to fund the aims within the Five Year Forward View, Michael Brodie, Finance and Commercial Director of Public Health England, responded “There is enough within the system.”127
98.Many of our witnesses took a less sanguine view of the financial situation in public health. The three health think tanks noted that the reduction in public health spending will affect a wide range of services including health visiting, sexual health and vaccinations, and argued that it “will have a significant knock-on effect on the NHS. This is a false economy, undermining the government’s commitments on prevention and the NHS Five Year Forward View”.128 NHS Clinical Commissioners made similar points.129
99.Sarah Pickup of the LGA called the situation with public health “local government’s worst fears realised … A service is transferred and then it is reduced.”130 The LGA told the Committee in written evidence that “Local authorities were eager to take on public health duties in 2013 but many now feel they have been handed all of the responsibility without the necessary resources to do the job.”131 Local authorities such as Cheshire West and Chester Council and Essex County Council expressed similar views, with the latter forced to impose “considerable cuts” in public health—£3.7m in 2015–16 and a further £2m in 2016–17.132
100.Some clinical organisations criticised the level of and reductions in public health spending.133 A range of charities also opposed the spending plans.134 The National Voices group of charities were concerned that cuts to local public health services “often in effect means a cut to what the public would consider ‘front-line’ NHS services—HIV and Aids support in sexual health clinics, and smoking cessation services, for example. This puts people’s health at direct risk.”135
101.Supplementary evidence sent to us by NHS England reinforces the point, quoting NHS England’s public Board assessment of the Spending Review settlement:
[…] the Forward View called for a radical upgrade in prevention, and support for wider public health measures. Given the funding pressures in the local authority financed public health services and the need for wider government action on obesity and related challenges, we cannot yet conclude that this test has been met. Much hinges on whether the Government’s proposed childhood obesity strategy [which has yet to be published] comprises an effective package of credible actions […] Absent this, and other linked action, the NHS will be exposed to patient demand and consequent funding pressures over and above that modelled in the Five Year Forward View assumptions.136
102.Cuts to public health budgets threaten to undermine key parts of the vision set out in the Five Year Forward View, which are predicated on, among other things, a “radical upgrade in prevention and public health”. Failing to promote prevention with sufficient vigour will mean increasing operational and financial pressure on the NHS. The overwhelming view amongst our witnesses is that the public health cuts will turn out to have been a false economy.
103.Given that even greater responsibility for public health has been transferred to local authorities, monitoring what is spent, how it is spent, and what it has achieved is of great importance. The Government needs to analyse and closely monitor the effects of the public health cuts on the aspirations set out in the Five Year Forward View. The Government should set out clearly, with measurable objectives and milestones, what it expects public health spending to achieve over the next five years, in terms of improved health and savings in NHS expenditure. We will return to this issue in future consideration of the financial situation in health and social care.
104.By the time this report is published, a new Prime Minister will have taken office. We are concerned about the future of the childhood obesity strategy. We call on the Government under Theresa May as Prime Minister to publish and implement the strategy at the earliest possible opportunity, and on the Chancellor of the Exchequer to implement the existing plans for a levy on the manufacturers of sugary soft drinks.
Transformation, integration and devolution
105.The Five Year Forward View and the Spending Review placed great emphasis on service integration, including “new models” combining primary and secondary care and health and social care. In some areas, there is not simply integration but also devolution of entire categories of public spending, including spending on health.
106.In Spending Round 2013 the Government announced the Better Care Fund (BCF), which in 2015–16 mandated local authorities and the NHS to establish pooled budgets in every area in England, totalling £3.8 billion nationally. The Department of Health told us that “Local leaders and clinical experts have put together plans setting out how these local pooled budgets will be used to commission more person-centred, co-ordinated services for local people, and these plans have been signed off by health and wellbeing boards.”137
107.The Spending Review 2015 included an obligation on every part of the country to have a plan for longer term integration in place by 2017, to be implemented by 2020. The Spending Review said that “Areas will be able to graduate from the existing BCF programme management once they can demonstrate that they have moved beyond its requirements, meeting the Government’s key criteria for devolution”.138 We understand that further details of the policy are being worked out and will be announced in due course. There are 50 “vanguard” projects across England, taking the lead on the development of new care models.
108.As noted above, NHS England is also placing £2.1 billion in 2016–17 into a Sustainability and Transformation Fund, rising to £3.4 billion (in cash terms) in 2020–21. The transformation element of the fund is intended to support “the ongoing development of new models of care along with the investment identified to begin implementation of policy commitments in areas such as seven-day services, GP access, cancer, mental health and prevention.”139 However, these plans have been delayed because of the deficit position of the hospital sector. In 2016–17, £1.8 billion forms the sustainability element of the fund, the purpose of which is to support NHS Improvement to bring the provider trust sector back to financial balance in-year.
109.NHS England intends that over the five-year period the split between sustainability and transformation requirements for local health economies will change. The Department told us: “As the provider sector comes back into underlying balance under NHS Improvement’s supervision, the share of the funding available for transformation and new policy commitments will increase in subsequent years.”140
110.The purpose of front loading the financial settlement over the spending review period had been to allow the funding of the transformation of service. This is fundamental to delivering the efficiency savings necessary to close the financial gap set out in the Five Year Forward View. So much has now been diverted to plugging provider deficits that we are deeply concerned about the funding available for service transformation.
111.There was a welcome from a number of witnesses for the policy of integration and transformation. The Turning Point social enterprise, for example, acknowledged that “Although cuts can be detrimental, they also (to a degree) provide an opportunity for providers to do things differently, to develop new partnerships, to integrate provision in different areas where needs overlap, and deliver digital solutions.”141
112.The most ambitious and comprehensive plan for integration is that being implemented in Greater Manchester. This is the Greater Manchester Combined Authority, responsible for the programme which is popularly known as ‘Devo Manc’, under which the councils and NHS in Greater Manchester have taken control of the region’s £6 billion health and social care budget, as well as other public spending. This is being delivered in ten ‘localities’–parts of Greater Manchester which will have their own approach within an overall framework. We took evidence in Salford from two people closely concerned with the devolution of health and other public services in Greater Manchester.
113.Sir Howard Bernstein, Head of the Greater Manchester Combined Authority Paid Service, summarised the key framework for devolution that is embodied in that health and social care plan, which describes a “collective set of priorities”, including driving “radical changes in improvements in population health … not just around the public health programme, but a wider public sector reform, a behavioural change programme for Greater Manchester.” Another priority is transforming community-based care, “with a real focus on how we shift the demand away from acute hospitals into community settings.” Thirdly, there is the standardisation of acute care itself and “how we move increasingly to more collaborative service models around particular localities … we are working towards an integrated hospital service.” There is also an aim of standardising clinical support and back office services.142
114.Most other areas of England, except those with highly developed vanguard schemes, are not as far advanced towards integration as Greater Manchester, although good progress was being made. In Somerset, we heard, planning is going ahead for a programme called Somerset Together, a key component of which is to introduce outcome-based contracts from April 2017 across as many services as possible, including health. The intention is to pay for services on a per capita basis or per head of population rather than an activity-basis, making the service focused better on the user rather than the organisation.143 Other parts of the country have less well-developed plans.
115.We heard evidence on one issue which appeared to have the potential to slow progress towards integration. The original intention in Somerset was to set up joint commissioning across health and social care. David Slack of Somerset CCG explained that this was not thought to be possible, because the CCG wished to be able to award contracts to bodies that qualified as Most Capable Providers, while Somerset County Council, responsible for social care, believed that it had to follow stricter procurement rules which precluded such considerations.144 There have been a number of recent changes to these regulations. NHS Improvement told us that there was nothing in the regulations to prevent joint commissioning as “both CCGs and local authorities have freedom to design appropriate processes that meet their commissioning objectives as long as they meet the minimum standards for transparency and equal treatment required by the rules.”145
116.We expect the Government to clarify the situation for CCGs wanting to adopt integrated commissioning with local authorities including through “most capable provider” approaches. During the passage of the Health and Social Care Act, the then Secretary of State assured our predecessor committee that integration would trump competition where that was in the best interests of patients. All those working towards the goal of providing an integrated service need clarity about the legal avenues open to them in order to do so.146
117.The current financial problems of the NHS, in particular trust deficits, have provided a difficult backdrop for the efforts at transformation and integration. Many witnesses expressed concern at what they saw as the diversion of the Sustainability and Transformation Fund to correct deficits rather than to support transformation. Chris Hopson of NHS Providers suggested that there might not be a provider surplus in 2016–17, which would mean that “you will probably need to take another chunk out of the 2017–18 sustainability and transformation fund to get providers back into surplus. You then have the worrying-looking 2018–19 and 2019–20 settlement”. Mr Hopson believed that in these circumstances “you could not afford to spend the money on sustainability and transformation in those years because you would need to keep the day-to-day ship upright”.147
118.Several witnesses agreed that the problems caused by deficits hampered the early investment that was important if integration and other transformation projects were to be successful. UNISON said that it had often pointed to the need “to provide upfront investment when moving to new models of care to allow for items such as double-running costs or staff redeployment and retraining when establishing new systems.”148 Similar points were made by the County Councils Network and also by NHS Clinical Commissioners, who told us: “The current CCG annual spending round [militates] against investment in services that will transform the NHS and make savings in the longer term … In order to support transformation there needs to be a shift away from annual budget rounds towards a more mature funding cycle that will allow CCGs to plan with certainty and clarity.”149 Similar points were made by Anita Charlesworth of the Health Foundation.150
119.It was also clear to several of those close to the process of integration that, if savings were to be realised, they would take some time to emerge. It seemed unlikely that there would be substantial savings within the Spending Review period. When we asked David Slack from Somerset CCG about the prospects of savings from the integration projects in his county, he was cautious, saying that “I think the savings will take a significant period of time”.151 We had a similar answer from Sir Howard Bernstein of the Greater Manchester Combined Authority, who told us “The key is that over the next five years, we have to get pretty close to delivering financial sustainability.”152 Whether this meant that in fact devolution in Greater Manchester would contribute to the savings targets set out in the Spending Review is not clear.
120.There is evidence that there might be net costs rather than net savings from integration. Professor Nick Mays of the London School of Hygiene and Tropical Medicine said that “if anything … the most consistent finding of better co-ordinated care is that it uncovers unmet need and raises costs.” 153 The Health Secretary said that he did believe there were savings to be produced by integration, although “We are not putting a cash amount to it except for the fact that, across all our plans, we recognise that we will only make the numbers add up if we reduce demand for services by getting care to people earlier.”154
121.The programme of work being undertaken in Greater Manchester to integrate health, social care and other public services is highly impressive in scope and aspiration. ‘Devo Manc’ is the product of a long period of growing co-operation between the NHS, local authorities and others and appears to be have been well-prepared and widely supported. There is confidence among those running the devolution programme that it will be financially sustainable by 2020–21.
122.Chris Hopson of NHS Providers warned against talking about transformation as purely “a money issue”. He said it was also “a capacity and a timing issue. Our members are currently being asked to keep a very unstable operational day-to-day ship upright, being asked to find their pretty stretching share of £22 billion-worth of savings and, at the same time, being asked to move to new care models, which, to be frank, in most other advanced western health economies have taken 10 or 15 years to deliver.”155
123.The Royal Society for Public Health agreed that the key to success of health and social care integration “may not be a financial issue”. They stressed the importance of strong relationships built on trust between those who lead local bodies, something that would take time to build.156 Such long-term relationships were seen as vital to the development of the Greater Manchester devolution model.157
124.Doubt was also expressed about the capacity of the national body NHS Improvement to promote transformation; that body was described by Anita Charlesworth of the Health Foundation as “very distant” from local decision-makers, when it was important to understand the right solution for different areas will need to be “tailored”.158
125.Several witnesses pressed for regular and rigorous evaluation of the vanguards and of transformation and integration projects more widely; it was seen as important to assess the impact of these schemes, to identify the ingredients of success, to communicate the lessons across the country and to find out what works. Professor Matt Sutton said: “Things like the Five Year Forward View are going to take a lot of very measured evaluations of what is being done and all the ideas in the vanguards so that you can see a sort of sustainable, generalisable solution rather than small ideas that appear to work.”159 Professor Mays called for a “sustained” commitment to evaluation.160
126.We heard some impressive evidence of the work going on to integrate health and social care services, and to incorporate other public services in ways that meet the needs of patients better and improve the local population’s health. These initiatives for integration have great potential. In many areas, patients are already benefitting from better integration and other transformation initiatives. This will however not necessarily save money in the short term, as this approach also identifies more individuals who could benefit from services.
127.Integration and devolution do not offer a quick solution to the financial problems facing the NHS and social care services. Such projects require substantial investment in preparation and during the early years of operation, and may in some cases add to costs in order to deliver long term savings. The Government needs to take a long term view in assessing their financial benefits and should define how the success of the vanguards will be evaluated.
128.With much of the upfront investment in the Spending Review being used to plug deficits, there is a real danger that greater integration and the move to the new models of care set out in the Five Year Forward View will be jeopardised by the shortage of transformation funds across the wider NHS outside the vanguards. At present the Sustainability and Transformation Fund is being used largely to ‘sustain’ in the form of plugging provider deficits rather than in transforming the system at scale and pace. If the financial situation of trusts is not resolved or, worse, deteriorates further, it is likely that the overwhelming majority of the Fund will continue to be used to correct short-term problems rather than to support long-term solutions. We call on the Government to set out how it will protect the Transformation element of the Fund to ensure that the ambitions of the Five Year Forward View are realised.
Health education funding
129.The importance of substantial improvements to workforce planning for the achievement of the ambitions set out in the Five Year Forward View has already been noted.161 We took specific evidence on several aspects of the work of Health Education England, which “works across England to deliver high quality education and training for a better health and healthcare workforce”.
130.The Department of Health told us early in our inquiry that “Although Health Education England’s funding for 2016–17 is yet to be determined, the aim is to broadly maintain programme funding at current levels.”162 Later Health Education England Board papers confirm that position, stating that “HEE’s Programme allocation has been held at the 2015–16 cash level for the whole of the CSR period, with an increase of c£30 million to mitigate the effect of changes to employers’ National Insurance contributions.”163 In their joint submission, the three health think tanks, the Health Foundation, King’s Fund and Nuffield Trust, note that of HEE’s £5 billion budget, “£3.5 billion goes straight back to the NHS front line to pay the salaries of doctors while they are undergoing training.” They comment that “Freezing this budget risks increasing pressure on hospitals if Health Education England is forced to reduce the subsidies it pays providers to cover these costs.”164
Nursing bursaries and loans
131.One of the key changes announced in the settlement was the planned removal of nurse bursaries. The three health think tanks who gave evidence to us estimated that this would save £1.2 billion a year.165 Nurses and other non-medical undergraduate students do not currently pay tuition fees; they receive a grant towards their living expenses and a means-tested bursary. This will change from 1 August 2017, when new nursing, midwifery and allied health students will no longer receive NHS bursaries. Instead, they will have access to the same student loans system as other students. The Government says that it will run a consultation on how best to implement these changes. We heard sharply contrasting views as to the merits of the new arrangements.
132.The Department of Health put the changes in the context of the Five Year Forward View, which “outlined the need for a modern NHS workforce, with the right numbers, skills, values and behaviours to deliver it. Under the loans system, most students on nursing, midwifery and allied health courses will receive around a 25% increase in the financial support available to them for living costs.”166
133.The Department said that the current system, with its limited number of bursaries, denies thousands of applicants a place to study health subjects at university, because the limited number of university places on offer is insufficient to meet demand. The new system “will ensure that there are enough health professionals for the NHS while reducing the current reliance on expensive agency staff and overseas staff and giving more applicants the chance to become a health professional.” This will “enable universities to provide up to 10,000 additional nursing, midwifery and allied health training places over this parliament, so more applicants will have the chance to become a health professional.”167
134.The Royal College of Midwives told us that the impact of these changes on those studying to become midwives would be “sizeable.” The RCM says that student midwives starting their training in autumn 2017 could graduate with up to around £60,000 of debt. The RCM estimates that the NHS in England is short of the equivalent of around 2,600 full-time midwives. They commented “We are unaware of evidence that increasing the likely debt to be carried by graduates will lead to an increase in training numbers, as the Government suggests it will.”168
135.The Royal College of Nursing, while recognising “the need for a new funding model for nursing students”, was also concerned about the effects of student debt, and told us that it was “deeply disappointed” by the announcement that NHS nurse bursaries were to be replaced by a loans based system”. There had been “no prior consultation or evidence gathering” by the Government before the decision. The RCN said that “the purported benefits” of such a change had been “overstated”.169
136.These views contrasted with those of Universities UK and the Council of Deans of Health. In evidence submitted for our inquiry into primary care, they said this measure would provide the financial headroom to be able to loosen controls on student numbers. They added that it would provide a framework for long-term planning as the current system of bursaries creates a rigid dependence on Health Education England’s annual budget. They stressed, however, that such reforms would need to be handled carefully to manage the risk of reducing demand from applicants.170
137.Professor Cumming of Health Education England identified “opportunities and disadvantages in both the current system and the new system.” The current system was “cash constrained” and did not allow recruitment of enough nurses. He recognised that the new system would result in individuals incurring debt through the student loan system, but “if people are willing to incur that debt, then there will definitely be more opportunities.” He said that he was currently talking to universities that were planning to increase their intakes on nursing, physiotherapy and other courses. Professor Cumming also said that HEE had examined the impact of the introduction of the previous student loan system and “it did not seem to have a huge impact on the number of students applying in those days.”171
Effect of HEE’s budget on hospital finances
138.The BMA said that, by freezing the budget of Health Education England, 70 per cent of which currently goes on subsidising the salaries of doctors in training, the Government was only increasing the financial pressure on hospitals.172 Similar concerns were expressed by the Royal College of Surgeons and Faculty of Dental Surgery and the Shelford Group of major academic healthcare organisations. The Shelford Group said there was a risk that restricting the HEE budget would affect “the transformation of the workforce, which is key to underpinning the delivery of a transformed NHS.” 173
Health education funding: conclusions
139.The failure to train and retain an adequate supply of clinical staff is causing great strain in many parts of the NHS. This is undermining patient care, driving up the use of more expensive agency staff to fill rota gaps and diverting resources away from other important priorities. We expect Health Education England to set out their strategic plan and state whether they expect it to be achievable, and whether it will deliver the staff needs of the NHS, within their current budget. As we return to this subject through the spending review period we intend to examine the progress which HEE is making in improving workforce planning and effecting the transformation of the workforce at the heart of achieving the aims of the aims of the Five Year Forward View.
140.We have heard concerns about the potential impact of the proposed abolition of NHS bursaries on the supply of nursing staff and other allied health professionals. We recommend that the Government review the impact on those training as a second degree and examine a transitional approach to support this section of the future workforce. We welcome the introduction of new routes to Associate Nurse and degree level nursing for those working as Health Care Assistants. We plan to return to this issue.
The Government’s aspirations for service improvement
141.The Government also has a number of ambitious and specific aspirations for service improvement in the NHS. In particular it has made it clear that it wishes to see:
- more NHS services available at the weekends, and
- parity of esteem being given to mental health services.
142.However, it was not clear to us that the Government had fully considered the expenditure implications of these aspirations. Given the financial situation described in Chapter Two, there is a risk that the funds will not be available to make them a reality.
Seven-day services
143.We heard a great deal of evidence about the Government’s ambitions for a seven-day NHS. In its written evidence to this inquiry, the Government said that it had
set the NHS the objective of guaranteeing that, by the end of this parliament, anyone who needs urgent or emergency hospital care will have access to the same level of consultant assessment and review, diagnostic tests and consultant-led interventions, whatever day of the week it is. Hospitals will deliver this for 25% of the population by March 2017, 50% by March 2018 and everyone by 2020.174
144.A 2015 Conservative Party election manifesto commitment under the heading “We will make the NHS more convenient for you”, said: “We want England to be the first nation in the world to provide a truly seven-day NHS. Already millions more people can see a GP seven days a week, from 8am-8pm, but by 2020 we want this for everyone. We will now go further, with hospitals properly staffed, so that the quality of care is the same every day of the week.”175
145.The pledge on hospitals was apparently motivated by what the Government claimed was evidence of higher mortality at 30 days among patients who are admitted to hospital at weekends. During our inquiry, we heard conflicting evidence about the so-called ‘weekend effect’. The Secretary of State for Health told us that the evidence showed that: “there is a weekend effect … the standard of care we give at weekends is different because you have to be more ill to get a decision to admit you … there are, I think, internationally 15 studies that show that there is a weekend effect.”176 Other studies suggest that such an effect is at most very limited. We note that there are a variety of views on this question and whilst there is a statistical increase in mortality at 30 days for those admitted at the weekend, there is no consensus about the cause, which is likely to be complex and multifactorial, and neither is it clear to what extent these are preventable deaths. For this inquiry we have focused on the financial implications of the policy and whether it represents best value for patients from a limited resource.
146.There has been confusion about the range of services which would be provided at the weekends under the Government’s plans, confusion perhaps prompted by the broad wording of the manifesto pledge. There have been suggestions that this implied complete replication of weekday services across the weekend in all areas of the NHS. When we took evidence from him in February, Professor Matt Sutton of Manchester University urged the Government to be clear about its priorities for seven-day working. “Instead of having this extremely large-scale plan for a major overhaul, we need to identify the individual things that will make a difference to patient outcomes and that can be afforded within the existing budget.”177 The BMA noted that the money to pay for a seven-day service “was not factored into the funding scenarios in the Five Year Forward View.”178
147.Research suggests that trying to provide a full range of services over seven days would not be a good use of scarce resources. While acknowledging that there appeared to be higher mortality at the weekends, Professor Sutton said that “There is as yet no clear evidence that seven-day services will reduce weekend deaths or can be achieved without increasing weekday deaths.” In oral evidence, Professor Sutton said “if we took the most optimistic scenario, where we assumed we could save all of those excess deaths, because the NHS, we think, is planning to spend £1.1 billion to £1.4 billion, it cannot be cost-effective. I think that, because of a concern about what might be a genuine problem, we have a very large response, but that response is only going to divert money away from better things that the NHS could be doing with that money.”179
148.Since we began this inquiry, the Government and NHS England have clarified their aims for seven-day working. On 25 April, the Secretary of State for Health told the House that “there is a concern that the Government may want to see all NHS services operating seven days a week. Let me be clear: our plans are not about elective care, but about improving the consistency of urgent and emergency care at evenings and weekends.”180 Simon Stevens of NHS England gave us more detail in oral evidence of what is considered “the appropriate clinical standard of care for any emergency in-patient on a weekend”. Mr Stevens said that the Service was guided by the Academy of Medical Royal Colleges, which, listed “four things that emergency patients on a weekend, just as on a weekday, should expect:
One is that they should get an assessment of their need and their treatment by a senior doctor within 14 hours at the latest; the second is that there needs to be diagnostic back-up available on a weekend, including CT, MRI, ultrasound and pathology … The third is that there should be consultant-directed treatments available for emergency patients on a weekend, including in critical care, interventional radiology, interventional endoscopy, emergency general surgery. The fourth is that there should be ongoing review for acutely ill patients.181
149.Asked about the extra costs of these changes, Mr Stevens said “There will be a smart way and an unaffordable way of doing this, so the reason for doing this … on a phased basis is precisely to figure out what is the smart, most cost-effective way of implementing this.” He told us that “a quarter of the country will be covered by these standards from next March at really very modest incremental cost—indeed, a number of trusts are already providing services to these standards.”182
150.The Government says it is also “committed to improving access to GP services as part of our plan for a seven-day NHS. Achieving improved access not only benefits patients but also has the potential to create more efficient ways of working, which benefits GPs and practice staff.”183 Mr Hunt gave more details of how this would work:
When it comes to GP care, we have also been very clear that, yes, we do want people to be able to make routine appointments at the weekend. We think that is an important thing for the NHS to offer people who work during the week and may not be able to take time off work … We have said we would like them to be able to make appointments until eight in the evening and at weekends, but we are not asking every GP surgery to open at weekends.184
151.Mr Hunt suggested that “networking arrangements”, involving a number of surgeries, could help provide a service enabling patients to see a GP, if not their usual GP, at weekends.185
152.Asked whether the GP changes would be funded from the £2.4 billion package for GP Services announced as part of the General Practice Forward View in April 2016, Mr Stevens suggested that they would be. He said that the money was “a comprehensive package of support for GPs … [the package] is a range of things which is, frankly, all about implementing the strength of out-of-hospital new care models that were envisaged in the forward view, so I think delivering the GP forward view is one and the same as delivering that pillar of the Five Year Forward View.”186 When we asked him whether the Treasury would be providing any extra money for the £2.4 billion package, Mr Stevens said: “It is coming from the overall funding increase available to the National Health Service over the next five years”. It will, therefore, be important to understand what other spending commitments will be re-prioritised to release the funds for this package of support.
153.The Government and NHS England have now produced a clearer account of their intentions for seven-day services in hospitals and GP surgeries. We welcome the more realistic vision for seven-day hospital services, focussing on urgent and emergency care. We will continue to monitor progress on seven-day services across the Spending Review period, with the aim of assessing whether the Government’s ambitions are achievable and delivering value for patients given the constraints on available resources and the risk of displacing measures which would be more cost effective.
Parity of esteem for mental health
154. ‘Parity of esteem’ means mental health is valued as much as physical health, for example in terms of access to care and allocation of resources on the basis of need. The principle of parity of esteem was enshrined in legislation as part of the Health and Social Care Act 2012. The Spending Review made explicit reference to mental health, pledging to “improve quality, choice and clinical outcomes in areas such as cancer, dementia and mental health”.187
155.The NHS shared planning guidance for 2016–17 to 2020–21 made it clear that Clinical Commissioning Groups must continue to increase investment in mental health services each year at a level which at least matches their overall expenditure increase. The main source of published information on how much clinical commissioning groups spend on mental health comes from annual ‘programme budgeting’ data. However, the information is not up to date, with the most recent published data, released in June 2015, relating to spending in 2013–14.188 The Department of Health’s evidence to this inquiry, which does not include audited figures, suggests spending on mental health increased by 3% between 2013–14 and 2014–15, from £11.4 billion to £11.7 billion. It reports that its in-year information for 2015–16 is showing that spending on mental health is continuing to increase.189
156.A number of organisations told us that there was limited accurate information on how much the NHS currently spends on mental health services. Rethink Mental Illness expressed concern at what it called “the lack of a robust, transparent national picture of mental health funding. This means accurate and accessible data about spending on mental health is not available.”190 Julie Wood of NHS Clinical Commissioners told the Committee that the data suggest the majority of Clinical Commissioning Groups have met their commitment to increase their investment in mental health by the overall increase in their allocation.191 In contrast, Chris Hopson at NHS Providers said its members feel strongly that they have not seen an increase. He explained that “There is a bit of a sense that CCGs are using some slightly weird and wonderful calculation methodology to prove they have delivered this increase, when our members are saying it is not coming to the front line where it really is needed.”192
The spending review settlement and its impact on mental health
157.The Spending Review committed the Government to spend an extra £600 million on mental health over the course of the spending review period. The Department of Health clarified in written evidence that the funding is in addition to funding already announced in the March 2015 budget and Autumn Statement 2014, meaning the Government will have invested an additional £2 billion in mental health by 2020-21.193 The sum is however included in the overall figure of the £8.4 billion increase to NHS England’s budget (by 2020–21, in 2020–21 prices), a point made clear by three leading health think tanks during oral evidence to us. The £2 billion for mental health is made up of:
- £150 million for young people with eating disorders (announced in Autumn Statement 2014);
- £1.25 billion for system-wide transformation of children and young people’s mental health and perinatal mental health (announced in March 2015 budget); and
- £600 million for mental health, which will particularly focus on improving access to psychological therapies, perinatal mental health and crisis care (announced in the Spending Review for 2015).194
158.NHS Providers, the King’s Fund and Mind were all concerned about the risk that additional funding set aside for mental health will be diverted to alleviate financial pressures in the acute sector. Mind noted that some 98% of the NHS’s estimated £1 billion deficit lies in the acute sector. It said that the solvency of mental health budgets had been achieved through cuts to services, which has “severely impacted the care available to people needing support”.195 Julie Wood of NHS Commissioners told the Committee that in the case of mental health, she would support the introduction of a ring-fencing on funding so that spending could be guaranteed, “because of where it is starting from—very much a Cinderella service”.196
159.There was also concern about the impact of public health cuts on mental health. The Mental Health Foundation argues that “achieving better mental health and wellbeing for the nation cannot be achieved purely through crisis care investment, and the focus needs to be moved upstream to prevention and early intervention, particularly for those most at risk”. It therefore says the cuts to public health budgets for mental health are “a clear missed opportunity for the government”.197 Geoff Heyes at Mind shared these concerns, adding that its analysis of freedom of information requests suggests just 1% of public health budgets are currently spent on mental health.198
160.Similarly, the LGA is concerned that pressures on spending by councils will have an impact on funding for mental health services. It explains that most people who receive support from mental health services do so within the community and do not need hospitalisation. It therefore considers that council funding reductions will have an impact on funding for mental health.199
The Mental Health Taskforce findings on mental health
161.As part of the NHS Five Year Forward View, NHS England commissioned a Mental Health Taskforce to produce a strategy for improving mental health. In February 2016, the Taskforce published its Five Year Forward View for Mental Health, setting out a series of recommendations for the government and NHS. The report says that significant progress had been made in areas such as public attitudes, improved outcomes, and developing services like psychological therapies. However, there were also huge challenges.200
162.The report called for improvements in the three main areas of prevention, seven-day services for people in crisis and integrated physical and mental health. It set out an ambition to make mental health services available to one million more people by 2021, stating that the Government would need to invest an additional £1 billion in 2021 to make this a reality.
163.Following the publication of the Taskforce’s report, NHS England declared there would be the “biggest transformation of mental health care across the NHS in a generation”. It said it would spend more than a billion pounds to support the vision outlined in the Taskforce’s report and committed to a series of recommendations.201 In oral evidence to this inquiry, the Secretary of State for Health said that “Broadly, we agree with all those recommendations. It is a very ambitious programme … and something we are very much committed to delivering”.202
164.Chris Hopson of NHS Providers told us that the funding of the implementation of the recommendations of the Mental Health Task Force was “all rather foggy.” Mr Hopson asked for “absolute clarity on how much extra money is going to be given to mental health to deliver priorities; secondly, a very clear instruction to CCGs … about how much extra will be spent; thirdly, a completely transparent methodology so that we can see if, in the case of each individual CCG, that commitment has truly been met.”203
165.‘Parity of esteem’ is about more than simply funding commitments. The Mental Health Task Force has rightly identified “a cross-society consensus on what needs to change [in mental health provision] and a real desire to shift towards prevention and transform NHS care.”204
Funding for mental health: conclusions
166.Delivery of the funding commitments the Government has made for mental health is crucial to the delivery of meaningful parity of esteem. As we return to this subject through the Spending Review period, we will be looking for clear, verifiable evidence that the additional funding for mental health is being delivered to the front line, as well as evidence of sustainable progress towards the culture change across the NHS, from commissioners to providers, necessary to deliver genuine parity of esteem.
116 NHS England, Five Year Forward View , p.35
117 Ibid. p. 9
118 Five Year Forward View, p.3. A report by Derek Wanless, Securing our future health: taking a long-term view - the Wanless Review, was published in 2002.
123 Health Service Journal, 22 October 2015
125 Q346
127 Q172
130 Q210
133 In particular in written evidence from the Royal Society of Public Health, Royal College of Physicians, Royal College of Nursing, Royal College of Surgeons/Faculty of Dental Surgery and the British Medical Association.
134 Several submissions on this issue were from organisations concerned with sexual health – the FPA, National Aids Trust, the Advisory Group on Contraception and the Terrence Higgins Trust. Other charities making similar points included Cancer Research UK and the British Heart Foundation.
138 HM Treasury, Spending Review and Autumn Statement 2015 (Cm 9162 )November 2015, para 1.112
140 Ibid. para 48
142 Q227
143 Q214, Q226
144 Q214, Q221-225
146 Health Committee, Report of the NHS Future Forum - Oral Evidence, HC 1248 – I, 5 July 2011 Q156, Andrew Lansley: “What we are doing, through amendments to the legislation, is to make it absolutely clear that integration around the needs of patients trumps other issues, including the application of competition rules.”
147 Q100
150 Qq77-78
151 Q218
152 Q227
153 Q32
154 Q334
155 Q99
157 Q227
158 Q68
159 Q28
160 Q43
163 Health Education England, “2016/17: Budget Setting & Business Plan: Paper 1: HEE Budget 2016-17”, para 4. Available from www.hee.nhs.uk (accessed 22 June 2016)
164 The Royal College of Surgeons and Faculty of Dental Surgery agreed, indicating that the HEE funding changes could have “negative consequences for the health service”. Para 3.4.1
167 Ibid. para 87
168 Royal College of Midwives (CSR56) para 19. See also the Committee of Public Accounts, Fortieth Report of Session 2015-16, Managing the supply of NHS clinical staff in England, HC 731, p.7
171 Q157
175 Conservative Party General Election Manifesto 2015 : Strong Leadership, A Clear Economic Plan, A Brighter, More Secure Future, April 2015, p. 38
176 Q365
177 Q24
179 Q22
180 HC Deb, 25 April 2016, column 1152
181 Q368
182 Q378
184 Qq 371–72
185 Q374
186 Q373
187 HM Treasury, A country that lives within its means: Spending Review 2015, July 2015 (Cm 9112) para 3.7
188 NHS England, Programme Budgeting data, accessed on 17 June 2016.
191 Q143
192 Ibid.
193 Department of Health (CSR42) para 152
194 Q84
196 Q143
198 Q275
200 The Five Year Forward View for Mental Health: A report from the independent Mental Health Taskforce to the NHS in England, February 2016
201 NHS England press release:NHS commits to major transformation of mental health care with help for a million more people, 15 February 2016
202 Q381
203 Q144
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15 July 2016