206.The NHS is over halfway through the most austere decade in its history. Simon Stevens told us that over the last five years constraints on NHS funding have contributed £27billion to the country’s deficit reduction. If health spending had kept pace with historic trends then the NHS would be expected to receive an extra £8.8billion next year than is currently planned.
207.Bringing local health and social care services together through STPs and ICSs to plan and organise care within their footprints is a much better way to manage constrained resources than the siloed, autonomous and competitive arrangements imposed by the Health and Social Care Act 2012. Our view is that STPs and ICSs are a pragmatic response to the current pressures on the system, rather than a smokescreen for cuts, but that these mechanisms are not a substitute for adequate funding of the system. Funding them properly, including access to ring-fenced transformation money, is necessary and would allow a far better assessment of their potential.
208.The systemic pressure on the finances of the NHS and social care has shaped the context in which local organisations have come together. In some cases, where financial problems are looming, yet less serious, the circumstances facing local areas have acted as a catalyst for constructive conversations. However, there are local areas with deeply entrenched financial problems. Areas in greater financial distress can be consumed by maintaining day-to-day levels of performance and find it very difficult to find the capacity to engage in longer-term transformation. Nigel Edwards, Chief Executive of the Nuffield Trust, told us that:
A significant number of systems are under such financial distress that even the task that they have been set to try to agree shared control totals is causing problems. One of the reasons why many change programmes fail at the system level is that people stop working in a system way and go back to managing the financial objectives of their organisations. There is a significant number of systems where the level of financial distress is such that the time and space to be able to deal with some of the bigger transformational changes that we all know need to be made is being diverted by the search for financial balance.
209.Since 2014/15 the Department of Health and Social Care has relied on transfers from its capital budget to finance day-to-day running costs. The Department, in evidence to the Committee of Public Accounts, confirmed that capital to revenue transfers are set to continue during this Parliament. Using capital resources to fund day-to-day running and maintenance means there is less within the existing budget to transform care. Sir Robert Naylor’s report on the NHS estate set an ambition for capital investment of £10billion in the NHS, with half going on transformation and the other half on addressing the backlog of maintenance within the system.
210.In March 2017, the Chancellor announced £325million in capital funding for the most advanced STPs. An extra £3.5billion over the next four years was subsequently announced in the Autumn Budget in November 2017. Most of this funding, £2.6billion, has been earmarked to help STPs deliver their plans.
211.The Government’s intention is for this funding to be supplemented by £3.3billion from the sale of surplus land and buildings and “private finance investment in the health estate where this provides good value for money.” In addition, NHS England is investing £1billion in primary care infrastructure and £808million for national priorities.
212.The capital resources provided so far fall short of Sir Robert Naylor’s estimate and the amount of capital resource local areas are calling for. London South Bank University’s analysis of all the 44 sustainability and transformation plans calculated the capital requirement to be over £14billion. Nigel Edwards from the Nuffield Trust echoes the concern that the capital resources available to local areas are going to be significantly less than what they are calling for. Mr Edwards told us:
We also know that, where they have made capital requirement estimates, they are significantly in excess of what is likely to be available, even if there are substantial land sales. The London STPs alone would account for an entire year’s capital allocation, and more.
213.The Department of Health’s original intention was for the Sustainability and Transformation Fund (STF) to restore the NHS to financial balance and support the transformation of care. However, the use of the STF to date has predominately been to address NHS deficits, rather than fund transformation. The Fund, and the way it is allocated, has helped NHS organisations to improve their financial discipline.However, according to the NAO, the remaining deficit continues to create problems for future years and leaves less funding available for transformation.
214.The NHS planning guidance recently spilt the Sustainability and Transformation Fund in two: the Provider Sustainability Fund and the Commissioner Sustainability Fund. Simon Stevens told the Committee of Public Accounts that “I think the “T” was probably a misnomer and that’s why we dropped it.” The Government and national bodies have committed to the two Sustainability Funds for the next financial year, at which point they can choose to use this resource differently.
215.A clear message from our inquiry is that transformation is key to sustainability. Ian Dalton, Chief Executive of NHS Improvement, described the difficult dilemma facing national and local leaders, saying that:
if we do not make the changes to care, we will be committing to dealing with potentially an ageing population, and the consequent rising demand, with care models that were designed for a different era, and we know that that is not the way forward either.
216.The OECD’s analysis of health systems across Europe acknowledges that making the transition to more efficient ways of delivering acute and chronic care is likely to require upfront investment. We heard how many health systems that have undergone a similar journey to more integrated models of care have done so over 10–15 years, with dedicated upfront investment reserved for transformation. As health spending looks set to consume an increasing proportion of GDP in western countries over the coming decades, investing in more integrated care is a way of getting better value for patients and taxpayers.
217.The NHS is “still very much in survival mode”, according to the Public Accounts Committee. Simon Stevens confirmed this view, stating that within the “aggregate funding available” national bodies decided to focus on supporting services in the “here and now,” which left less resources available “for pump-priming and extending wider changes.”
218.The King’s Fund and the Health Foundation in 2015 identified the following key components for funding transformation in health services: physical infrastructure, programme infrastructure, staff time and double running of services, in which new services are run alongside incumbent services before the latter can be safely decommissioned.
219.Rather than changing administrative structures, the sort of change required to design and implement integrated care is often at a micro-level and concerns how frontline staff work together. Staffing is not the only component, but a clear message from our inquiry is that investment in staff capacity is critical for service transformation.
220.Quantifying the amount of funding required to deliver new and more integrated models of care across the NHS is very difficult, given both the scale of the transformation and the length of time needed to deliver the changes. We are disappointed that neither the Department of Health, NHS England nor NHS Improvement were able to provide an estimate of the scale of funding needed to deliver new models of care at scale or the approach they would take to make such an assessment. Greater Manchester had a £450million transformation fund over 5 years. Multiplying the level of transformation funding provided to Greater Manchester for the whole population of England comes to a figure of £9billion over 5 years.
221.Integrated care at the patient, service or organisational level is dependent on relationships between people working in health and social care. Whether patients experience holistic, coordinated and person-centred care depends on staff working together across acute, community, primary care, mental health, social care services and the voluntary sector.
222.The capacity, capability and motivation of staff to engage in transformation is also critical. Moving to new models of more integrated care requires:
a)the capacity and capability of staff to participate in complex service redesign;
b)engagement in dialogue with healthcare professionals and unions;
c)time to train staff with new skills; and
d)funding the staffing costs associated with double-running.
It should also include time for meaningful local engagement with those who rely on services both now and in the future.
223.National bodies are endeavouring to transform care during a period in which NHS and adult social care services are struggling to recruit, train and retain sufficient numbers of staff to cope with rising, and increasingly complex, demands. We have heard throughout this inquiry and our recent inquiry into the nursing workforce that professionals often worry about their ability to maintain professional standards when confronted with relentless, complex or unmanageable caseloads.
224.Moving care out of hospitals is only acceptable if there is adequate provision already in place within community and primary care settings to meet changes in demand. This depends on having sufficient numbers of suitably qualified staff within these settings. However, recent workforce trends run counter to this objective. The acute workforce has grown at a faster rate than primary, community and mental health services, some of which have seen numbers of staff drop considerably in recent years. Where communities see highly valued resources, such as community hospitals, closed down before the promised new services to replace them are up and running, it seriously undermines trust in future service changes.
225.More collaborative, place-based ways of working, through sustainability and transformation partnerships and integrated care systems, provide an opportunity for local areas to deploy and retain limited pools of existing health professionals in the short term. However, without effective delivery of Health Education England’s workforce strategy, collaborative working may be put at risk as staffing pressures encourage organisations to compete rather than look to share limited pools of staff.
226.NHS and social care professionals are likely to be the best advocates for more integrated care. Effectively communicating service change to the public depends on who presents the message as well as the message itself. Public trust in nurses (93%) and doctors (91%) is significantly higher than politicians (17%), Government ministers (19%) and journalists (27%). Alongside the NHS’s strong brand, Ipsos MORI argue public trust in these health professions is a key advantage in making the case for change to the public, although Ipsos acknowledge:
...while this can be a benefit to be harnessed, it can also work in the opposite direction: a reform or message without NHS staff backing is unlikely to be popular with the public where staff are vocal, and the impact of this should not be underestimated.
227.The NHS Constitution, the Royal College of Nursing told us, includes a requirement for NHS-funded organisations to “engage staff in decisions that affect them and the services they provide.” Staff engagement was limited in the development of the original plans. Professional bodies, including royal colleges and trade unions, continue to perceive staff engagement in sustainability and transformation partnerships as insufficient, poor and patchy.
228.Local GPs appointed by the Royal College of General Practitioners to act as regional ambassadors in the development and implementation of STPs have “struggled to find a voice or influence on key STP boards.” Similarly, allied health professionals (e.g. physiotherapists, occupational therapists, paramedics, speech and language therapists), we heard, have also struggled to find a voice in the leadership of STPs. None of the clinical leads on STP boards come from the ranks of allied health professionals.
229.We also heard reports of limited clinical engagement in proposals that clearly affect specific professional groups. For example, despite plans to reconfigure acute hospitals within many of the plans, the Royal College of Emergency Medicine reported that clinical engagement of its members was widely considered to be poor or patchy.
230.Funding and workforce pressures on NHS, social care and public health services present significant risks to the ability of the NHS even to maintain standards of care, let alone to transform. Funding and workforce pressures, if not adequately addressed, risk compromising these fragile local relationships which are pivotal to transforming care. We are concerned about workforce and funding shortfalls in community services, primary care and mental health, which are seriously limiting the capacity to shift more services closer to individuals within their communities.
231.The NHS and local government have not been given adequate investment, support and time to embark on the scale of transformation envisaged. Transformation depends not only on having sufficient staff to maintain day-to-day running of services, but in the capacity and capability of staff to redesign services, engage in dialogue and consultation and develop new skills. Transformation also requires funding the staff costs associated with double-running new services, while old models are safely decommissioned.
232.The Government’s long-term funding settlement should include dedicated, ring-fenced funding for service transformation and prevention. We recommend that the Government commit to providing dedicated transformation funding when it announces its long-term funding settlement this summer.
191 Q304 Simon Stevens
192 Q246 Nigel Edwards
193 National Audit Office, Sustainability and transformation of the NHS, January 2018 Session 2017–19 HC 719, para 118
194 Oral evidence to the Committee of Public Accounts on 5 March 2018 Session 2017–19 HC 793 Q41 [Sir Chris Wormald]
195 Department of Health and Social Care, NHS Property and Estates: Why the estate matters for patients. An independent report by Sir Robert Naylor for the Secretary of State for Health, March 2017
196 HM Treasury, Autumn Budget 2017, November 2017 (Session 2017–19) HC587, page66 para 6.8
197 HM Treasury, Autumn Budget 2017, November 2017 (Session 2017–19) HC587, page66 para 6.9
198 National Audit Office, Sustainability and transformation in the NHS, January 2018 Session 2017–19 HC719
199 London Southbank University, Sustainability and transformation plans: How serious are the proposals? A critical review, June 2017
200 Q247 [Nigel Edwards]
201 National Audit Office, Sustainability and transformation in the NHS, January 2018 Session 2017–19 HC719
202 Oral evidence to the Committee of Public Accounts on 5 March 2018 Session 2017–19 HC793 Q55 [Sir Chris Wormald]
203 National Audit Office, Sustainability and transformation in the NHS, January 2018 Session 2017–19 HC719
204 NHS England and NHS Improvement, Refreshing NHS plans for 2018–19, February 2018
205 Oral evidence to the Committee of Public Accounts on 5 March 2018 Session 2017–19 HC793 Q67 [Simon Stevens]
206 Oral evidence to the Committee of Public Accounts on 5 March 2018 Session 2017–19 HC793 Q55 [Sir Chris Wormald]
207 Q359 [Ian Dalton]
208 OECD, Health at a Glance: Europe 2016. State of Health in the EU Cycle, November 2016
209 NHS Providers ()
210 House of Commons Committee of Public Accounts, Sustainability and transformation in the NHS, March 2018 Session 2017–19 HC793
211 Oral evidence to the Committee of Public Accounts on 5 March 2018 Session 2017–19 HC793 Q85 [Simon Stevens]
212 The King’s Fund and the Health Foundation, , July 2015, page 6
213 The King’s Fund and the Health Foundation, , July 2015
214 Q110 [Lara Carmona] Q105 [Dr Nagpaul].
215 Ipsos MORI ()
216 Ipsos MORI ()
217 Ipsos MORI ()
218 Royal College of Nursing ()
219 British Medical Association (BMA) () Royal College of Emergency Medicine ()Royal College of General Practitioners ()Royal College of Nursing ()
220 Royal College of General Practitioners ()
221 The Royal College of Speech and Language Therapists ()
222 Royal College of Emergency Medicine ()
Published: 11 June 2018