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The long and rocky road to NHS sustainability

By Philip Reid, Managing Partner, London

Despite the EU Referendum dominating the political landscape in 2016, it will still have been hard to avoid the choppy waters in which Jeremy Hunt has been navigating over recent months. Indeed the first half of the year can only be described as an extremely bruising one for the health secretary, with a bitter junior doctors strike, large and growing financial deficits amongst an increasing number of NHS providers and a rising regularity of missed targets in key health indicators.

Interestingly and despite the signs of a system increasingly under strain, health policy has received comparably little focus in the new Parliament. The bitterly divisive reforms of the Coalition Government have entrusted stewardship of the lion’s share of the NHS’s £116 billion annual budget into the hands of NHS England’s Chief Executive Simon Stevens; effectively putting some clear distance in terms of accountability between Government and NHS England. The Five Year Forward view has been accepted, the politicians are stumping up the cash, now go solve the problems is the clear message from Government. This strategy would have been similar, from all the major political parties from the 2015 general election campaign.

In fact, there appears to be a growing consensus amongst both politicians and senior civil servants around the key challenges and the methods to tackling the problems of the NHS. These include:

  • a focus of improved integration between health and social care
  • a greater emphasis on public health, prevention and diagnostics
  • a more personalised care model
  • a greater use of technology to assist different types of care
  • a more streamlined and consistent route to market for new treatments
  • a drive for significant efficiency savings
  • an agreement to more funding

The talk from the top has been consistent and upbeat and time will certainly tell whether the Five Year Forward view can help steer the NHS to a sustainable future. Admittedly, it is early days but there is already growing evidence to suggest that the competing priorities within the NHS could make the overall strategy particularly challenging.

From our own experience of working in the health sector, particularly in the area of market access, there are many challenges around commissioning and reimbursement, which don’t appear to be in tune with the new strategy. Whilst the rhetoric to adopt new technology and “spend to save” is there in principle, the experience on the ground appears less convincing. Despite new technologies having the necessary regulatory approvals and consent from NICE, there are still significant obstacles for these treatments to be used within the Health Service. This is preventing patients from accessing new treatments and also preventing the NHS from realising long term savings. In turn this is making the NHS a less appealing market for the MedTech and pharma industry to invest in. A lose, lose, lose scenario.

The reality on the ground appears to show that the intense pressure to prevent budgetary overspend will often override and delay options that rollout new technology and treatments. This can manifest itself in various forms, but regularly appears to fall into the area of coding – the mechanism for reimbursement. There appears to be too many instances where new devices or procedures, which are potentially quite costly upfront but have proven to save costs in the long term (through reduced bed days and patient follow up care) have received the wrong clinical coding or a delay in coding revision; essentially meaning providers are unable to be reimbursed for the cost of the treatment, despite being approved for use on the NHS.

This maybe because of procedural inefficiencies that have developed (due to the split in responsibility for the National Tariff system between NHS England and Monitor) that can be improved or individual mistakes through poor communication. However the number of instances suggest a deeper systemic problem that is clearly at odds with their strategic goals. The further delay of the HRG4+ currency rollout for the national tariff again outlines a growing concern that new services are being delayed due to the financial constraints that exist. Other concerns include a general lack of communication to both commissioners and GPs about new technologies that are available as well as differing interpretations on procedural guidance that is produced by bodies such as NICE. The All Party Group for Diabetes have provided an interesting example of the barriers to entry here.

It will clearly be interesting to see how reform in this area develops and the upcoming final report in the Accelerated Access Review will be followed closely by the health industry. It will be equally interesting to see how successful the Five Year Forward View will be in achieving its main aims. It has correctly identified many of the problem areas; the question is whether such a huge organisation is able to change its culture effectively and adapt to the ever increasing demand in new treatments through a mix of new technologies, better prevention, more joined up integration combined with some approved extra funding (whether that funding is enough is up for debate).

One question on NHS sustainability which has continued to remain off limits with politicians and civil servants is the debate as to whether the NHS should and can continue to be free at the point of use for all of the services it currently provides. The demographic juggernaut of our ageing population combined with the technological advances to treat diseases means financial pressures are most likely to increase, no matter how successful Simon Stevens is in undertaking his vision. This is a discussion for another day and indeed the Five Year Forward View will mothball this debate for the foreseeable future. However sooner rather than later, politicians will have to start thinking about a more grown up conversation with the electorate about the future of health funding. In the meantime, it is fingers and toes crossed that Mr Stevens can deliver!


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