The Long-term Sustainability of the NHS and Adult Social Care Contents

The Long-term Sustainability of the NHS and Adult Social Care

Chapter 1: Introduction

Headline after headline

1.Our NHS, our ‘national religion’, is in crisis and the adult social care system is on the brink of collapse. No one who listened to the evidence presented by the vast array of expert witnesses who appeared before us can be in any doubt about this. Immediate measures are undisputedly needed to alleviate the situation in the short term. Our task, however, was different. We took—indeed our terms of reference stipulated that we should take—a longer-term view. The questions we asked were: How can we retain the basic principles of the NHS: healthcare largely free-at-the-point-of-use, for all citizens? How can we secure an adult social care system which meets the needs of a rapidly changing population? Ultimately can we get beyond today and envisage a long-term future for an integrated health and care service?

2.Our conclusion could not be clearer. Is the NHS and adult social care system sustainable? Yes, it is. Is it sustainable as it is today? No, it is not. Things need to change.

3.The NHS has been serving the nation well for almost 70 years. We were told that it is increasingly effective, affordable and a net asset for the country as a whole.1 Remarkably, the founding principles which underpinned Aneurin Bevan’s pioneering NHS of 1948 are taken to be as valid today as they were then—that the NHS should provide a comprehensive service, available to all. The service one receives should depend on clinical need, not the ability to pay.2

4.The NHS has survived a long series of crises since its foundation. Accusations of underfunding, back-door privatisation and unnecessary reorganisations, together with claims that inefficient clinical and administrative practices prevail, have plagued successive Secretaries of State for Health. Many of our witnesses portrayed an NHS which is now at breaking point.

5.The House of Commons Public Accounts Committee (PAC) recently reported on the financial sustainability of the NHS. It found that the financial performance of NHS bodies had ‘worsened considerably’. NHS trusts’ deficits had reached £2.5 billion in 2015/16, up from an £859 million deficit in 2014/15. According to the PAC two-thirds of NHS trusts (65%) and NHS foundation trusts (66%) reported deficits in 2015/16, up from 44% of NHS trusts and 51% of NHS foundation trusts in the previous financial year.3 This downward spiral cannot continue.

6.This, together with increased demand, is stretching the NHS’s ability to cope. Headline after headline report that key NHS targets are being missed; performance against the four-hour Accident and Emergency (A&E) waiting time targets is worsening, as is performance against the ambulance response time standards and the target requiring patients to be treated within 18 weeks of referral.4

7.Increasing demand from an ageing population, when coupled with cuts to local authority funding, is placing immense pressure on adult social care services. Shortfalls in social care provision are placing an unprecedented and increasingly unmanageable strain on the NHS. A health service being forced to cope with higher demand and increasingly complex patient needs, as well as trying to secure its own financial sustainability, is being asked to achieve the impossible. The evidence we received was clear: a social care system in crisis will only exacerbate the funding and resource pressures on the health service, but a lasting settlement for social care has the potential to alleviate some of those pressures. The social care crisis is deepening, and unless it is tackled, the health service will not be able to survive in its present form.

Beyond the here and now

8.Beyond the immediate financial and operational pressures, we heard evidence of other challenges which, if left unaddressed, pose a serious threat to the long-term sustainability of the health and social care systems.

9.The UK has historically spent less on health when compared with the Organisation for Economic Co-operation and Development (OECD) averages. UK health spending per head is markedly lower than other countries such as France, Germany, Sweden and The Netherlands.5 The UK also performs poorly in comparison with other countries on many indicators of acute care, achieving worse outcomes for survival from stroke and heart attacks.6 It continues to lag behind comparable European counterparts for cancer survival over five years and 10 years.7 We heard that the UK also has fewer hospital beds, fewer doctors and fewer nurses per head than the OECD averages.8

10.Low productivity in the health and care systems remains an endemic problem and there are wide variations in provider performance. The Care Quality Commission’s (CQC) latest report The State of health care and adult social care in England 2015/16 concluded that the quality of care provided across England still varies considerably “both within and between different services.”9 We heard that there is variation present in the system that is wholly unwarranted and which “cannot be explained by variation in need or explicit choice of populations or individuals.”10 Action must be taken to change this.

11.Significant health inequalities persist. This is felt markedly in the pronounced inequalities between the treatment of physical and mental health; people with severe and prolonged mental illness are at risk of dying, on average, 15 to 20 years earlier than others.11 The reductions in health inequalities called for by the Marmot Review have yet to be realised.12

12.Innovative technologies can produce both large cost savings and more effective treatment. Yet the evidence highlighted that the NHS is often a slow adopter of new technologies. We heard that there is significant under-use of technology, data and digitisation, which slows innovation and reduces levels of productivity.13

13.The public is committed to the NHS as a service which is tax-funded and free-at-the-point-of-use. However, a recent opinion poll conducted by Ipsos MORI showed that the future of the NHS is an increasing concern, with 55% of people—the highest figure they have ever recorded—saying they expected the NHS to deteriorate over the longer term.14 There has been an entrenched reluctance to engage in a serious conversation with citizens about how the system they have grown used to will need to change to meet new challenges. People need to be educated to take responsibility for their own health. Politicians need to be honest that with patient rights come patient responsibilities.

14.We were afforded the rare opportunity to look beyond the immediate pressures facing the health and social care systems and instead focus on how to ensure they are sustained in the long term. We asked many of our witnesses what the perfect health system would look like in 10 to 15 years’ time. The answers we received were consistent; fully integrated health and social care services, more care delivered in primary and community settings, a greater focus on prevention, supported by adequate and reliable funding—all of which should provide seamless, patient-centred care. Although there was widespread agreement on the vision for the health and social care system of the future, we are clear that this cannot be delivered as things stand.

15.Short-term funding fixes will not suffice. Neither will tinkering around the edges of service delivery. We believe that, in order to achieve long-term sustainability of the NHS, we need:

16.It is our firm belief that the NHS can be sustained and, indeed, that it should be sustained. However, unless the issues outlined above are addressed as a matter of urgency, there is a real danger that the NHS will be rendered incapable of delivering on its much-cherished foundational principles.

17.This crisis is different from the other crises. Whatever short-term measures may be implemented to muddle through today, a better tomorrow is going to require a more radical change. Of course, more money will be required, but political and professional conservatism is as much a threat to long-term sustainability as a lack of funding. In this report we set out a holistic plan for long-term change that should deliver a flourishing health and care service not only for ourselves, but for our children and grandchildren.

The inquiry and the Committee’s work

18.In March 2016 the Liaison Committee recommended that the House should appoint an ad hoc committee to consider the long-term sustainability of the NHS. On 25 May 2016 we were appointed and ordered to report by 31 March 2017.15 We started work in June 2016 and took the decision early on to focus on the following themes, structuring our Call for Evidence document accordingly:

(1)resource issues, including funding, productivity and demand management;

(2)workforce, especially supply, retention and skills;

(3)models of service delivery and integration;

(4)prevention and public engagement; and

(5)digitisation of big data, services and informatics.

19.The broad scope and relatively long timeframe for the inquiry afforded us the opportunity to examine cross-cutting issues such as planning, the quality of political leadership, and consensus-building, which have often been overlooked in other, more narrowly defined parliamentary inquiries or government-initiated reviews.

20.Although we were appointed with the clear remit of considering “the long-term sustainability of the National Health Service”, as the inquiry developed, we were struck by the inextricable link between the NHS and the provision of social care. The evidence we received was clear that a social care system in crisis would only exacerbate the funding and resource pressures on the health service, and that a lasting settlement for social care had the potential to alleviate some of those pressures. It would therefore have been impossible to carry out this task without investigating the inter-related nature of health and social care and the need for a lasting settlement for both. Consequently, much of our evidence-gathering and deliberations focused on this important issue.

21.We gathered a wide range of evidence from a large number of individuals and organisations. We received 192 written submissions and heard from well over 100 witnesses in oral evidence sessions between July and December 2016. The level of public engagement was noteworthy; members of the public submitted over 3,000 letters and emails in the final stages of the inquiry with many personal reflections and heartfelt opinions. We would like to place on the record our sincere thanks to all those who contributed to the inquiry by appearing before us in Westminster, by taking the time to submit written evidence or through sending personal correspondence.

22.Health is a devolved matter in the United Kingdom. Consequently, much of the evidence we received and the corresponding conclusions and recommendations we have drawn focus on the situation in England. It is our hope, however, that where applicable, the devolved administrations and those who work in and make use of the NHS throughout the entire United Kingdom may find in this report a set of worthwhile reflections on the future of health and social care provision in all four constituent nations.

23.The following six chapters contain conclusions and recommendations aimed not only at the UK Government, but politicians of all parties, those who work in the NHS, those who represent them and those who make use of its services. The report begins with a consideration of what service transformation is required to support the long-term sustainability of the NHS and adult social care systems (Chapter 2). The workforce is the lifeblood of the NHS and this is discussed in Chapter 3 before the controversial matter of funding for both the NHS and adult social care is considered in Chapter 4. Attention is then given to levels of productivity and the NHS’s approach to innovation and the uptake of new technologies (Chapter 5). The move from an ‘illness service’ to a ‘wellness service’ and the role of the patient is considered next in Chapter 6. The report concludes with a discussion of political leadership, the need for a cross-party consensus on the way forward and a call for a longer-term solution to funding and planning (Chapter 7).

24.The members of the Committee are listed in Appendix 1, along with declared interests. The witnesses and those who submitted written evidence are listed in Appendix 2. The Call for Evidence is given in Appendix 3. All evidence is published online on the Committee’s website.

25.We were ably assisted in our work by two specialist advisers. Anita Charlesworth, Chief Economist at the Health Foundation, was an invaluable aide as the inquiry progressed and Emma Norris, Programme Director at the Institute for Government, was particularly helpful with an audit of independent and semi-independent public bodies, details of which can be found in Appendix 5. We are deeply grateful to both of them. We are also grateful to the staff who worked on the Committee: Patrick Milner (Clerk); Emily Greenwood (Policy Analyst to October 2016); Beth Hooper (Policy Analyst from October 2016); Thomas Cheminais (Committee Assistant to November 2016); and Vivienne Roach (Committee Assistant from November 2016).


1 Q 285 (Simon Stevens)

2 Department of Health, ‘The NHS Constitution for England’: https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#principles-that-guide-the-nhs [accessed 28 March 2017]

3 House of Commons Committee of Public Accounts, Financial Sustainability of the NHS (Forty Third Report, Session 2016–17, HC 887)

4 House of Commons Committee of Public Accounts, Financial Sustainability of the NHS (Forty Third Report of Session 2016–17, HC 887)

5 The Health Foundation, ‘How does the UK compare internationally for health funding, staffing and hospital beds?’: http://www.health.org.uk/chart-how-does-uk-compare-internationally-health-funding-staffing-and-hospital-beds [accessed 28 March 2017]

6 Q 70 (Ian Forde)

7 Q 70 (Professor Alistair McGuire)

8 Q 70 (Ian Forde)

9 Care Quality Commission, The state of health care and adult social care in England 2015/16 (12 October 2016): http://www.cqc.org.uk/sites/default/files/20161019_stateofcare1516_web.pdf [accessed 28 March 2017]

10 Q 60 (Sir Muir Gray)

11 Written evidence from Mind (NHS0179)

12 Q 322 (Professor Sir Michael Marmot) and The Marmot Review, Fair Society Healthy Lives (February 2010): http://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf [accessed 28 March 2017]; the report identified striking levels of health inequalities across the country.

13 Q 72 (Professor Alistair McGuire)

14 Q 105 (Ben Page)

15 Liaison Committee, New investigative committee activity (3rd Report, Session 2015–16, HL Paper 113) and House of Lords Minutes of Proceedings, 25 May 2016




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