Myth Busting

“Demand for NHS services shows no signs of abating. With hospital finances increasingly weak, growing pressures on staffing, and the goal of moving care out of hospitals and into the community proving elusive, the NHS is heading for a funding crisis this year or next.” So reported the Nuffield Trust last month, with mental health services particularly hard hit. And may hospitals are now on ‘black alert’ and turning ambulances away in the summer So can anything achieve the quick and massive efficiency savings necessary to get the NHS out of financial meltdown?

No, is the simple answer- not that you’d realise it as the government and NHS England furiously try to paper over the cracks in the run up to an election. Many of the ideas doing the rounds make sense – investing in prevention, encouraging healthier lifestyles, moving care closer to home and better support for people with long term conditions. They could make the service better, but there is little evidence they will save it a lot of money. The average age of a GP patient is 75, and a hospital patient over 80, and as people live longer they simply need more care. Most people who go into care homes have had numerous failed attempts to stay at home (despite big cuts in social care funding) and only go in as a last resort. People in care homes tend to be very dependent, disabled, demented, frail and unwell. It’s a fantasy to think we could ever close all the care homes, and yet NHS England chief executive Simon Stevens told a recent Age UK conference that nursing homes could become redundant during his lifetime if only we invested in “new technologies.”

The idea that new technologies will save the NHS a popular recurring myth, especially amongst companies who manufacture them, and the many MPs and Lords who have shares or other vested interests in them. We clearly need to use electronic records, telehealth and telecare better but the Cochrane reviews and the Department of Health’s own Whole System Demonstrator trial (WSD) have thus far shown very limited evidence for their clinical and cost effectiveness.

WSD benefits were over-claimed by senior government officials before trials were published with NHS England’s Jim Easton (now of Care UK) saying: “Now we know telehealth works, there is no excuse or not rolling it out at pace”. Also, DH director of innovation Miles Ayling has penned pieces in the Health Service Journal next to sponsored pull-outs for telecare and plugging new technologies. Such enthusiasm despite the fact that the Connecting for Health NHS IT disaster cost an estimated £12 billion (more than the cost of all primary care), with many hospitals squandering large amounts on useless IT systems. How will new technologies be better this time round? Where’s the evidence?

Likewise, giving very frail, dependent patients their own health and social care budget is politically appealing and opens up the NHS to the private market, but there is as yet no evidence it will keep them out of hospital. Sweden and Holland – very ‘age-friendly’ countries with good integrated care – still need care homes. Another NHS myth is that there are too many hospital beds. In fact, we have lost around one-third of our acute beds since 1979; lost them faster than nearly all OECD countries; and have fewer beds per head of the population than nearly all. Urgent admissions have risen year on year during this downsizing and NHS hospitals are run very “hot” and close to capacity.

All four NHS countries have full hospitals, and the market in England is neither the cause nor the solution. In the NHS, it’s still doctors rather than finance directors who admit patients, and none would hospitalise a patient unnecessarily to make money for their trust. Far more likely is that patients are sent home when they need to be in hospital because there are no beds. Slashing hospital bed numbers further would be a very dangerous game, even if better community support existed (it doesn’t – social care and general practice are woefully underfunded). NHS England claims emergency admission of someone with frailty or long term conditions can become a ‘never’ event, but if you have a hip fracture, acute stroke, heart attack, severe sepsis etc, hospital is the only place to be if you want active treatment. The issue is patients stay too long after because there is nowhere for them to go. As people age, the demand for excellent care homes and hospital care will increase, and we need to get real about funding it, not obsess with market solutions of no proven benefit other than they make money for MPs, Lords and the former business associates of those now running NHS England.

Shop till you drop?

Is giving patients with chronic diseases their own health budget to buy the care they need a good idea? It’s certainly got Simon Stevens, NHS England’s new Chief Executive, very excited. Personal budgets for social care have been around for some years, and Stevens believes ‘north of five million patients’ will have a combined personal health and social care budget by 2018. £5 billion will be taken out of the NHS pot and handed directly to patients. What could go wrong?

Very few politicians will dare argue against such a grand scheme to ‘trust the people’, and if the people decide to buy all their healthcare from private providers rather than the NHS, it’ll be the cleverest Trojan horse to get private providers a slice of the NHS cake yet invented. That makes it even less likely that many in either House will kick up a fuss. Around 200 honourable members in the Lords and Commons voted through the Health and Social Care Act knowing the private health companies they have an interest in could benefit. None had the ethics or insight to abstain.

Personal budgets in health have been piloted in England only on a small scale and the PHB website has lots of heart-warming stories of patients with chronic diseases and disabilities who have benefited by, say, getting the physiotherapy, nursing or counselling care they need, when they need it.

In social care, patients are allowed to employ their own carers and take them into the NHS. As one Eye reader wrote: ‘‘I have a degenerative neurological condition and I’m completely bedridden.  My diet is mostly fluid (I have a peg into my stomach) and I’m fortunate in that I receive Direct Payments from social services to fund my team of carers (that was a battle with social services… drove them potty but I knew what my rights were). My support workers always accompany me on admissions to hospital, otherwise I’d never receive the assistance I need as the wards are so understaffed. They are my advocates and they keep me safe and speak up for me in the NHS”

Stevens, and the government, believe that giving patients combined health and social care budgets will keep them healthier, happier and more independent in their homes and this will reduce hospital admissions, therefore compensating for the £5 billion that may be taken out of the NHS to pay for the scheme. It would be easy to set up a trial to prove this. Recruit a few thousand patients who are eligible for personal health budgets, split the group in half and randomly assigning them to either get a budget or not. Then follow them all up to see if the people with their own budgets have fewer hospital admissions. Sadly this has not yet been done. Research and reform rarely go arm in arm in the NHS. Enthusiastic ideology nearly always trumps evidence.

The experience in social care is that early adopters of the scheme get a healthy budget and do very well, to make it look a political success, but when you try to roll it out to millions it gets more problematic, particularly as budgets are then squeezed year on year. Also, new layers of bureaucracy – the ‘resource allocation system’ (RAS) – are invented to try to let people know the size of their budget upfront so they can make sensible decisions about how to spend it. This hasn’t worked well in social care and many clients on personal budgets now get either get exactly what they got before and often less, as all social care funding has been cut.

The patients who benefited most in social care opted for direct cash payments, rather than letting someone else manage their budget, and those considering the health budget should choose this option and get in there early – preferably before the election – and before the money is cut back. If people are given excellent advice and support on how best to make complex choices and spend the money, the system could work very well for some. But this support too costs money. And we could enter a world where the health and social care you get depends less on your needs and more on how good you are with the money. And what happens if you overspend?

Universal healthcare is being replaced by a market system on a very personal level, with no evidence base. There will be winners and losers, and you either opt for a budget or stick with an NHS that’s £5 billion poorer. Say yes, and two hundred happy Lords and MPs will be after your business.