Breakfast seminar

By 2021 the gap in NHS funding was likely to have reached around £30bn, Paul Burstow told Care Conversation delegates. On top of that, to maintain even current levels of social care provision against demographic changes would take another £7-9bn. “The reality is that public finance is still in intensive care.”

Since 2010 the NHS had been “quite effective” at responding to austerity, he said – “via the low-hanging fruit of pay freezes and so on” – but it was poorly placed to do so in the future. “There’s a real set of pressures building up in the system,” he told the seminar.

The principle focus of the 2012 Health and Social Care Act, however, had been reform on the commissioning side, and “getting that clinical engagement” was crucial to the future of the system. “Clinical Commissioning Groups and Health and Wellbeing Boards deserve the time, space and support to be allowed to mature and deliver.”

The Act also represented a shift in focus towards outcomes, he said, with integration and coordinated, joined-up care now essential to both mental and physical health provision. “But the problem is that we have a healthcare system that’s fundamentally designed around body parts and fixing body parts. The ‘diagnosis and cure’ scenario that people are used to from TV dramas is not the reality that most people experience.”

Instead, the emphasis was on caring for people with chronic, long-term conditions, and in terms of the wellbeing of this population, coordinated care “should be the norm and should be expected”, he stressed. However, many of the necessary changes needed to happen beyond the healthcare system – matching local priorities to local needs – and Health and Wellbeing Boards were ideally placed to do this. “Indeed, individual wellbeing should be an organising principle for adult social care, as defined by the 2012 Act.”

“So, commissioning for wellbeing – what does it mean?” he said. “It means commissioning for outcomes,” and there were excellent examples around the country that were increasing productivity and delivering gains. However, change was also needed on the provider side, he argued, for example a focus on sharing risks and rewards across providers. “To this end, Monitor and NHS England could and should be doing more to dispel some of the myths about the impact of competition on services.”

The forthcoming Better Care Fund would amount to at least £3.8bn, he said, but the government needed to be “talking about how it sees that evolving”. It was also vital to go further and include things such as housing and employment, or even pooling budgets with police services to help reduce the number of people with mental health problems who ended up being detained in the criminal justice system.

A “significant back-office cost” could be saved though more innovation in system design and use of new technology, he stated, although this could often lead to battles over implementation. Also vital was a national programme to map out services at local level to help support people living with long-term conditions, with some GPs and primary care practices already embracing this approach. Mental health, despite causing and exacerbating a huge burden of physical disease, received only a small percentage of NHS funding, he stressed.

In terms of overall wellbeing, there had been a lot of good work “going on quietly” around reducing levels of salt in food, with similar action now needed over sugar. There had also been “a good mix of education and legislation” in terms of tackling smoking, while financial mechanisms such as minimum unit pricing and excise duty could help address alcohol-related ill-health. “The responsibility deals with industry have been more effective than they’ve often been given credit for,” he said.

“Can the NHS survive another five years of flat cash? If things stay as they are, then the answer is no. That’s why things like integration of the provider side and commissioning for outcomes are so important. It’s very easy to get trapped into talking about more money on its own, without talking about what it’s needed for. There needs to be clarity in the system, and it needs to be made much more transparent to the public what it is they’re paying for".