Health: the spending dilemma

16 Mar 2018 Nick Garbutt    Last updated: 16 Mar 2018

Picture: Nicoleon, Wiki Commons

Senior health officials will be wrestling with an extremely tricky dilemma this week.

They now have a budget to work with, but it is insufficient to cover anticipated need. On the positive side they also have an extra £100 million to help fund the transformation of health and social care. Yet with no Minister in place to provide direction, how do they spend the money?

And, given the lack of government, what else, if anything, can be done to help ease the growing burden on a service which everyone knows is no longer fit for purpose?

First to the budget. Secretary of State Karen Bradley’s written statement commits to a 5.5% uplift on last year’s allocation.

This sounds terrific. But it is important to remember that the increase is based on last year’s starting position.

However last year an extra £140 million was found for Health through in-year allocations – redistributing unspent monies from other departments. This was used to fund pay increases, reduce waiting lists and cope with winter pressures in Emergency Departments.

When this £140 million is factored back in, we find that the actual increase is just 2.6% - this is not enough to maintain existing services. We know this because demand is increasing by between 5-6% every year.

Therefore the department is having to gamble on further in-year allocations just to stand still. This is a precarious position to be in, to say the very least. These monies are unpredictable because they depend on budgets not being spent in other departments. As the squeeze on public spending tightens, it is not at all certain how much, if any, will become available this year.

So far so bad.

However there is the £100 million in transformation money. How to spend that will also be causing considerable internal debate.

But what can be done without a Minister in place and the consequent lack of policy direction, against a backdrop of a general lack of understanding of the necessity for change and ferocious resistance to some of the measures that need to be taken?  There will be a temptation to look for “wriggle room” – to see how at least some of this might be re-allocated to prop up a system in crisis.

There is a delicious irony here. In the past Trusts have prioritised propping up existing services over reform and so therefore successive Ministers have been relying on in-year allocation to fund reform – and not all bids have been successful. Back in March 2015 the Department was estimating £45.3 million was required to shift from hospital to community services in order to reduce admissions and cut waiting lists.

The current situation has changed everything. This time around the money for reform is available, yet there is not enough to maintain existing services without extra funds.

There are no easy answers, but at least the civil service can take comfort in doing the right thing – by spending money for the purpose it was allocated – on change. However tempting it might be to find ways of diverting cash elsewhere this should be resisted because the transformation money represents a one-off opportunity and has the additional benefit of providing savings in the medium to long term.

The most obvious area to concentrate on is a concept that is central to the 2011 landmark document Transforming Your Care, and one on which some progress has been made – the development of effective Integrated Care Partnerships (ICPs).

ICPs are fundamental to a reformed health service because they are designed to ensure that a person’s home is the hub for their care and that hospitals are for those in acute need.

Transforming Your Care outlined the need for 17 ICPs across Northern Ireland and specified what they would provide: “Partnerships will be set up to join together the full range of health and social care services in each area including GPs, community health and social care providers, hospital specialists and representatives from the independent and voluntary sector.

And it further laid out how strains on acute services would be reduced: “Under the new model more of the services that currently require a hospital visit will be available locally.  This may include for example, X-rays and other diagnostic tests, and oral surgery.  GPs will be enabled to undertake minor procedures in their surgeries.  Outpatient appointments in many instances will be provided in the community rather than in hospital.  In some specialties, care will be organised directly by the Integrated Care Partnership.”

This concept of care in the home, or close to home, is critical to the future of the health service and the department has an opportunity to invest further in it, which in turn will reduce costs and pressures.

Progress on this would be the most positive contribution the department could make at this difficult time.

But there is more.

Many are confused when it is pointed out that of all the health indicators only around 20% are related to the work of health professionals.

A few moments reflection reveals the truth of this. For many the individual who has made the greatest contribution to health in the UK is the late Nye Bevan who created the NHS in 1948. Yet it is arguable that an even more important development was the one spearheaded by Edwin Chadwick almost precisely 100 years earlier.

Chadwick’s pioneering work Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain contains the following colourful passage:

“That the various forms of epidemic, endemic, and other disease caused, or aggravated, or propagated chiefly amongst the labouring classes by atmospheric impurities produced by decomposing animal and vegetable substances, by damp and filth, and close and overcrowded dwellings prevail amongst the population in every part of the kingdom, whether dwelling in separate houses, in rural villages, in small towns, in the larger towns — as they have been found to prevail in the lowest districts of the metropolis.

“That such disease, wherever its attacks are frequent, is always found in connexion with the physical circumstances above specified, and that where those circumstances are removed by drainage, proper cleansing, better ventilation, and other means of diminishing atmospheric impurity, the frequency and intensity of such disease is abated; and where the removal of the noxious agencies appears to be complete, such disease almost entirely disappears.”

The work led to the Public Health Act of 1848. And so it came about that the health of a nation was transformed, not by more hospital beds or operations but by building sewage systems and water treatment facilities – infrastructure projects.

After the “Great Smog” of 1952 killed 4,000 in London, a series of Clean Air Acts were enacted, again having a dramatic impact, this time for respiratory illnesses. This yet again was not about treatment, but prevention through environmental measures.

It is time that policy-makers woke up to this. What might be called pure health spending tends to get ring-fenced, which means that the 80% of other factors are not, which inevitably means they are not prioritised, which again increases the burden on the health service.

We need to start thinking of health in much broader ways than is current – just like our ancestors did.

Thankfully there is some evidence of this happening. The Sugar Tax is due to be introduced next month. It will help to combat childhood obesity – currently around a fifth of children leave primary schools clinically obese. Childhood obesity is regarded by the World Health Organisation as one of the most serious public health challenges of the 21st Century. The tax at once raises the profile of the problem, makes sugary drinks more expensive and raises revenue.

It is projected to bring in around £520 million per annum. England’s portion of revenue will be used to fund sport in school. It will be up to whatever government we have at the time to decide how it is deployed in Northern Ireland.

In 2012 local authorities in England were given more responsibility for public health. In response the King’s Fund published a guide which outlines some of the actions that could be taken. It is just as relevant here and useful in that it outlines the savings that can be made for the public purse if recommendations are acted upon. But it does require the realisation that health is not just for doctors and the Department but a collective responsibility for every organ of government, wider society and every individual within it.


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