NHS constitutional standards
- Nearly three quarters of trust leaders (71%) think that it is very unlikely (25%) or unlikely (46%) that the NHS can meet the constitutional standards over the next five years. 13% said it was neither likely nor unlikely. Only 14% of trust leaders think it is very likely (1%) or likely (13%).
- Looking across the different trust types, all respondents from acute specialist (100%) and ambulance trusts (100%) said it was very unlikely or unlikely that the NHS can meet the constitutional standards over the next five years. Three fifth of leaders from mental health trusts thought it unlikely or unlikely the NHS can meet the constitutional standards (63% from mental health/learning disability trusts, 60% from combined mental health/ learning disability and community trusts). Those from combined acute and community trust were the most optimistic compared to other trust types however, 59% still said meeting the constitutional standards is very unlikely (41%) or likely (19%).
What does the government need to do to enable trusts and systems to achieve this goal?
- The comments gave a mixed picture of what government needs to do to enable trusts and systems to achieve this goal. Some trust leaders highlighted the need for clear direction on where to focus efforts. However, others wanted local systems and providers to have more freedom and less bureaucracy, allowing them to adapt and meet the needs of their local population.
- Another key theme was the need for appropriate revenue and capital investment, alongside support to enhance community services, social care and prevention efforts.
“Avoid structural reorganisation and major changes to legislation (except the planned MHA reform). Set realistic aims and policy with an appropriate financial settlement. Work with NHSE to establish a capital funding model that meets the needs of the NHS (and wider public sector).”
“The focus on transformation is right but that needs to be underpinned with funding, or short term decision making will trump the longer term goals. Specifically, funding mechanisms and national targets need to be adjusted to make the long held ambition around "left shift" a reality.”
“Address the long term decline of revenue and capital and develop a ten year strategy which incentivises local systems and providers to work in a more flexible and adaptive way. A range of earned flexibilities and freedoms would help, also."
“See through the approach to prevention, primary and community care outlined in the Darzi report and resist the temptation to change organisational structures!”
The government has announced that it will formulate a 10-year plan for the NHS. What would be your top three priorities for the plan?
Trust leaders suggested a wide range of priorities, but there was clear agreement on the top three: supporting investment and reform in social care, ensuring adequate investment in and supply of the workforce, and increasing capital investment.
Additionally, many expressed strong support for shifting investment towards community-based care, out-of-hospital services, and preventive care.
Top priorities for the new government to enable improvement of patient care over the next decade
- When considering enablers for improving patient care over the next decade, over half of trust leaders (54%) said that they would like capital investment in estates, fleet or equipment to be a top priority for the new government.
- Just under half of respondents (48%) said they would like to see capital investment in digital a top priority for the new government.
- Two in five trust leaders (41%) said they would also like social care to be a top priority for the new government.
- Nearly a third of respondents (32%) said they wanted to see investment in mental health services.
Shifting care from acute services to community and moving care closer to home for patients
- The majority of trust leaders (98%) supported the national policy agenda to shift more care from acute services to community and move care closer to home for patients. 1% said no.
- In the comments, there was widespread support for the national policy agenda to shift more care from acute services to community and closer to home, but some important caveats were highlighted. Some trust leaders said there may be a need to double run services; invest in community services before reducing demand and reallocating resources from acute services.
“But there has to be an exception that we need to double run. In that we need to invest in our community services to manage the increasing demand before you can reduce hospital demand and reallocate resources.”
“Recognising that there is demand growth, so it is increasing community w/o necessarily reducing acute capacity - we need lower occupancy to provide better care and more efficient care.”
What do you think is key to facilitating this shift?
- Many trust leaders said that a change in incentives, including financial incentives, were needed to facilitate this shift. They also thought that there should be a shift in accountability measures beyond just outputs.
- Trust leaders were also keen to highlight the need to increase capacity in the non-acute sectors including social care, community and primary care.
- Additionally, integration, including between the NHS and social care and local authorities, was identified as important.
- Several trusts also spoke of the need for a shift in public perception and improving understanding of moving care away from acute services and into the community.
“Collectively, as an NHS and its regulators and politicians must shift the accountability focus to prevention rather than the output based measures that we spend more than 90% of our time focused upon.”
“Hard wiring the financial flows and public engagement to help with wider understanding.”
“Allow ICSs to set their own priorities based on good population need assessments. Set investment standard targets for minimum amounts for each system to spend on prevention/public health, primary care and mental health. Fixing the social care funding model is also key to this.”
What barriers currently exist that have stopped this shift to date?
- Trust leaders offered further insight into the key barriers that have prevented this shift taking place before. Many said funding structures have not encouraged the move towards providing more community-based care, particularly due to the need to cover double costs during the transition.
- In addition, trust leaders emphasised that organisational and cultural resistance, and the political focus on acute care targets, has reinforced the status quo and hindered progress.
“The amount of system resources consumed by acute care coupled with national focus on A&E performance and elective waiting times.”
“Costs are incurred in hospitals to care for patients who could be cared for out of hospital, therefore not freeing up funds to create the services needed out of hospitals. Investment in community, mental health and social care needs to happen first to reduce the work in hospitals, to get on with caring for patients it should be caring for.”
“The challenge of significant inter-organisational change while under such extreme clinical pressures.”
Confidence that support and infrastructure is in place locally to enable a more integrated service across primary care and secondary care
- Three in five trust leaders (62%) were very worried (21%) or worried (41%) that support and infrastructure is in place locally to enable a more integrated service across primary care and secondary care. This is higher than the proportion last year (57%). Almost a quarter (24%) were neither confident nor worried and 12% were confident.
- Trust leaders raised some concerns about a lack of coordination at ICB level in supporting joined up services locally. There were also concerns about the GP dispute; a lack of infrastructure to scale integrated care plans and the difficulties arising from funding flows between primary and secondary care.
“Primary Care is under real pressure and their "Collective Action" approach will only yield to more pressure in the system.”
“Funding flows do not support a well-integrated service model across primary and secondary.”
Confidence that sufficient investment is being made in public health and prevention in local areas, including direct investment by trusts, or by the system and its partners
- Nearly three quarters of trust leaders (72%) were very worried (36%) or worried (36%) about whether sufficient investment is being made in public health and prevention in their local area. This is a similar proportion to last year (73%).
- Looking across different trust types, the majority of trust leaders from community trusts (91%) were very worried (45%) or worried (45%), and over eight in 10 leaders from combined mental health and community trusts (83%) were very worried (39%) or worried (44%). Leaders from combined acute and community trusts reported lower levels of worry, but over half of these (57%) were still very worried (32%) or worried (24%).
Confidence that sufficient investment is being made in social care in local areas
- When asked about national funding for social care via local government, a large proportion (89%) were very worried (61%) or worried (28%) that sufficient investment would be made.
- However, when thinking about direct investment by the trust, a smaller proportion (46%) were very worried (21%) or worried (25%). When asked about direct investment by the system and its partners, 82% of trust leaders were very worried (38%) or worried (44%) about whether sufficient investment is being made. Trust leaders raised concerns about impact of insufficient social care funding on the delivery of healthcare services.
“The underfunding in social care is undermining every effort the NHS is making that directly affects patient care.”
“There is, in my view, still too much on short term financial balance without the necessary courage and ambition to prioritise the right investments in social care”.