NHS - Preparing for winter and beyond: speech by the Health and Social Care Secretary
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Please see below a checked-against-delivery copy of the Health and
Social Care Secretary Rt Hon Steve Barclay MP’s Policy Exchange
speech: NHS - Preparing for winter and beyond Intro Thank you Dean
for that introduction, and thank you Policy Exchange for hosting
this speech ahead of the appointment of the new Prime Minister and
the return of Parliament next week. Over the summer we have made
progress on a range of issues in the Department of Health and
Social Care,...Request free trial
Please see below a checked-against-delivery copy of the Health and Social Care Secretary Rt Hon Steve Barclay MP’s Policy Exchange speech: NHS - Preparing for winter and beyond Intro Thank you Dean for that introduction, and thank you Policy Exchange for hosting this speech ahead of the appointment of the new Prime Minister and the return of Parliament next week. Over the summer we have made progress on a range of issues in the Department of Health and Social Care, including:
Today I want to focus on our preparation for the inevitable winter pressures, and outline wider opportunities for the NHS - within the context of someone returning to a department 4 years after last serving in it, and who has been able to view it in the interim from the Treasury, Cabinet Office and as Chief of Staff in number 10. And of course, to do so as we emerge from the pandemic which has hampered the progress which the NHS and social care system was making prior to that. Winter Ambulances First let me turn to winter, and the number one priority for the department and NHS England, which is ambulance handover times - and you will have seen this is not just my number one priority but from the recent viral video with my heckler that this is also a wider priority as well. To tackle the problems, we are bringing a new focus on operational performance, underpinned by data. A small number of Trusts account for almost half of ambulance handover delays, and so targeted work over the summer has been focussed in particular on these trusts, including building capacity in emergency departments, introducing pre and post cohorting and observation areas, supporting Emergency Department triaging and the risk assessment across the hospital as a whole. Yet the issues are not totally within those hospitals’ own control. Some actions sit with the ambulance trusts (such as variance in conveyance rates or different performance on call handling), some will sit with Integrated Care Boards (such as providing a single point of access for paramedic crews, particularly when dealing with the frail elderly), others will sit with care homes (such as innovative equipment – I had a demonstration on one visit with an ambulance crew of the Mangar Elk lifting cushion – of course, other brands are available, but it shows how technology can speed up how quickly the frail elderly who are on the ground can get back on their feet), and some of these issues sit with NHS England itself in terms of how it prioritises national funding. Delayed discharges A lack of flow within our hospitals is also driving ambulance delays, as if those in A&E cannot access beds on wards, it in turn prevents ambulances dropping off patients. We currently have over 12,000 beds occupied by patients who are medically fit to discharge. This is also resulting in poor patient outcomes, in particular with the frail elderly, as patients often deteriorate if they remain in hospital beds too long. So over the summer we have been working with an NHS England taskforce to put in place best practice interventions. Crucial this winter will be the effective operational performance management to identify where accountability sits for delayed discharge in a complex system. This includes the level of integration with social care including care homes and at home care. It also includes addressing problems within the NHS’s own control: one fifth of delays are due to NHS community services and another fifth due to NHS hospital delays – so for example looking at plans around lower weekend discharge rate, specific action on conditions such as dementia, Parkinson’s or palliative care, the delivery of long-term plan commitments on mental health, and of course the additional 7,000 beds capacity which NHS England has asked for in the community. Cancer Capacity is also key to addressing the important issue of cancer backlogs. With urgent care referrals now at 118% of pre pandemic levels, and the growing number of Targeted Lung Health Checks, we need to make a significant uplift in diagnostic capacity to match this. The roll out of Community Diagnostic Centres - we have announced a further 7 today- are a key step in doing so, but these take time to open. So we also need all Trusts to prioritise the three cancers which account for two thirds of current delays in diagnosis, which are skin, prostate, and gastrointestinal, and on which there is too wide a variation particularly with the bottom 20 trusts. Integrated Care Boards will also need to prioritise new cancer pathways, such as through pharmacy and community referral. Electives
Alongside ambulance delays, a second dominant health issue is clearing the Covid waiting list backlog. Over the summer the two-year waits were virtually eliminated, with the final 2,000 cases set to be resolved by the end of September. We have accelerated key programmes - in particular Professor Sir Tim Briggs’ Get It Right First Time Programme with quicker patient routes to surgical care, supported by the additional 50 surgical hubs announced last week alongside the existing 91. In tandem we are shifting more operations from the operating theatre to outpatients, with the Right Place Right Time programme - an example when I visited Homerton was that they told me they are delivering 3 times the productivity rate on certain gynaecological procedures in outpatients than if carried out in the operating theatre. There is also low hanging fruit from addressing variation in performance. Let me give you an example. If all operating theatres move to 85% utilisation from the current average of 72% - as indeed the GIRFT programme recommend - that alone unlocks an extra 410,000 operations a year. This extra capacity, including from the surgical hubs, will be crucial in terms of resilience, given that in each year since 2015 operations have been put on hold as winter pressures mount. The adoption of surgical hubs therefore on standalone sites helps mitigate against this risk. We also need to make sure that patients are able to exercise choice at the very start of their care – and that’s why more choice will be offered at the point of GP referral. It’s not just about the right to choose a hospital with a shorter wait, but we need to make better use of the NHS App so patients can organise appointments in a seamless way as in other parts of their lives. For operations like hip replacements, currently patients face average waits ranging from 6.8 weeks to 34.4 weeks, so we should empower patients with the choice to travel if they are willing to do so. GP access Empowering patients is also part of addressing GP access concerns. There are over 6 million GP registrations a year, with early testing suggesting online registration reduces processing time by 15 minutes for each application, as well as improving choice and convenience. So we will lay a statutory instrument next week to amend the GP contract to enable this. Significant GP time is also taken as a result of the interface with secondary care, and we have prioritised work over the summer how we reduce this burden for GPs including prescription requests from discharged hospital patients. We are also working with NHS England to determine how additional flexibility could be brought into the Additional Roles Reimbursement Scheme in Primary Care Networks so we can free up GPs time where possible. Mental Health Integrated Care Boards also need to continue to demonstrate how the increase in over 24,200 new staff in mental health services since March 2016 and is set to grow further over the coming year, and how the £2.3bn real terms annual budget increase by next year, are starting to shift the dial on services. We know the pandemic has seen an increase in demand for mental health services, and that we need to prioritise mental health going into the Winter. The NHS has responded to this by expanding community and crisis care mental health services, and it has helped keep stable the emergency attendances to A&E for mental health concerns. This includes a rapid roll out and expansion of community-based crisis services, and there is now a complete coverage of 24/7 of crisis resolution and home treatment teams across the country, that is bringing care closer to the home into a more therapeutic environment and reducing pressure on hospitals. This means we are treating more people now than ever before. Use of digital products with the best evidence of clinical and cost effectiveness can also greatly help with the management of demand for mental health services. NHS England have found a low level of awareness of this work, and I share their desire to see it more widely promoted. Medium-term opportunities Those have been key immediate priorities over the summer. But I have also been examining the opportunities for the NHS in the future, and what we need to do to grasp them. Workforce is of course critical, for both health and social care, and we need to act fast to address the high number of vacancies. That is why we have set up an international recruitment taskforce, and it is also why we need to think more about retention, given it is a cheaper way to retain a clinician than train a new one. By way of example, it takes 10 years to train a GP, but currently around 500 GPs aged 55 to 59 leave the profession each year. There are clearly a range of options that are being publicly debated on pensions which colleagues in the Treasury will wish to consider, and indeed I have discussed with them. Last week we launched a consultation on a retire and return easement to encourage staff to return given the pressures expected in the months ahead. We also need to make sure that we use the workforce we have as flexibly and efficiently as possible, and I have been hugely encouraged to see the excellent work being done as part of the forthcoming workforce strategy and workforce plan. We need to see new roles such as Advanced Practitioners embedded in the NHS, and we need to see more staff practising at the top of their licence. We are also taking targeted action in specific priority areas, for example investing £127 million to increase and support the maternity NHS workforce and increase neonatal care capacity over the next year. This is on top of £95 million investment into recruitment of an additional 1,200 midwives. Community-based care We should also continue to push for more decentralisation of NHS services away from hospital sites where that is appropriate. A key objective of the Government is to level up, including in communities with poor health outcomes which often have a significant journey time from the nearest major hospital. A good example is Community Diagnostic Centres which bring treatment often closer to the home, and which so far have delivered 1.7 million tests. There is also scope for more home testing and I have commissioned the department to consider how we embrace home testing for a wider range of conditions through a modernised health check and can announce today that I have asked Professor John Deanfield to take this forward. Tech One consistent priority of successive Secretaries of State has been the greater use of technology, including areas like machine learning. We need to ask ourselves why it has seemingly been so difficult to scale innovation, with many pilots commissioned but those that are successful not always rolled quickly across the NHS. In practice, NICE is already breaking new ground. Together with NHSE they are working to develop a policy framework for an Early Value Assessment for digital health technologies, which can also be applied to medtech. This policy framework will greatly improve the uptake and adoption of well-evidenced technologies and provide clarity to industry partners of their route to scaling and reimbursement, and again I have written to NICE asking for this work to be expedited. Longer-term Turning to the longer-term, we need to act on the large number of priorities being set by the centre, many of which are not measured in a way that supports individual accountability. I’ve got the sense – I may not be alone in the room – that over the years that the NHS likes to hire McKinsey and I think it was McKinsey which said that quote “you cannot manage what you do not measure”. By way of example, when I replied earlier this month to the recently launched Health Select Committee investigation into digitisation in the NHS, and was somewhat surprised that the attachment to my letter shared with me by the department ran to 20 pages all with past commitments that were worthy, but clearly some are more urgent priorities than others. And yet for all the priorities, when I visited North Warwickshire Hospital Trust, a major trauma centre, a leading surgeon told me how his team often sit around on a Monday morning waiting for images to load. Ensuring all trusts have effective wifi, and patient electronic records, should be part of prioritising fewer but more impactful issues. We therefore need fewer central priorities which free up more local decisions with a focus on those that are most impactful and scalable. For example, at the national level, my focus on ambulance handover times will improve patient flow, which will help improve care for anyone in need of hospital treatment. We also need to have better alignment in priorities between the Department, ALBs, and ICBs, and ensure there is a focus on delivery and accountability. This is not about relaxing core NHS standards but clarifying the performance management of those standards to enable meaningful accountability. A key driver of the large number of priorities is the size of the centre. Both leadership candidates for Prime Minister, as former Chief Secretaries themselves, have signalled the need for efficiency savings across Whitehall. Given the Department of Health and Social Care is expected to account for £4 in every £10 of day-to-day Government expenditure in the near future, it is a natural place to start to identify what can re-prioritised to meet front line pressures. DHSC and its arms length bodies cost £2.8bn a year to run. The department itself employs 4,335 staff with a pay bill of £260m and estate and other costs of £125m, and NHS England, 13 ALBS plus several other similar bodies, together employ a further 37,200 FTE with a payroll of £1.9bn and estate and other costs of £470m. In addition, the 42 new integrated care systems have 25,000 staff transferred earlier this year from clinical commissioning groups, and there is a further 7,000 in Commissioning Support Units. So even if you exclude ALBs like the NHS Blood and Transplant Service where staff support blood and organ supply to hospitals, if you exclude the CQC which has inspectors playing a key role, just across the ICSs that’s 32,000, the department with 4,300, NHSE with 10,117, NHS Digital 3,950, HEE 2985, that equates to over 53,000 staff in organisations where the majority are not providing direct patient care. That is in addition to the actual management within hospitals, community settings, primary care, and health research, that is additional to that. My point is, this is not just an issue of cost. It is also about effectiveness. Too much management can be a distraction to the front line. Staff at the centre need to streamline the administrative burden of those on the frontline and not risk adding to it. If we are to re-prioritise back-office costs to the front line, there needs to be more transparency. As such in my first week I commissioned the first ever digital map of the department, and this was initially extended to the 8 largest ALBs and now has been applied to the remaining 7. I can announce that the department will publish its organogram on Monday, with a searchable format to follow shortly afterwards, and I have instructed all ALBs to do likewise in publishing a searchable organogram by the end of September at the latest. This will show all job titles and the number of people working in each team, and I have asked the department and ALBs to add by the end of September the cost of each team reporting to Director level. This will enable those within the NHS, as well as those outside, to better understand how this £2.8bn is being spent, and in particular to empower NHS staff to identify whether this funding is being spent in areas that are most helpful for them in terms of delivery on the front line, so it will stimulate I hope a conversation within the NHS about how priorities and resourcing is best aligned. In the meantime, I have put in place a recruitment freeze in the department and set the expectation across ALBs and on consultants and contingent labour. I have asked the department to review all contracts this year with a view to a minimum 20% saving with the expectation of going further this year - in some cases 80% savings - informed by contract analysis – and I’m hugely grateful to Lord Agnew for the support he has given in this area. This would unlock £170m at 20% savings across the department and ALBs as in-year savings this year, with much more scope for higher savings next year given that obviously we have already lost 7 months of this year in terms of the saving opportunity.
Estate Finally, I want to turn to an area of potentially greatest saving and indeed one that unlocks improved performance following specific changes I have agreed with the Treasury over the summer – and that is how the NHS procures new hospitals and in time wider buildings within the NHS estate. When I was in the department 4 years ago, I visited Midland Metropolitan Hospital in Birmingham shortly after the collapse of Carillion, which I’m sure some in the room will remember, and I was surprised to discover that even the bathrooms could not be built to an offsite modular design as each one was a different size. In the past each trust executive has been largely free to embrace unique or varied designs. Indeed, if you look at the last 10 hospitals built, 9 have seen significant cost overruns and delays. That’s not just a cost issue, it means the benefits operationally of those hospitals are delayed for staff and patients. Allowing trusts to design and procure bespoke hospital buildings frequently results in poor scoping work before contracts are awarded, contracts awarded at too early stage meaning too much risk is priced in and trusts with little or no past experience who are simply not geared up to build complex schemes. In turn bespoke designs require more work in terms of their approval process including from Treasury whereas greater standardisation can streamline that process. Applying a standard design and specifications - model hospital 1:0 - allows greater cost price certainty with factory build, economies of scale through standardisation, and quicker onsite construction. In turn this means the operation benefits of the new buildings are unlocked much sooner. Conclusion Put together the steps we have taken, whether on estates or the other areas I have set out, will enable the department to finish the summer better prepared for the winter ahead. And although the winter will be challenging, we should be confident there are opportunities to improve the NHS and social care systems beyond it:
In conclusion, the NHS demonstrated during Covid its ability to move at pace, adapt and innovate and within Whitehall different ways of working as we saw on the vaccines taskforce showed that schemes could be delivered in a more agile way. Whilst Covid has left us with challenges, in particular the elective backlogs, it has also shone a light on the way that we can deliver differently which will be essential if the NHS is to meet the immediate challenges this winter and those in the longer term. |