Latest NHS reforms will not succeed until Government fixes longstanding problems, say MPs

 - Benefits for patients of new Integrated Care Systems have not been made clear 

 - Decrepit NHS estate, record treatment backlogs; workforce and financial issues risking patient safety, national health - and success of reforms 

 - “Paralysis by analysis” as crucial projects are repeatedly delayed 

Major new reform of the NHS will not work until Government addresses multiple chronic issues in the Service, says PAC in a report released today. The case has not been made for what improvements Integrated Care Systems (ICSs) will bring to patients, and by when.   

ICSs are the latest attempt to bring NHS and local government services together to join up services and focus on prevention. But the Committee says the reforms will founder if the major systemic problems in the NHS are not addressed by Government at a national level: the elective care backlog has breached seven million cases for the first time; major workforce issues have hamstrung both the NHS and social care; constantly increasing demand; a crumbling NHS estate; and limits on funding.    

These challenges require national leadership but there is a worrying lack of oversight in the new system, and crucial national projects like the NHS Workforce Plan and capital funding strategy are repeatedly delayed – what the Committee calls 'paralysis by analysis'.

The cost of overdue maintenance has reached £9 billion - £4.5 billion classed as high or significant risk - and there are questions about who gets to keep proceeds of any assets sold under ICSs.   

Not enough is being done to focus on preventing ill-health, and not enough joint working between government departments to tackle the causes of ill-health. The failure to ensure adequate NHS funded dental care risks creating more acute dental health problems.  

Dame Meg Hillier MP, Chair of the Public Accounts Committee, said: “Far from improving the health of the nation, staff shortages and the dire condition of the NHS estate pose a constant risk to patient safety. But Government seems paralysed, repeatedly rethinking and delaying crucial interventions and instead coming up with plans that do nothing to address the fundamental problems of funding and accountability. 

 “The ICS reforms have potential but there is no clear responsibility for ensuring that social care is properly integrated with health care or that patients will see the difference on the ground. Changes will not succeed if they are imposed on the NHS in its current state. Government needs to get a grip on the wider, full-blown health and social care crisis it allowed to develop from long before the pandemic.” 

Lead PAC Member Anne Marie Morris MP said: “Everything changes yet nothing changes. ICSs are the latest iteration of a plan to organise the NHS and integrate health and social care. While the ambition is right, the tool kit simply isn’t there to deliver on it. As one of the biggest spending departments funded by taxpayers, more transparency is needed to show what, how and by when the taxpayer will see not just an improvement but a health and care system that works and is truly there when it’s needed.”    

Conclusions and recommendations 

1.      It is not clear what tangible benefits for patients will arise from the move to ICSs, nor is it clear by how much or by when things will improve.  We are still unclear on what specific benefits ICSs are expected to achieve and are concerned it would take another three to ten years for ICSs to significantly improve population health outcomes. ICSs’ capacity to progress longer term objectives such as preventing ill-health is at risk from shorter term pressures. While 77% of senior ICS staff consider their ICSs intend to invest in preventative measures, only 31% feel they currently have the capacity to. The Department is yet to publish its response to its consultation Advancing our health: prevention in the 2020s which closed in October 2019. We were encouraged when the Department told us that the leading indicators around prevention, such as smoking and obesity, are well-understood and should show measurable difference as a result of the move to ICSs. We look forward to hearing what level of measurable improvement the Department expects, and by when. 

Recommendation: The Department should write to us within six months and set out: 

a.      What specific measurable benefits it expects from the formal move to ICSs, including a clear description of the benefits, relevant metrics, and the timeframe for achieving them.    

b.      What barriers have been overcome between the NHS and social care to support the integration of their objectives and funding.  

c.       What action it took as a result of its 2019 consultation on prevention, and whether and when it expects to finally publish a response. In publishing its response, it should set out the known drivers of better health outcomes, how they are measured, and which improvements ICSs will be specifically accountable for, which are the responsibility of NHS England and the Department, and which are wider government responsibilities.  

2.      We remain very concerned about the critical shortages across the NHS workforce and the Department’s repeated delays in publishing a strategy to address them. Workforce shortages are widespread across the NHS, and particularly acute in some specialisms, for example midwifery. This can result in unsafe care for patients. This is a long-standing issue which pre-dates the pandemic and which has continued to worsen: NHS vacancy rates increased from 8.3% in December 2021 to 9.7% by June 2022. The NHS Long Term Plan committed to producing a Workforce Implementation plan by late 2019, and in September 2020 the Department told us that it expected to publish it following the 2020 Spending Review. It still has not done so. The Department’s ongoing failure to publish the workforce plan is extremely disappointing. It is unclear how ICSs are supposed to plan for workforce shortages when the Department has not published a national plan, or the analysis underpinning it. We are encouraged that, not long after our evidence session, the Department committed to publishing a full NHS workforce plan during 2023, and we hope it is finally able to meet its own deadline. 

Recommendation: The Department should make good on its commitment to publish a comprehensive NHS workforce plan and the forecasts underpinning it in 2023. That plan should set out the assumptions it is based on, including what the NHS will achieve if it is staffed to the target level. If the Department intends for NHS staffing levels to remain significantly below OECD comparator countries, it should explain why. The Department should write back to us a year after the plan is published to provide a progress update on what the plan has achieved, including changes in NHS staff numbers.  

3.      The Department has started taking some action to address workforce challenges in social care, but vacancies have increased by 50% in the last year and the number of people working in social care fell in 2021/22 for the first time in at least 10 years. The NAO report sets out a very high level of social care vacancies in ICSs of up to 13%, and high turnover rates ranging from 23% to 37%. The Department has taken some action to improve the situation, including adding care workers to the shortage occupations list and launching a national advertising campaign. It told us that numbers of both domiciliary workers and care home staff are now increasing. However, as written evidence to this committee sets out, there are now 165,000 vacancies in social care, compared with 110,000 in 2020/21, and the workforce has decreased by 3% in the last year. We challenged the Department on what the £500m it has committed for social care reform would achieve, and it stated this money would be used to support discharge to assess and other measures for domiciliary care. 

Recommendation: Alongside its Treasury Minute response, the Department should:  

a.      write to us by the end of March 2023 and provide a breakdown of how it spent and what impact it achieved, in terms of health outcomes as well as operational improvements, from both the £500m committed to workforce reform in December 2021, and the £500m announced in September 2022 to tackle delayed discharge.  

b.      The Department should also write to us within six months setting out the underlying reasons for social care vacancies, its forecasts for them, and its further plans to address them. 

4.      These reforms do nothing to address the longstanding tension caused by differences in funding and accountability arrangements between the NHS and social care. The Department, which has policy responsibility for both health and social care, is showing a worrying lack of leadership, and it is not clear who will intervene if relationships between local partners break down. The interdependency between health and social care services is well established. However, we are concerned these reforms will be a missed opportunity to make meaningful progress on how the NHS and local government can work together. The NHS and social care continue to maintain separate budgets despite the ambition of integrating services through these new reforms. NHS oversight is focused on the NHS’s objectives and while the CQC can identify problems in joint working, it is not clear how the Department intends to resolve them when they do arise. It is essential that MPs can support their constituents when they encounter problems with health and social care services, but the arrangements for doing so within ICSs are very patchy. 

Recommendation: The Department should, within six months, publish guidance for ICSs setting out how it will support systems to resolve joint working issues when these are identified by the Care Quality Commission.   

5.      The NHS estate is in an increasingly decrepit condition, but the Department seems unable to make timely decisions to address these problems. The NAO report found that the cost of tackling outstanding maintenance work on the NHS estate has now reached £9 billion, up from £5 billion seven years ago. Alongside this, there are long delays in making decisions on capital programmes.  For example, staff and patients at the Queen Elizabeth hospital in King’s Lynn have been waiting for years for a decision, now expected later this year, about whether it will be part of the new hospitals programme.  At present the hospital has 3,000 timber and steel supports holding up a cracked aerated concrete roof. The Department has set an aspiration that Integrated Care Boards within ICSs can retain the proceeds of any asset sales, but it is not clear whether they will be able to retain the full value of proceeds given wider pressures on public sector budgets. The Department has still not published its long-term strategy for capital, despite telling us in September 2020 that it would be published in Autumn 2020, and in June this year that it would be published in Autumn 2022. It now tells us it expects to publish in early 2023.   

Recommendation: The Department and NHS England should ensure the capital strategy is published in early 2023. This strategy should set out an analysis of need and plans to address this. The Department and NHS England should also provide an annual progress update against the strategy, to include progress on nationally determined commitments and priorities, such as the New Hospital Plan, and system-wide ICS-led issues such as addressing the backlog of maintenance work. The progress update should also include details of when the Department and NHS England expect to make decisions that affect current and potential capital projects, to enable ICSs to plan with more certainty. 

6.      NHS funded dental care is in crisis in some parts of the country, and NHS England’s failure to ensure people can access routine dental care is leading to more acute dental health problems. NHS England, rather than ICSs, remains responsible for most NHS dentistry but in some parts of the country it is impossible to find a dentist offering NHS treatment. At our evidence session in November NHS England could not tell us how much longer it expected these gaps in the provision of an essential service to remain. It told us about several changes it has recently made, including increasing payments for complex work, allowing dental health technicians to accept NHS patients for treatment, and increasing the activity cap for high performing practices. Following the session NHS England wrote to us to set out more details on these plans. We welcome NHS England’s assurance that it sees restoring dental services as a critical priority. However even in December 2019, before the pandemic, more than 40% of children and half of adults in England had not received any NHS dental care at all in the previous two years. We were disappointed that NHS England is still unable to say by when it expects the changes it is making to result in more dentists offering NHS treatment. 

Recommendation: Alongside the Treasury Minute response to this Report, NHS England should write to us and set out:  

a.      The funding intended for NHS dentistry in 2022/23 and 2023/24 and what coverage this provides, in terms of the proportion of adults and children who could access these services, and what services the funding will and will not cover.  

b.      Its understanding of the proportion of adults and children using non-NHS dentistry, and the proportion of people who do not access any dentistry services at all.  

c.       By when it expects to be able to consistently provide the target level of coverage, and  

d.      What patients should do if they require dental care and are unable to find a dentist offering NHS treatment.