BGS response to DoH consultation on NHS England mandate to 2020

Our responses to the consultation questions posed by the Department are set out below.

Q.1 Do you agree with our aims for the mandate to NHS England? 

While the BGS is in broad agreement with the aims for the mandate to NHS England, we are not assured that the analysis of the challenges currently facing the NHS is sufficiently robust.  The proposed aims are predicated on a set of priorities.  With regard to those priorities, the Society wishes to highlight the following issues:

• While there is a stated emphasis on prevention of ill health and maintenance of wellbeing, the reality is that there have already been cuts to public health budgets in the order of £220 million. 
• There is agreement among all informed commentators (including The King’s Fund, The Health Foundation, The Nuffield Trust) that maintaining current performance levels in health and care systems with current levels of funding and staffing will require heroic efforts.  Financial returns for the first quarter of 2015 show that 96% of all acute Trusts are now in deficit and the expectation is that the NHS will have overspent by between £2 and £billion by the end of 2015.  This is indicative “of a system in crisis”.  It is inevitable that a promise to deliver 7 day services in either acute or primary care will be broken in the absence of additional resources, increased capacity in intermediate care, and workforce planning and skills development to address well documented staffing deficits in social care, nursing, general practice and medical specialities including emergency medicine.  
• The ambition to transform out of hospital care is widely shared by health and social care stakeholders, including the BGS.  However, a mandate to transform out of hospital care must address deficits in social care funding and intermediate care capacity.  According to the Local Government Association, social care budgets have been cut by £5billion between 2010 and 2015.  Delayed transfers of care (DTOCs) from acute hospitals are at their highest level ever and the upwards trend in DTOCs is directly associated with gaps in intermediate care and social care funding.
• There are implications for patient safety, access to and quality of care, and systemic effectiveness arising from resource pressures in the health and care systems.  These are concerns that need to be addressed directly now at this planning stage if, as is stated in the consultation paper, the aspiration that people will “have the confidence that the highest quality NHS services will be there when they need them” is to stand up over the 2015 – 2020 timeframe of the Mandate.  

The BGS strongly supports the endorsement of the Five Year Forward View in the Mandate. We also support the calls of The King’s Fund, the Nuffield Trust and The Health Foundation for a dedicated Transformation Fund to support the implementation of the Five Year Forward View.

Regarding the assessment of NHS England’s and CCGs’ performance against metrics and outcome measures as set out in the first aim, we strongly recommend that the Department of Health take account of the recommendations of the King’s Fund review, Measuring the Performance of local health systems; of the insights of the Health Foundation policy analysis On Targets; and of the commitment given in the current Mandate 2015-2016  “to make progress in measuring and understanding how people really feel about the care they receive”.

In particular, we advise that the Mandate should drive practical action in breaking down barriers in how care is provided by different parts of the health and social care system.  The BGS believes that the Mandate should specifically address the statutory right to healthcare of all residents in care homes.  The BGS also believes that the Mandate should support and promote the role of intermediate care in enabling care of older people.

In addition, the BGS recommends the inclusion, in the NHS Outcomes Framework, of measures assessing waiting times for access to intermediate care services and tracking access of care home residents to NHS services.

Q.2 Is there anything else we should be considering in producing the mandate to NHS England? 

The BGS believes that the Mandate should be framed – as in Mandate 2015-2016 – with reference to the vision for the NHS articulated in the NHS Constitution. 

The BGS believes that it is essential that the Mandate restate the NHS commitment to provide comprehensive care free at the point of access. 

The preparation of the Mandate also offers an opportunity to highlight the implications of the Age Equality Act, and specifically of age equality duties under the Act, for health and social care providers. 

We believe that, in addition to processes of assessment and evaluation, the DH should consider how the Mandate can support the more effective exchange of learning and good practice throughout the health and care systems. 

While large budgets do not guarantee high quality care, there is no doubt that reduced budgets and resource pressures challenge quality, effectiveness and safety in the delivery of health and social care.  As stated above, we would like the Mandate to directly address these issues. 

Q.3 What views do you have on our overarching objective of improving outcomes and reducing health inequalities, including by using new measures of comparative quality for local CCG populations to complement the national outcome measures in the NHS Outcomes Framework? 

We agree – with the proviso stated above that the introduction of new measures of comparative quality should be in line with recommendations of the King’s Fund Review. We also support the recommendation that, longer-term, the outcome frameworks for healthcare, social care and public health outcomes should be combined.

Given our professional commitment to ensuring that older people get the best possible healthcare, we highlight the need for access to age-disaggregated data in measuring the effectiveness of health and care systems in meeting the needs of all age groups within the population.  

The BGS strongly recommend the development and application of measures for access to, and quality of, community care, including intermediate care.  Local CCG populations include care home residents and we recommend the inclusion of measures assessing care home residents’ access to NHS services, and the performance of CCGs in commissioning services for care home residents.

Q.4 What views do you have on our priorities for the health and care system? 

We support priorities of preventing ill health, supporting people to live healthier lives, creating a safe and high quality health and care service and transforming out-of-hospital care, including the health care of care home residents. 

We would like to see explicit recognition of the role of Intermediate Care in transforming out of hospital care.  

We would also like to see explicit recognition of the challenges associated with transforming out of hospital care for older people with complex needs, dementia, frailty, and multi-morbidities.  As specialists in the healthcare of older people, we are committed to maximising the independence of older people.  In that context, we see the value of the growing systemic emphasis on self-management and personal responsibility for healthcare.  However, we also recognise the need for nuanced responses to the care needs of older people with cognitive impairment, frailty and possibly a life limiting illness.  In the provision of person-centred, individualised care – a principle and a practice to which the BGS is deeply committed -  there is a balance to be struck between self-management and support.  Individuals will require different levels of support depending on their unique circumstances and health status. The BGS recommends that, in DH and NHS England presentations on self-management and personal responsibility for healthcare, a more nuanced approach is adopted in the future. 

We have concerns that, overall, the priorities lean too heavily towards achieving financial balance at a time when it is widely recognised that funding is insufficient to meet requirements. The BGS is concerned that, in these circumstances, older people’s rights to high quality health and social care will not be honoured.

Q 5. What views do you have on how we set objectives for NHS England to reflect their contribution to achieving our priorities?

The process whereby priorities  are set for NHS England by DH is not delineated in the Consultation Paper. 

Further enquiries

Further enquiries related to this submission may be directed to Patricia Conboy, Policy Manager, British Geriatrics Society, tel.0203 747 6940 and policy [at] bgs [dot] org [dot] uk.