This week, our Deloitte public sector practice, in collaboration with Reform, published their fifth annual report – The State of the State 2016-17: Brexit and the Business of Government. The report is a unique analysis of the UK public sector and provides a compelling commentary on the big challenges it faces as the UK Government moves from an era focussed on eliminating the budget deficit, into an era of multiple and complex challenges. Specifically, the need to manage the UK's departure from the EU, drive major reforms and maintain business as usual.
Having led a number of interviews with NHS leaders, I thought I'd use this week's blog to highlight key findings from the report, the issues that relate to the NHS and the insights gained from the NHS interviewees.
This year's report finds the UK disrupted by a new pressure – Brexit - which has created a complex, era-defining challenge for the UK Government and the devolved administrations. However it also provides an opportunity to rethink how the public sector manages everything that it repatriates from the European Union. Although most sectors of the UK economy will be affected by Brexit, just one – the public sector – is responsible for planning and implementing the exit strategy. The next five years will therefore place additional demands on the public sector as it manages the UK's departure from the EU, continues to drive major reforms and maintain business as usual.
The 1,000 people surveyed as part of the study put the NHS at the top of their concerns with 57 per cent feeling that the NHS should be the Government's top priority, compared with 33 per cent who believe the Government should focus on Brexit in the year ahead. In addition the public want better public transport, improved hospitals and more investment to improve local services. Public support for taxes to fund public spending increased for the first time since the 1990s. It also found that a digital divide exists amongst citizens by age and social class.
There remained strong public satisfaction with public services despite the past few years of austerity, seen as a testament to the sense of public service, resilience and professionalism created by the leaders of our public services. Overall, public sector leaders and citizens want services that are flexible, personalised, digitally enabled and appropriately funded.
The views of NHS leaders on the need for reform
When it came to the NHS, all interviewees described an extremely challenged health service. Most were clear that while additional funding might provide short-term fixes to current problems, they also feel that real transformation is required if the NHS is to be put on a sustainable footing.
All of the NHS interviewees told us that nationally, health service finances are a pressing concern with 95 per cent of NHS hospitals ending 2015-16 with a combined deficit of Ł2.45 billion. In exploring this issue, one trust chief executive told us that "hospitals are full to the gunnels with people who don't need to be in expensive hospital beds and would be better cared for at home". The director of a leading health body described current demand pressures as "a hospital sector under siege".
Many interviewees see the deficit as symptomatic of more long-standing problems that need to be resolved to ensure the NHS is fit for the future. Some even thought that promises of additional funding, including those made during the referendum campaign, were counterproductive and an "excuse to avoid doing the big stuff" for some NHS trusts. Most agreed that progress in reforming the health service needs to accelerate.
"With over 1.4 million people working in the NHS, health care is fundamentally a people business and workforce policy is central to the quality and finance challenges that the NHS faces". However, several interviewees mentioned that NHS workforce planning has been fundamentally flawed for a number of years; with "workforce policy often considered as an afterthought". One senior interviewee commented that "the use of agencies is a symptom, not a cause of NHS workforce problems". Several called for investment to address workforce shortages rather than demonising hospitals for using agency staff to meet immediate needs.
Most NHS interviewees raised concerns about spending cuts in social care and their impact on the NHS. A trust chief executive told us that such cuts "are a deep concern because they loop back to us." Another, mentioned "there is a sense in which austerity kick-started the drive to bring health and social care together – with increased understanding of their interdependence – now given huge impetus by the Manchester devolution".
On the question of NHS's progress towards digital or other technologies NHS interviewees were particularly vexed by the lack of progress. A non-executive described the NHS as "one of the biggest unreconstructed services" in terms of digital, and went on to question why people are not able to speak to a GP via video calls or routinely make appointments online.
Most agreed that technology is key to improving services for older people. However, "the kind of care enabled by new technologies remains out of reach for most of the NHS". These technologies could potentially be put to use in the NHS, but the main challenge lies in persuading health care providers to take up new models and methods of care". Furthermore, that "Strategic decisions about clinical transformation and the associated investment in information and digital technology are all too often a footnote to NHS board discussions. This needs to change".
The future's bright
Notwithstanding the above concerns, most interviewees displayed a sense of optimism. Several mentioned the potential of implementing the Carter review, to reduce the wide variations in clinical and non-clinical practice across the NHS as well as the potential savings in creating greater consistency. Others suggested that there was substantial potential for the NHS to reconfigure facilities, reduce maintenance costs and move to more modern facilities rather than work in outdated and inefficient buildings. Many interviewees saw greater collaboration between NHS bodies as a source of major savings. Some hoped to see bolder change in which the NHS reviewed whether smaller hospitals were sustainable, restructured "sub-scale" GP practices, or explored how revenue could be raised with charges or premium services. The chairman of one NHS body accepted that such reform is "a national taboo politically – but if you're writing The State of the State, it's got to be flagged".
Whatever your views on the NHS I'd like to leave you with the following sentiments from a senior NHS leader: "Actually I'm quite optimistic – the NHS enjoys massive support - high levels of patient satisfaction – huge numbers of committed staff – tremendous amounts of good will – so the model is not broken – medical innovation continues at a pace – we're making huge in-roads in cancer treatment – there is now a real sense of importance of mental health issues – as we begin to understand the importance of mental health on physical health and treating people in different ways - this national conversation can and will move us to a better place".
If you haven't already done so, I would urge you to read The State of the State and consider how you might apply its findings to your own area of work.
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