Andrew Haldenby and Professor Nick Bosanquet are co-founders of Aiming for Health Success, a new health research body.
During the run-up to Christmas, some Conservatives began to ask why the NHS had not increased its capacity since the beginning of the pandemic. For example, Anne Marie Morris said, when lockdown regulations were debated in Parliament, that the “capacity issue … has hardly been addressed at all”.
NHS capacity is indeed a key factor, determining the ability to cope not only with Covid-19 but also with normal demand. But it is crucial, especially for Conservatives, to understand why capacity has not increased. It’s not the fault of unaccountable NHS leaders or the “Blob”. On this occasion, the Government has stuck for too long with obsolete policies. A renewed approach could improve the situation quickly, in two distinct ways.
The Party has a clear policy to increase capacity: to build or refurbish 40 acute hospitals. This was a key policy in the 2019 Manifesto and has been promoted by Ministers and the Prime Minister many times since then. The problem is that this method to raise capacity is by far the most expensive and time-consuming way to do it.
Extra NHS capacity is needed now but hospitals take years to build or upgrade. Delays are likely because these are complex projects, subject to national regulatory approval and political intervention. Earlier this year, the Government’s in-house rating agency found that the 40 hospital programme was “unachievable” by the target date of 2030. The total cost of the programme has been estimated at up to £24 billion. Little wonder that worldwide, building large hospitals is seen as a solution from the past.
The good news is that building hospitals is not the sovereign and lone way to more capacity. We would propose two ways to increase capacity with benefits starting in 2022.
The first is to improve access to social care. The real capacity problem is that up to 25 per cent of patients in hospital beds need not be there. That has been known for many years but developing new services to solve this problem has had little priority.
During the pandemics Trusts have paid for out-of-hospital support packages and this could be developed further, starting straight away. Care provided in the home is a massive resource which did not exist 20 years ago. This could provide support both immediately post discharge and over the longer term.
For residential care, access is set to worsen as homes close. An immediate positive change would be to enable local authorities to pay homes at realistic and sustainable rates. Currently, care homes use the much higher fees paid by private residents to subsidise their local authority residents, but this is a pernicious arrangement which weakens all types of access.
The second step is to develop care teams outside hospitals which can deliver care closer to home with results within two years. Integrated Care Systems should have the lead in developing services, measured against their ability to deliver care most efficiently. Care “closer to home” is likely to mean two types of service: joint primary care / secondary care hubs in community sites, and diagnostics, rehabilitation and direct care provided in the home itself.
These hubs could provide the support for high-risk patients who were shielded during the pandemic. Paramedics are already showing how it is possible to treat children and elderly patients at home.
A realistic first target would be to reduce local hospital admissions by ten per cent, releasing resources for treating patients who are on the backlog. Reducing admissions would also free up resources for investing in end-of-life care.
The infographic shows that NHS leaders are ready to respond to this approach. It was published by the Devon Integrated Care System. As the Devon ICS says, “whilst our first priority is always to provide high quality and compassionate care, we have a duty to do this within the available budget. To enable us to continue delivering high quality care within our budget we need to shift our resources from hospital beds to the care surrounding patients in their own homes”.
These hubs could offer big advantages to elderly patients. Hospital admissions can offer specific treatments, and this will remain vital for some, but they often reduce capability for independent living outside the hospital through weakening physical resilience and support networks. Hospital admission is often the first step towards permanent care. The new hubs can involve and help carers through respite care, falls prevention and social support. For elderly patients, minimizing admissions is a key step towards better outcomes and continued quality. It also shields them from deeply worrying financial problems. Such support will become more important as increasing numbers of people over 85 live on their own.
We understand that the hospital refurbishment programme has much political capital invested in it. Still, Conservatives must ask whether a new approach is needed, which delivers much faster results in terms of capacity and which greatly improves outcomes for elderly people within the next two years.