Special report: 'This can’t go on' - NHS chiefs urge new debate on health service reforms

An unprecedented crisis is approaching, say the health service’s most senior figures

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Hospitals are “staring down the barrel” of having to cut the jobs of doctors and nurses – actions that could lead to another Mid-Staffordshire scandal – unless the NHS radically reforms, the organisation’s head warns today.

In a stark assessment of the perilous state of NHS finances, Sir David Nicholson said the health service faced a £30bn black hole in its finances by the end of the decade because of rising demand.

And he predicted that unless politicians and the public accepted the need to shut and centralise services such as accident and emergency care, cardiac surgery and maternity units, the NHS would no longer be able to cope with demand. Sir David was backed in his remarks by the Medical Director of the NHS, Sir Bruce Keogh, and the Chief Nursing Officer, Jane Cummings.

They called for a “national conversation” about how to reform the NHS and called for politicians to be honest with the public about what needed to be done.

“What we’re really worried about is an approach that would muddle through,” Sir David said. “It won’t. Seventy-five per cent of all the money spent by hospitals is on staff. [We’re] looking down the barrel of reducing staffing on wards and that is just not acceptable.”

Asked if that could lead to another scandal similar to that which contributed to the unnecessary deaths of hundreds of patients at Mid Staffs, he replied: “That is exactly the position.”

The comments by the three most senior figures in the NHS underline the growing frustration in the organisation at the slow pace of change in reconfiguring NHS services.

While senior politicians accept the need to merge services, when individual hospitals are affected they lead to a barrage of local protests – which often delay plans for months and sometimes years as they are fought through the courts.

Sir David and Sir Bruce argue that specialised services – such a paediatric cardiac surgery, stoke and cancer services – are best if they are centralised in fewer, more experienced units.

Sir David warned that ministers – who have to approve all such changes – had to act in the long-term interests of the whole NHS and not short-term political considerations.

“The current regulatory process around those changes is very slow and we need to talk to the Government about how we streamline that because those changes need to happen and happen rapidly,” he said. “More importantly we need to have a conversation with patients about the necessity to make that happen.”

But he added: “If a political manifesto does not say that service change is absolutely essential and that you need to concentrate and centralise services – it will not be being straight forward with the British people.”

He also hinted at a new shake-up of primary care, with smaller GP surgeries being forced to merge with other practices where they could provide a greater range of services in the community. This is also likely to meet fierce opposition as it will almost certainly mean patients having to travel further to see their local GP.

Sir Bruce said that patients needed to be aware of the true picture facing the health service. “The NHS is caught in a triple pincer of rapidly escalating demand, rapidly escalating cost and restrained resources,” he said.

“And all of that is against a background of increasing expectations of better quality care with the principles of the NHS maintained. So that’s it is such a complicated issue. As guardians of the NHS purse we have a duty to ensure we get the best value for the taxpayer.”

Jane Cummings, the Chief Nursing Officer, said even at the moment care was not good enough in certain parts of the country.

If Sir David, who is to retire next year following criticisms of his handling of the Mid Staffs crisis, gets his way it is likely to result in the downgrading of services currently provided by district general hospitals around the country.

They are unlikely to be closed altogether – but will merge services with other local hospitals meaning patients will have to go further to be treated.

But Sir David insisted it was the only way to provide consistent high quality care in an age of effectively frozen budget.

“The nature and scale of the challenges that we face are so great that we really do have to have a much more radical view about the way we are going to [change],” he said. “The general approach will be specialisation and concentration in a smaller number of organisations. That is inevitably the consequence.”

Mike Farrar, head of the NHS Confederation, which represents hospital managers, said the Government needed the “courage and willingness” to challenge how health services were structured.

“NHS England is right to call for an honest and realistic debate between NHS staff, the public and politicians about what needs to change. When that debate has been had, it is crucial that those in charge of the NHS make the changes a reality.”

Chris Ham, chief executive of the health think-tank The King’s Fund, added: “The significant financial and service pressures facing the NHS and social care will continue for some time yet, so it will be important to be honest with the public about the implications of this in the run-up to the next general election and beyond.”

Straight talk: What they say

Sir David Nicholson (NHS chief executive) “Every year from now on we have to find £4bn-£6bn of savings, to deal with new demand.”

Sir Bruce Keogh (NHS Medical Director) “The NHS is caught in a triple pincer of escalating demand, escalating costs and restrained resources.”

Jane Cummings (NHS Chief Nursing Officer) “Staff and patients say repeatedly we are not providing the best possible care.”

Patients face treatment rationing

Patients are having their access to some treatments restricted by one in seven of the Government’s new clinic commissioning groups, new research suggests today.

The groups were set up by ministers to replace Primary Care Trusts as part of the Government’s health reforms. Led by GPs, they have responsibility for deciding what treatments to offer their patients on the NHS.

But an investigation for the BMJ found that some CCGs have tightened the thresholds for access to “low priority” surgery such as hernia and joint problems. Others have introduced new systems to restrict the flow of patients being sent to hospital.

Eight CCGs across north-west London added new restrictions for nasal surgery and a new general cosmetic policy, but also removed restrictions for several procedures including asymptomatic gall stones and caesarean section for non-medical reasons.

Oliver Wright