About you
3. What is your name?
Name
(Required)
Andrew Bone
5. Are you responding as an individual or on behalf of an organisation?
Organisation
NHS Borders
Budget context
6. How would you see these planned budget increases meeting the various challenges facing health and social care over the next four years, including: addressing the treatment backlog; the planned creation of a National Care Service; cost and demand pressures in areas such as NHS pay, drug costs and demographic pressures?
Please provide your response in the box provided.
Overall it seems likely that a 4% increase, whilst welcome, will be consumed in addressing core pressures and growth arising from economic factors. There is unlikely to be sufficient resource available to fully achieve the policy objectives and performance improvement arising from NCS and Access standards.
Legacy Pressures
The experience of the past 2-3 years has indicated that healthcare costs are growing at a rate in excess of the combined level of investment available and savings identified. Even if this situation is arrested, the burden of existing deficits will mean that current budgets are under significant pressure before any future commitments are considered.
Pay Policy & Price Inflation
Levels of cost growth in pay settlements, medicines, healthcare specific price inflation, general inflationary pressures (e.g. energy, construction costs, food) are driving cost growth in excess of 4%. Assuming improvement in inflation in line with economic forecasts there is still a risk that the deferred impact of previous growth has not yet fully manifested.
Given the expectation of public sector workforce towards pay restoration it is hard to envisage that the totality of the budget increase would not be fully consumed by pay policy and price inflation alone, leaving no additionality to address system pressures.
Treatment Backlog
The cost of addressing the backlog has not been fully assessed however it will be significant and can only be achievable over a number of years and with additional investment. Investment alone will not resolve this however, since workforce and infrastructure requirements will be significant. Recruitment, training and capital investment will all present challenges to this objective.
National Care Service
The development of the National Care Service if progressed in line with the original recommendations would see significant progress towards addressing the persistent challenge of delayed discharges and the deficit in social care capacity. As with the treatment backlog, there are likely to be significant workforce challenges associated with this programme which will limit the impact from investment alone.
Legacy Pressures
The experience of the past 2-3 years has indicated that healthcare costs are growing at a rate in excess of the combined level of investment available and savings identified. Even if this situation is arrested, the burden of existing deficits will mean that current budgets are under significant pressure before any future commitments are considered.
Pay Policy & Price Inflation
Levels of cost growth in pay settlements, medicines, healthcare specific price inflation, general inflationary pressures (e.g. energy, construction costs, food) are driving cost growth in excess of 4%. Assuming improvement in inflation in line with economic forecasts there is still a risk that the deferred impact of previous growth has not yet fully manifested.
Given the expectation of public sector workforce towards pay restoration it is hard to envisage that the totality of the budget increase would not be fully consumed by pay policy and price inflation alone, leaving no additionality to address system pressures.
Treatment Backlog
The cost of addressing the backlog has not been fully assessed however it will be significant and can only be achievable over a number of years and with additional investment. Investment alone will not resolve this however, since workforce and infrastructure requirements will be significant. Recruitment, training and capital investment will all present challenges to this objective.
National Care Service
The development of the National Care Service if progressed in line with the original recommendations would see significant progress towards addressing the persistent challenge of delayed discharges and the deficit in social care capacity. As with the treatment backlog, there are likely to be significant workforce challenges associated with this programme which will limit the impact from investment alone.
Longer-term outlook
7. Given the short-term and immediate pressures on the health and social care system, how can the Scottish Government take the more radical decisions required around service redesign, or reducing/stopping existing services?
Please provide your response in the box provided.
Public Engagement. The long term impact of demography and changing care needs, together with changes to working age population at a regional and national level, means that we cannot continue to deliver the existing models of health & care without an increasing likelihood that there will be a growing level of unmet need and a corresponding requirement for prioritisation of care for those who have the greatest needs. We need honest engagement with the public about how this can be addressed. Even assuming a willingness to pay a higher level of taxation, the reality of workforce availability will mean these constraints cannot be fully addressed.
Regional Planning. The current model of Health Board accountability does not promote regional collaboration and will increasingly lead to a post code lottery based on affordability of services; as well as inequities of access due to the circumstances of where recruitment challenges manifest in individual services. There is a need to strengthen the planning at a regional and national level and to use this as a vehicle for establishing the best value model of service delivery, finding appropriate balance between centres of excellence and locally delivered care.
Infrastructure Investment. There needs to be a rationalisation of public sector estate, which will require that those buildings which remain are fit for purpose and well maintained. The existing models of financing for health & local authorities, both revenue and capital, do not promote cross sector collaboration. In order to create a more effective public sector estate over the medium term there needs to be new models of financing for capital projects.
Digital. Investment in digital is limited and often directed towards cyber resilience and basic service infrastructure. There needs to be a higher priority on 'digital first' solutions to all policy commitments instead of the traditional approach which drives a demand for increased workforce which is increasingly challenging to meet.
Clinical Prioritisation. There is a need to engage clinicians in the design of value based health & care beyond the principles and towards a framework that drives out variation and improves quality. Often choice is promoted at individual patient level, and through clinical judgement, but major changes to how services are delivered will require a consistency of approach that is best achieved through national standards and guidance, including minimum treatment thresholds.
Drugs & Prescribing. There is clear indication that the long term trend in medicines costs is to annual increases above the level of funding available. We either need to develop a different approach to funding of medicines growth (such as creation of a national cancer fund similar to NHS England) or otherwise introduce restrictions to access for some medications, whether related to treatment thresholds, or price.
Regional Planning. The current model of Health Board accountability does not promote regional collaboration and will increasingly lead to a post code lottery based on affordability of services; as well as inequities of access due to the circumstances of where recruitment challenges manifest in individual services. There is a need to strengthen the planning at a regional and national level and to use this as a vehicle for establishing the best value model of service delivery, finding appropriate balance between centres of excellence and locally delivered care.
Infrastructure Investment. There needs to be a rationalisation of public sector estate, which will require that those buildings which remain are fit for purpose and well maintained. The existing models of financing for health & local authorities, both revenue and capital, do not promote cross sector collaboration. In order to create a more effective public sector estate over the medium term there needs to be new models of financing for capital projects.
Digital. Investment in digital is limited and often directed towards cyber resilience and basic service infrastructure. There needs to be a higher priority on 'digital first' solutions to all policy commitments instead of the traditional approach which drives a demand for increased workforce which is increasingly challenging to meet.
Clinical Prioritisation. There is a need to engage clinicians in the design of value based health & care beyond the principles and towards a framework that drives out variation and improves quality. Often choice is promoted at individual patient level, and through clinical judgement, but major changes to how services are delivered will require a consistency of approach that is best achieved through national standards and guidance, including minimum treatment thresholds.
Drugs & Prescribing. There is clear indication that the long term trend in medicines costs is to annual increases above the level of funding available. We either need to develop a different approach to funding of medicines growth (such as creation of a national cancer fund similar to NHS England) or otherwise introduce restrictions to access for some medications, whether related to treatment thresholds, or price.
Financial Sustainability
9. Is the achievement of financial sustainability a realistic prospect in the face of continuing pressures around pay costs, treatment costs and rising demand?
Please provide your response in the box provided.
It is hard to see how the existing challenges to financial sustainability will be addressed through ‘more of the same’. The level of investment outlined in proposed budget commitments is significant but is still only likely to be sufficient to meet pay policy and price inflation without consideration of wider investment required to meet demographic challenges, introduction of new health technologies, addressing backlog in existing treatment pathways, supporting the National Care Service, etc.
Progress towards financial sustainability will require a strategic approach that recognises the health & care system requires transformational change immediately and on an enduring basis. Key changes which need to be considered include:
- Local services to be focussed on those elements which must be delivered locally, and specialist services rebalanced on a hub & spoke model that maximises economies of scale
- Increased drive towards eliminating unwarranted variation and over-treatment/prescribing where there is limited evidence of effectiveness
- Rationalisation of support services and infrastructure, maximising digital solutions and driving collaboration across public sector and on a regional and national basis
- Public engagement in a conversation which resets expectations and shapes a future service model which is aligned to the principles of realistic medicine, the best value use of resources, and the reality of workforce availability within specialist and geographic segmentation
Progress towards financial sustainability will require a strategic approach that recognises the health & care system requires transformational change immediately and on an enduring basis. Key changes which need to be considered include:
- Local services to be focussed on those elements which must be delivered locally, and specialist services rebalanced on a hub & spoke model that maximises economies of scale
- Increased drive towards eliminating unwarranted variation and over-treatment/prescribing where there is limited evidence of effectiveness
- Rationalisation of support services and infrastructure, maximising digital solutions and driving collaboration across public sector and on a regional and national basis
- Public engagement in a conversation which resets expectations and shapes a future service model which is aligned to the principles of realistic medicine, the best value use of resources, and the reality of workforce availability within specialist and geographic segmentation
10. How can or should any additional health and social care funding be directed to support alternative models of service delivery?
Please provide your response in the box provided.
Constraints on existing health & care budgets mean that there is limited funding available to support truly transformational change.
Any new funds should be directed towards supporting transformation on a collaborative basis, with a requirement that solutions are provided on a cross-sector or regional basis.
These should come without new policy commitments wherever possible, to maximise the flexibility in their deployment towards delivery of changes which will reform the existing system and increase both sustainability and efficient use of existing resources.
Each region will have different priorities but the creation of recurring funding to support bridging investment on a non-recurrent basis of longer term strategic changes would be welcomed.
To deliver greatest effect these funds should be on a shared basis across stakeholders, either via IJB/HB/Local Authority partnerships, or across supra-regional groupings (East, West, North) in relevant sectors.
For more focussed investment, the biggest benefit will come through additional digital and capital investment.
Any new funds should be directed towards supporting transformation on a collaborative basis, with a requirement that solutions are provided on a cross-sector or regional basis.
These should come without new policy commitments wherever possible, to maximise the flexibility in their deployment towards delivery of changes which will reform the existing system and increase both sustainability and efficient use of existing resources.
Each region will have different priorities but the creation of recurring funding to support bridging investment on a non-recurrent basis of longer term strategic changes would be welcomed.
To deliver greatest effect these funds should be on a shared basis across stakeholders, either via IJB/HB/Local Authority partnerships, or across supra-regional groupings (East, West, North) in relevant sectors.
For more focussed investment, the biggest benefit will come through additional digital and capital investment.