Workforce key to meeting demographic challenge

by Anita Charlesworth

02 July 2018


big nhs2To mark the 70th birthday of the NHS, the HFMA invited a number of commentators to look ahead to what the NHS might look like in 30 years’ time, examining both the obstacles it will face and the opportunities to enhance health and healthcare. Here, Anita Charlesworth discusses the demographic changes facing the NHS over the coming decades and the continuing battle to increase not only life expectancy, but healthy life expectancy. She argues that focusing on workforce will be the key to transforming the NHS to meet these challenges.


Rising life expectancy was one of the triumphs of the twentieth century. In 1900, average life expectancy at birth was less than 50 years. By 2000 it was almost 30 years higher. This triumph is to be celebrated but it’s not job done. 

Extra years of life are important, but too many of those extra years are not being lived in good health. On average men are spending 16 years in poor health and women, 19. Worryingly, since 2011 the longevity increases that we’ve come to see as the inextricable march of progress have stalled.

Moreover, increased longevity is too often the preserve of the privileged. Despite 70 years of universal healthcare, the gap between life expectancy, and crucially, healthy life expectancy for rich and poor is enormous. In England, the least deprived men at birth in 2014-16 could expect to live almost a decade longer than the most deprived.

The NHS is not the source of inequality. Years of work by epidemiologist Sir Michael Marmot has shown that the root of health inequality is in the wider determinants of health. However, tackling inequality needs to be at the heart of the NHS mission.

In 1948 the NHS was focused on the health problems of the young and the impact of infectious diseases and accidents. Seventy years on, the task facing the NHS is to meet the needs of an ageing population with a growing burden of chronic disease, multi-morbidity and deep-seated inequalities in health outcomes.

The changing pattern of age and disease has profound implications for the delivery of healthcare that we have only begun to address. The first, and probably the easiest to fix, is money. The recent Health Foundation and IFS study on the future funding pressures facing the NHS, found that over the next 15 years there will be 4.4 million more people aged 65 and over.

This would pose a challenge for the NHS under any circumstances, but it is accompanied by a rapid rise in people with chronic conditions and in particular multi-morbidity. Over the past decade, emergency admissions have grown particularly quickly for patients with multiple health conditions.

In 2015/16, one in three emergency patients admitted for an overnight stay had five or more health conditions, up from one in ten in 2006/07. This means the NHS needs to run to stand still. Maintaining current standards of access and quality of care will eat up funding increases of around 3.3% a year. The government is promising 3.4%. 

But money is just the start. If we stick with the current model of care, demographic changes – coupled with the rise in multi-morbidity – will see hospital activity increase by 50%. There is no capital investment plan to build enough hospitals to provide 50% more activity. This has two implications.

First, any STP plan that is structured around cuts to current levels of acute activity has a major credibility hurdle to pass. Bending the acute activity growth curve will be a major achievement; reducing acute demand looks unrealistic to say the least. Second, current progress to develop and implement new models of care are way behind the pace and scale of change needed.

More fundamentally, too often the focus of effort is in the wrong place. Governance systems, contractual models and payment reforms will not deliver the profound change we need in the type of care. 

If we are to transform the NHS, the key is to focus on the workforce. This is in part a numbers game. Over the last 20 years, hospital doctors increased by 70%, GPs fell by 5%. The key staff groups we need – community nurses, generalist doctors, mental health – have all seen staff numbers move in the wrong direction. The forthcoming workforce strategy is critical – we need a fundamental change.

Extra staff are necessary, but not sufficient.  There needs to be a much deeper look at the type of workforce and skills within the NHS. Much of the work on integration is focused on multidisciplinary teams. In the future, patients require more radical change. We need to develop a workforce equipped to meet their needs holistically and less organised around body parts and diseases.


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Looking ahead: the NHS at 100.  To mark the 70th birthday of the NHS on 5 July 2018, the HFMA has carried out some long-term thinking about the factors that will impact on the financial future of health and social care over the next 30 years, taking it through to its 100th birthday in 2048.

 

NHS@100 blogs

Sanjay Agrawal on changing the balance of responsibility