BMA response to the House of Lords Select Committee inquiry into the
Long-Term Sustainability of the NHS
About the BMA
The British Medical Association (BMA) is a professional association and independent trade union,
representing doctors and medical students from all branches of medicine across the UK and
supporting them to deliver the highest standards of patient care. We have a membership of over
168,000, which continues to grow each year.
Executive Summary
The NHS is facing a funding crisis which can only be solved through increasing investment based on a
realistic assessment of what is needed to meet the health needs of current and future generations. We
have identified current challenges facing the NHS and explored how these can be addressed through
additional investment and measures that can be used to promote long-term sustainability.
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The BMA is committed to an NHS which is publicly provided, publicly delivered and free at
the point of need. Healthcare funding is a basic function of government and the NHS must
continue to be funded directly through general taxation.
The NHS offers the UK population financial protection from the potentially catastrophic costs
of ill health. By comparison, in the US, medical debt is the largest cause of personal
bankruptcy 1. By removing patients’ concerns over their ability to pay, doctors can better focus
on their clinical needs, eliminating an unhelpful distraction in the doctor-patient relationship.
Current funding levels are the biggest single threat to the sustainability of the NHS. There are
four main areas of concern that should be urgently addressed – the crisis in general practice,
hospital deficits, cuts of public health and inadequate levels of social care funding.
More attention must be paid to the serious and ongoing problems in recruiting and retaining
all grades of doctors and the impact this has had on already stretched services. Effective
workforce planning must be undertaken to ensure the right number of healthcare workers
are employed with the right skills and in the right places.
A cross-government action plan is required setting out short, medium and long-term actions
to help create a more preventative service. This should be complemented with measures to
mitigate the negative effects of austerity and welfare reform on health, including a ‘health in
all policies’ approach.
Increasing health literacy, particularly from an early age, is key to achieving public health
prevention measures and promoting better awareness of self-care. This will also help to
reduce pressure on overstretched health services and support the sustainability of the NHS
by preventing ill-health in the long-term.
Technological advances can support the redesign and delivery of healthcare to manage
increased demand on the NHS, but only if they are one part of a broader strategy of
investment.
C. LaMontagne, NerdWallet Health Study: Medical debt crisis worsening despite health care policy advances, NerdWallet, 2014,
http://www.nerdwallet.com/blog/health/2014/10/08/medic
al-bills-debt-crisis/
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BMA response to the House of Lords Select Committee inquiry into the
Long-Term Sustainability of the NHS
Introduction
The BMA welcomes this opportunity to submit written evidence to the House of Lords Committee on
the Long-Term Sustainability of the NHS and supports the aim of the Committee to explore the future
delivery of healthcare in England. This is a timely inquiry given that the NHS is currently facing
unprecedented demand across almost all services, an ageing population coupled with increasingly
complex patient illnesses and a drastic funding shortfall.
We believe that fundamentally, the NHS is facing a funding crisis which can only be solved through
increasing investment based on a realistic assessment of what is needed to adequately meet the health
needs of current and future generations. In this response we identify current challenges facing the NHS
and explore how these can be addressed through additional investment and measures that can be used
to promote long-term sustainability, such as integration, increased recruitment and retention of the
workforce and use of technology.
1. The future healthcare system
1.1. Taking into account medical innovation, demographic changes, and changes in the frequency of
long-term conditions, how must the health and care systems change to cope by 2030?
It is of critical importance to maintain and build upon the NHS’s fundamental principles of equality
by ensuring that the NHS continues to be free at the point of use. It is also crucial that government
explores new ways of delivering healthcare, such as those highlighted in the Five Year Forward View,
alongside ensuring that adequate resource is available to meet the health and social care needs of
the population.
1.2 Self-care will play an important role in helping to reduce pressure on overstretched primary care and
emergency departments during periods of increased demand and will support the sustainability of
the NHS by preventing ill-health in the long-term. It is crucial that patients’ knowledge of self-care,
and more widely their understanding of how to make healthy choices to promote overall wellbeing,
are communicated and learnt from an early age.
2. Resource issues, including funding, productivity, demand management and resource use
2.1 To what extent is the current funding envelope for the NHS realistic?
Does the wider societal value of the healthcare system exceed its monetary cost?
The wider societal value of a healthcare system which is free at the point of use exceeds its monetary
cost. On an individual and basic level, the NHS offers the UK population financial protection from the
potentially catastrophic costs of ill health. By comparison, in the US, medical debt is the largest cause
of personal bankruptcy2. By removing patients’ concerns over their ability to pay, doctors can better
focus on the clinical needs of their patients, eliminating what would otherwise be an unhelpful
distraction in the doctor-patient relationship 3.
2.2 A successful healthcare system can have a positive impact on economic growth in the long-term, by
creating a healthier, better educated, and more productive labour force. In particular, improved
health of children is linked to better cognitive function, which in turn improves their life chances.
C. LaMontagne, NerdWallet Health Study: Medical debt crisis worsening despite health care policy advances, NerdWallet, 2014,
http://www.nerdwallet.com/blog/health/2014/10/08/medic
al-bills-debt-crisis/
3 Porter & AL-Zaidy, A health service (re)designed to help doctors give the best possible care to their patients. In The Health of the Nation:
Averting the demise of universal healthcare. Civitas 2016.
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Improved health can also play a key role in reducing instances of long term sickness leave 4. Given
these wider societal benefits, the government should fund the NHS adequately. However, recent
trends such as A&E closures and increases in NHS waiting times 5 are early signs of inadequate
resources 6.
2.3 Although the Westminster Government has recently made a commitment to invest £4.5 billion to
deliver on commitments in the Five Year Forward View, this still falls short of what is actually needed7.
Much of this funding has been made available through cuts in other areas including public health,
education and training, capital spend and national bodies such as the NICE (National Institute for
Health and Care Excellence). Spending in these areas is being cut by more than £3 billion over the next
five years. Furthermore, this does not take into account funding for commitments for seven day
services. The result of this will be a 6.7% reduction in health spending as a proportion of GDP by
2020/21, creating a significant funding gap that will make it more difficult to provide high quality,
safe, sustainable health services.
2.4 We believe that current funding levels are the biggest single threat to the sustainability of the NHS
and would draw the Committee’s attention to four key areas of concern:
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General practice is in crisis: The proportion of NHS funding spent on general practice has
fallen from 10.4% in 2005/6 to 7.4% in 2014/15, leaving practices receiving an average of only
£141 per patient to deliver a year of general practice care. This approach is contrary to
evidence that shows that investment in general practice reduces secondary care costs and is
therefore crucial to NHS sustainability8. To address this crisis there needs to be a sustained,
year-on-year increase in the proportion of NHS funding going to general practice on a
recurrent, equitable basis for practices.
Hospitals are in deficit: The aggregate NHS provider and commissioner deficit increased from
£554 million in 2014/15 to £1.85 billion in 2015/16. In the provider sector alone deficits stood
at £2.45 billion at the end of 2015/16.To try to cut the combined provider deficit to around
£250 million in 2016/17, the DH (Department of Health) has made available £1.8 billion via
the STF (Sustainability and Transformation Fund) 9. As the STF can only be spent once, if most
of the funds are used to plug deficits there will be little money being left over for the
transformational change and long-term investment that the NHS needs to ensure its
sustainability 10.
Cuts in public health spending will increase future costs: Recent cuts to public health budgets
will damage the health of the public and the NHS’s long-term sustainability 11. The BMA has
concerns about the Government’s overall commitment to prevention in public health as
demonstrated by the limitations of its recent obesity plan (which are considered in more detail
later in this response).
A lack of social care funding is increasing costs for the NHS: Between 2009/10 and 2014/15,
funding for the provision of adult social care fell in real terms by an average of 2.2% a year,
Suhrcke M, McKee M, Stuckler D, Sauto Arce R, Tsolova S, Mortensen J: The contribution of health to the economy in the European
Union. Public health 2006, 120:994–1001.
5 Quality Watch, NHS Waiting Times, November 2015, http://www.qualitywatch.org.uk/news/%E2%80%98gradual-decline%E2%80%99nhs-waiting-times-unlikely-improve-soon-other-areas-care-quality-show-more
6
NHS England & NHS Improvement (2016) Strengthening financial stability and performance in 2016/17
7 BMA NHS funding and efficiency savings, pp. 4-5, https://www.bma.org.uk/collective-voice/influence/key-negotiations/nhs-funding/nhsfunding-and-efficiency-savings
8 Spend to save: The economic case for improving access to general practice A report for the
Royal College of General Practitioners, p.5, http://www.rcgp.org.uk/~/media/Files/PPF/2014-RCGP-Spend-to-Save-Deloitte-report.ashx
9 NHS England & NHS Improvement (2016) Strengthening financial stability and performance in 2016/17.
10 Nuffield Trust (2016) Feeling the crunch.
11 BMA Annual Representative Meeting 2016
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leading to a 25% reduction in the number of people receiving publicly funded social care 12.
One of the main consequences of this is delayed discharge of older patients out of hospital
into more appropriate care settings. The RCP (Royal College of Physicians) has reported that
the number of patients in hospital because of delays being discharged has risen by 80% over
the last five years 13. 14. This results in worse patient outcomes and problems further down the
line as older people can, for example, quickly lose mobility and the ability to do everyday tasks,
as a consequence of being in hospital. It has been reported that in healthy older adults 10
days bed rest leads to a 14% reduction in leg and hip muscle strength and a 12% reduction in
aerobic capacity 15. Not only is this bad for the patients stuck in hospital, it means that people
who do need hospital care cannot be admitted due to bed shortages, and is also wasteful of
NHS resources. The gross cost to the NHS of bed days occupied by older patients no longer in
need of acute treatment has been estimated at £820 million 16.
2.5 What funding models would best ensure financial stability and sustainability without
compromising the quality of care? What financial system would help determine where money
might be best spent?
The BMA believes that public funding must be used prudently and effectively. Previous attempts to
introduce new funding models in the NHS have lacked adequate scrutiny and effective risk
assessment. An example of this is the introduction of PFI (Private Finance Initiatives), which have
become a drain on the public purse, creating an enormous burden of debt. The Government must
undertake evaluation and learn from past experience and international comparators when
instigating new funding methods in the NHS. This will avoid further instances of individual hospitals
and CCGs becoming overrun by debt, compromising the care they are able to provide to patients.
2.6 What is the scope for changes to current funding streams such as a hypothecated health tax, sin
taxes, inheritance and property taxes, new voluntary local taxes, and expansion on co-payments
(with agreed exceptions)?
The BMA is committed to an NHS which is publicly provided, publicly delivered and free at the point
of need. We strongly believe that healthcare funding is a basic function of government and the NHS
must continue to be funded directly through general taxation.
2.7 We have supported some initiatives to increase the amount of funding available for public spending
generally, for example the proposed Tobin Tax of 0.05% on the banking sector, which could have
raised as estimated £20 billion. We also support taxation of some products and services which are
proven to have negative health impacts on the population, as direct economic disincentives. We
consider that it is appropriate to increase tax on tobacco, to introduce a minimum alcohol pricing
of 50p per unit of alcohol sold 17and we welcome the Government’s proposed soft drinks sugar levy.
Measures such as these could help to boost public finances overall, which could then result in
greater funding being made available to health and care services.
2.8 However, we have concerns regarding the ability of recent schemes, such as the social care precept
(see Annex 1), to raise the funding that is needed to meet patient need. It is therefore crucial that
these schemes are evaluated to ensure that they are effective and proportionate.
Lafond S, Charlesworth A, Roberts A (2016). A perfect storm: an impossible climate for NHS providers’ finances? The Health Foundation.
Underfunded, underdoctored, overstretched - the NHS in 2016, p.2
https://drive.google.com/file/d/0B59chPQfmIt1Y3RSSkN4OGZqam1BdzRGSHNCLWtIcWY4dVRZ/view
14 National Audit Office (2016) Discharging older patients from hospital
15 Monitor (2015) Moving healthcare closer to home: literature review of clinical impacts.
16BMA, minimum alcohol pricing briefing, https://www.bma.org.uk/collective-voice/policy-and-research/public-and-populationhealth/alcohol/minimum-unit-pricing
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13RCP:
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2.9 We have previously argued that it should be easier to share health and social care budgets where
professionals have identified that it would be beneficial for patients and service users, either
through existing mechanisms, or by creating new ways to pool budgets. However, these benefits
will only materialise if high levels of trust exist between the relevant local partners and enough
time is allowed for integration to be embedded18. We believe a national framework is needed to
set out how the NHS, public health and social care will be funded, commissioned and organised in
the future to meet the needs of the population.
2.10 Should the scope of what is free at the point of use be more tightly drawn? For instance, could
certain procedures be removed from the NHS or made available on a means-tested basis, or could
continuing care be made means-tested with a Dilnot-style cap?
The BMA firmly rejects any proposal of a means-tested monthly levy to pay for the NHS or to charge
for GP and hospital appointments19. User charges have been shown to limit access to healthcare on
the basis of wealth, undermining the very principles which lie at the heart of the NHS and quality of
service. Specifically studies show that more disadvantaged patients are likely to wait longer to seek
medical care if a cost is involved, which ultimately can impact upon their recovery 20.
3. Workforce issues and planning
3.1 What are the options for increasing supply, for instance through changing entry systems, overseas
recruitment, internal development and progression?
The BMA does not support unlimited immigration for doctors but believes that employers must have
the capacity to recruit and retain overseas doctors where other solutions to staffing have been
unsuccessful and where a clear workforce need exists. The immigration system must remain flexible
enough to recruit doctors from outside the UK should the resident workforce be unable to produce
suitable applicants to fill specialist or generalist vacant roles, or if an individual has particular skills
and knowledge not readily available in the UK.
3.2 What effect will the UK leaving the European Union have on the continued supply of healthcare
workers from overseas?
In 2014, 10,242 doctors (6.6% of the UK medical workforce) received their primary medical
qualification in another European Economic Area (EEA) country 21 . These doctors have become
essential members of the UK’s medical workforce and the NHS is dependent on them to provide a
high quality, reliable and safe service to patients. It is vital that the Government offers EU nationals
working in health and social care the right to remain in the UK. To help achieve this the BMA has
joined the Cavendish Coalition, a newly formed coalition of 29 health and social care organisations,
created to ensure standards of care are maintained as the Britain prepares to withdraw from the EU.
3.3 Currently medical research and the UK's expertise in planning and running health services are
effective ways of generating revenue for the NHS and for individual employers. This in turn helps to
resource services to patients and contributes to the sustainability of the NHS. The BMA recommends
that for this to continue to be the case, following the UK exit from the European Union, there must
continue to be a strong welcome for European and international students and trainees and a drive
for the UK to go out and share its knowledge and expertise overseas.
Williams et al (2013). Trust matters for integrated care? London: Kings Fund and Addicott R (2014). Commissioning and contracting for
integrated care.
19 BMA Annual Representative Meeting 2014
20
Rand Corporation, The Health Insurance Experiment, 2006 p.3 http://www.rand.org/pubs/research_briefs/RB9174.html
21 BMA Implications of the European Union referendum result for government policies on ensuring safe staffing levels in the National
Health Service and social care services https://www.bma.org.uk//media/files/pdfs/working%20for%20change/policy%20and%20lobbying/pa-briefeureferendumandsafestaffing-19-07-2016.pdf?la=en
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3.4 What are the retention issues for key groups of healthcare workers and how should these be
addressed?
The BMA is greatly concerned by the ongoing problems in recruiting and retaining all grades of
doctors and the impact this has had on already stretched services. Effective workforce planning must
be undertaken to ensure the right number of healthcare workers are employed with the right skills
and in the right places. Parts of the NHS currently lack a coherent and properly funded plan to deliver
a workforce that will meet the demands of the population. Workforce planning needs to take account
of the changing current and projected future demands and therefore needs to also look at training
requirements as well as measures to support greater retention of doctors. Governments should
retain control of workforce planning and development centrally, to prevent unacceptable regional
variations in training quality, the output of training and workforce availability. The lack of robust data
relating to the medical workforce across the UK is also a concern. Adequate data is necessary, not
only for the effective delivery of current care, but also for sustainable planning, and in understanding
the requirements for medical training provision. There needs to be improved availability, quality and
accuracy of NHS data collection across the UK, particularly around workforce numbers and vacancies,
which are not routinely collected.
3.5 General practice is the foundation stone of the NHS. However, just a year after the Government
promised to recruit 5,000 more GPs, a survey by GP magazine Pulse found that around 12% of GP
posts are vacant, the highest ever level of unfilled posts 22. The Government should work with doctors
to promote the uptake of general practice, increase the number of GPs, and implement the
recommendations included in the BMA’s report GP Safe working and locality hubs 23. These include a
safe level of appointments per day, appointment times that are sufficient to accommodate patient
need, and support and promotion for the rollout and evidence base for locality hubs, which are
beginning to be used to pool local primary care resources.
3.6 The BMA also has concerns regarding secondary care recruitment and retention. There are significant
gaps in recruitment of some consultants, including psychiatrists 24 , physicians 25 and emergency
medicine 26. Some A&E departments have already had to impose temporary closures due to lack of
medical staff27. Rota gaps are frequently reported as a problem, with evidence showing that seven
out of 10 doctors in training work on a rota with a permanent gap 28. In addition, only 52% of FY
(Foundation Year) 2 doctors are now progressing straight to specialty training, a drop of around 20
per cent over the past five years, while the number of FY 2 doctors leaving medicine over the same
period increased by nearly 10 per cent 29.
3.7 Following the announcement of the imposition of a national model contract for junior doctors in
England, morale amongst junior doctors has collapsed. Such a situation is hugely concerning for the
future sustainability of the NHS as it will have a significant impact on retention figures for current
and future junior doctors. To ensure the NHS is sustainable, the Government must prioritise
improving the recruitment and retention of doctors.
Pulse, 29 April 2015, GP vacancy rate at highest ever, with 50% rise in empty posts http://www.pulsetoday.co.uk/your-practice/practicetopics/employment/gp-vacancy-rate-at-highest-ever-with-50-rise-in-empty-posts/20009835.fullarticle
23 GP Safe working and locality hubs, https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpc-currentissues/safe-working-in-general-practice
24 Kings Fund, Workforce planning in the NHS, p. 7 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Workforceplanning-NHS-Kings-Fund-Apr-15.pdf
25
RCP (2016) Underfunded. Underdoctored. Overstretched.
26 The Guardian, 10 August, 2016, https://www.theguardian.com/society/2016/aug/10/hospital-a-and-e-crisis-shortage-emergencydoctors
27 Inews, 10 August 2016, https://inews.co.uk/essentials/news/health/emergency-departments-closing-nhs-trusts-deficit/
28
RCP: Underfunded, underdoctored, overstretched - the NHS in 2016, p.3
https://drive.google.com/file/d/0B59chPQfmIt1Y3RSSkN4OGZqam1BdzRGSHNCLWtIcWY4dVRZ/view
29 2015 F2 career destination report:
http://www.foundationprogramme.nhs.uk/download.asp?file=F2_Career_Destination_Report_2015_-_FINAL.pdf)
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3.8 How can the UK ensure its health and social care workforce is sufficiently and appropriately
trained?
The BMA has set out a vision for pre- and post-qualification training and development of doctors 30 ,
which centres on the purpose and goals of medical education, training and development being
universally understood and agreed with the profession. Medical education, training and
development must be responsive to the population’s health requirements and rooted in an ethos of
professional excellence. We also consider that there should be a process of continuous lifelong
learning, which in turn is valued and supported by employers and infrastructure.
3.9 The BMA has concerns, which are outlined in our recent response to the Higher Education and
Research Public Bill Committee 31, that new fee raising powers contained within the Bill, linking fees
to the TEF (Teaching Excellence Framework) could, in the long-term, lead to noticeable differences in
tuition fees across providers. We consider that in time this may negatively impact on the number of
applications to study medicine, as well as discouraging some of the brightest students from becoming
doctors. We recommend that the proposed flexibility of tuition fees based on their rating in the TEF
should be reconsidered.
4. Models of service delivery
4.1 What are the practical changes required to provide the population with an integrated National
Health and Care Service?
The BMA has consistently called for greater integration and collaboration between different parts
of the health service, including health and social care, as well as more integrated working across
the medical profession and other clinicians. We believe the focus needs to be on delivering joinedup services, rather than encouraging growth of the internal market.
4.2 We recommend that any local service redesign should involve primary, community and secondary
care, including mental health, working in collaboration. When appropriate, it will also be important
to involve public health, bringing service delivery and prevention closer together. Similarly,
integration with social care must be improved. There needs to be a concerted effort to bridge the
longstanding divides that exist between sectors. Without this, a successful transformation of the
NHS to a genuinely coordinated and integrated health system is unlikely to be achieved.
4.3 Changes that don’t ensure genuine collaboration will create division, particularly if they are
perceived to be led by a certain sector or profession. We therefore recommend that any plan to
integrate services must be based on collaboration without any group dominating. The process must
involve consultation and engagement with all sectors and patient groups from the earliest possible
opportunity. Any change must be clinically-led and based on good clinical evidence that care will
be improved or at least not compromised.
4.4 How could truly integrated budgets for the NHS and social care work and what changes would
be required at national and local levels to make this work smoothly?
The experience of our members suggests that cultural and behavioural change in organisations has
the biggest impact on integration and other service redesign projects. Rather than merging
budgets, the BMA recommends that organisations should be supported to work together, focusing
on partnership working. We are concerned that pooled budgets could result in decisions made on
health spend becoming rationed, to meet the existing outstanding needs of the care sector.
Pre and post qualification training and development of doctors, BMA, 2015, https://www.bma.org.uk/collective-voice/policy-andresearch/education-training-and-workforce/training-and-development-of-doctors
31 BMA response to the Higher Education and Research Public Bill Committee:
http://www.publications.parliament.uk/pa/cm201617/cmpublic/HigherEducationandResearch/memo/HERB28.htm
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4.5 Overall, we believe that virtual integration should be prioritised over structural integration as
evidence has shown structural integration is often insufficient in achieving better coordination and
improved patient outcomes 32 . In Northern Ireland, for example, patients share many of the
frustrations of patients in England despite integrated health and social care services. Organisations
working in partnership, with or without shared budgets, can effectively develop multidisciplinary
teams, managed clinical networks and joined-up care pathways. Virtual integration is also much
less disruptive. Given the need for stability in the NHS and for stronger relationships to develop
between service providers, this is very important.
4.6 We support local areas working together to maximise the benefits for patients in their locality and
collaborating to make the most out of common resources. STPs (Sustainability and Transformation
Plans) may present an opportunity to create a shared vision and objectives for all organisations
within an area, including a single shared set of measures to assess performance. However, it is
critical that these plans must not exacerbate the funding crisis in the NHS. In particular, it is
important that STPs do not result in health funding being used to prop up depleted social care
budgets rather than focusing on the health needs of the local population. The BMA strongly
believes that if NHS funding levels are insufficient, the government must look at developing a new
funding settlement for health and social care services.
4.7 We also consider that for STPs to be successful it is crucial that there is sufficient public awareness
of them and that they have the support of patients and doctors. The BMA is therefore calling for
all plans to be made public and for local clinicians to be fully consulted and involved in any planned
changes. In addition, a good governance structure must be developed to ensure proper
accountability in the long term.
4.8 How can the balance between (a) hospital and community services and (b) mental and physical
health and care services be improved?
Encouraging and enabling providers to work collaboratively around the needs of patients should
help deliver more joined-up services, with an improved balance between hospital and community
services. The evidence available suggests that community-based care improves patient access and
experience while maintaining a level of quality that is equivalent with services offered in acute
settings33. The evidence also suggests that managed care programmes, emphasising preventative
healthcare and home treatment, as would likely be found in mature MCPs (Multispecialty
Community Providers), would improve quality for patients with long term conditions 34.
4.9 The BMA recognises that payment by results (PbR) systems can create perverse incentives to treat
patients within secondary care systems. To address this, it is important that the government makes
faster progress towards payments mechanisms that support integrated personalised care, while
also recognising and rewarding good outcomes.
4.10 We believe that the overall level of funding available for the NHS must be increased. This would
allow for an improved balance between mental and physical health care, as spending on mental
health care currently only equates to 11% of the total UK NHS budget. We believe that this would
move the NHS closer towards the desired aim of creating parity of esteem between the two. There
also needs to be more integration of mental health services with physical health services, through
Kings Fund (2010). Clinical and service integration: the route to improved outcomes https://www.kingsfund.org.uk/sites/files/kf/Clinicaland-service-integration-Natasha-Curry-Chris-Ham-22-November-2010.pdf
33 Sibbald B, McDonald R & Roland M (2007). ‘Shifting care from hospitals to the community: a review of the evidence on quality and
efficiency’. Journal of Health Services Research & Policy, 12 (2)
34 Singh (2005). Transforming Chronic Care: Evidence about improving care for people with long term conditions. Surrey and Sussex Primary
Care Trust Alliance.
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careful commissioning and delivery that supports integration, such as implementing liaison
psychiatry services. Better integration of these services enables patients with common
comorbidities of physical and mental health problems to be helped and treated earlier with
collaborative, holistic care.
5. Prevention and public engagement
5.1 What are the practical changes required to enable the NHS to shift to a more preventative rather
than acute treatment service? What are the key elements of a public health policy that would
enhance a population’s health and wellbeing and increase years of good health?
We believe that the 2010 Marmot Review 35 sets out a comprehensive method to shift towards a
preventative approach to healthcare based on action through the life course. The BMA strongly
supports this approach, and believes that a cross-government action plan is required setting out
short, medium and long-term actions against each recommendation in the Marmot Review. There is
also a need to complement this action with measures to mitigate the negative effects of austerity
and welfare reform on health, including a ‘health in all policies’ approach, which would require all
policy to take into account the health implications of decisions, and avoid harmful health impacts, in
order to improve population health and health equity.
5.2 Prioritising a focus on ill-health prevention activities to address the health risk factors significant to
the development of long-term conditions, such as cancer and cardiovascular diseases, will contribute
to promoting future sustainability of the NHS. These risk factors include smoking, alcohol misuse and
poor nutrition. The BMA believes there is a need to develop a long-term, comprehensive public
health strategy aimed at improving health over a generation (ie 25 years). Focusing on the long-term
is necessary to deliver sustained behaviour change among a population because of the way in which
poorer health outcomes accumulate over time. It would also overcome the inherent weaknesses of
existing strategies that are typically short-term, and that can radically change in focus after each
parliamentary cycle. Its development, implementation and monitoring should be overseen by a
standing Royal Commission on Public Health.
5.3 We recommend that investment in ill-health prevention programmes should be prioritised and
proportionate to the burden of disease across the social gradient. There is also a need for the
Government to utilise the full range of interventions: clinical; social; behavioural; educational;
environmental; fiscal; and legislative, to tackle the main drivers of unhealthy lifestyle risks. BMA
policies in relation to tobacco, alcohol and food and non-alcoholic drink products are included as
Annex 2.
5.4 In addition, as highlighted at the start of this submission, we also recognise that increasing health
literacy, particularly from an early age, is key to achieving public health prevention measures and
promoting better awareness of self-care. This is crucial as people with low health literacy report
worse physical and mental health, along with a higher prevalence of a number of serious health
conditions 36 . This issue is compounded by the number of competing messages associated with
commercial marketing. For example, there is a stark contrast between government expenditure on
public health communications and the money spent by companies advertising unhealthy food and
drink products. According to PHE, while the government’s public health marketing programme
Change4Life has an annual budget of £10 million, nearly £150 million was spent on marketing
unhealthy food and drink products in 2013. We recommend that to address this, government must
explore how to better promote health literacy from childhood and couple this improvement with
reviewing existing promotions and advertising for unhealthy food and drink products.
Marmot M, Allen J, Goldblatt P et al (2010) Fair society, healthy lives. Strategic review of health inequalities in England post-2010.
London: The Marmot Review.
36 Rowlands G, Protheroe J, Richardson M et al. Defining and describing the mismatch between population health literacy and numeracy
and health system complexity. Submitted for publication.
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5.5
What are the best ways to engage the public in talking about what they want from a health
service?
It is important to involve patients and the public in the planning, monitoring and development of
health services. Listening, engaging and empowering patients will help deliver services that reflect
what patients want and need. NHS England has produced specific guidance for commissioners on
how to involve patients and the public in this area which includes some helpful best practice case
studies37. Commissioners need to make sure they engage with all parts of their local communities,
especially disadvantaged and disenfranchised groups, as their needs are often amongst the most
challenging.
5.6
The BMA actively promotes the importance of communication and genuine cooperation with
patients, and their families and carers, through its PLG (Patient Liaison Group). Since its launch in
2004 the PLG has produced a number of patient-focused resources on topics ranging from selfcare to toolkits for doctors on patient involvement. It also provides support for doctors, offering
communication skills courses and an online toolkit. We believe that this focus on patients should
be ingrained into the delivery of health care in the England.
6. Digitisation of services, Big Data and informatics
6.1 How can new technologies be used to ensure the sustainability of the NHS? What is the role of
technology such as telecare and telehealth, wearable technologies and genetic and genome
medicine in reducing costs and managing demand?
Technological advances can support the redesign and delivery of healthcare to manage increased
demand on the NHS, but only if they are used as one part of a broader strategy of investment. We
consider there is a role for technology to support patients to self-manage conditions, as well as to
support clinicians to deliver care more quickly, access improved decision support and communicate
more effectively between primary, secondary and social care. For example, Asthma UK reports that
trials of smart inhalers to monitor medication adherence are showing evidence of improved asthma
control, through both improving self-management and providing clinicians with real time, precision
data to inform the development of asthma action plans 38. The BMA is supportive of further work to
develop our understanding of the potential benefits and risks associated with these types of
innovations.
6.2 However, there is currently limited evidence that emerging technologies such as telemedicine,
wearables and apps do in fact reduce costs and manage demand. There is also inconclusive evidence
as to whether or not remote consultations reduce the number of in-person consultations or improve
clinical outcomes. Research into genome medicine remains at an early stage, so the role it could play
in reducing costs and managing demand is still unknown.
6.3 What is the role of ‘Big Data’ in reducing costs and managing demand?
The BMA believes that ‘big data’ technologies offer considerable opportunities for research into
health, healthcare delivery and public health. We are supportive of uses of data for secondary
purposes, with appropriate safeguards and transparent processes in place. Given the scale of
datasets used in big data, it is of paramount importance that the public fully understands and
supports the use of big data technologies, and all data uses are fully transparent and in line with
patient expectations.
6.4 What are the barriers to industrial roll out of new technologies and the use of ‘Big Data’?
37
38
https://www.england.nhs.uk/commissioning/primary-care-comm/involving-the-public/
Asthma UK. 2016. Connected asthma: how technology will transform care. Report.
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One of the key barriers to large scale roll out of new technologies and big data is the lack of resources
and capacity available to do it properly. The NHS is experiencing intense financial and workload
pressures, directly caused by continued underinvestment. The government needs to provide
significantly increased and ongoing investment if healthcare organisations are to resource and deliver
IT programmes that actually achieve the desired outcomes of reduced costs and demand. Any
intention to roll out programmes for new technologies needs to ensure that the mistakes of the 2002
– 2011 National Programme for IT are not repeated. For example, additional funding would be
needed to successfully implement and embed an IT programme for a range of activities, including
training clinical leadership to understand digital opportunities and technologies. In addition,
extensive planning and piloting would be needed to develop evidence that the intervention will be
clinically beneficial.
6.5 Many of the opportunities offered by advances in technology and informatics require changes to the
way information about patients is collected, stored and shared. For the NHS to realise the benefits
offered by data sharing between providers and from wearable technologies into patient records, NHS
Digital needs to continue its current work of ensuring all systems and third party providers are fully
interoperable.
6.6 Fragmented IT development leads to difficulty achieving interoperability, which limits collaboration
and undermines the quality of care that can be provided. Local IT systems in the health and social
care sector are often outdated and unsupported 39 and present a serious barrier to the successful
uptake and embedding of new technologies. There needs to be increased and sustained investment
in programmes of regularly updating software and hardware. For example, if clinicians are expected
to reduce workload by using telemedicine tools like video consultation, the software used needs to
provide adequate resolution and fully integrate with the clinical system.
6.7 Healthcare professionals often do not have access to general IT help and support to resolve technical
issues in a timely manner, often meaning that using technology inhibits the safe and efficient delivery
of care rather than enhancing it. Relevant bodies should ensure there are adequate dedicated
resources made available to provide technical support for IT systems, either through contracts with
suppliers and/or a dedicated support service.
6.8 How can healthcare providers be incentivised to take up new technologies?
In addition to addressing the barriers described above, healthcare providers would be incentivised
to develop and deliver programmes using new technologies if there was a comprehensive, peerreviewed evidence base showing that there are measurable benefits of using new technologies for
reducing workload and managing demand.
6.9 Where is investment in technology and informatics most needed?
Programmes should focus on improving how healthcare professionals currently work, finding new
ways to work more efficiently, with fewer errors. Long-term investment in research and delivery is
required to understand what technology is useful for patients and professionals, as well as what
technology creates unintended negative consequences. Any large-scale implementation of
technology-enabled services also requires significant and long-term funding in change programmes
to ensure that technology is embedded within an organisation and used effectively, rather than
imposing further workload on clinicians and creating potentially dangerous situations for patients.
6.10 75%of doctors feel that doctors and medical students need more training and education about
information, data and technology 40. If IT and new technologies are to be used more within the NHS,
National data guardian for health and care. 2016. Review of data security, consent and opt-outs. Report.
BMA. 2015. BMA member survey – NHS IT. Survey of ca 500 doctors across all branch of practices, conducted between 13 January and 3
February 2015.
39
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increased and sustained investment in training will need to be prioritised to ensure that healthcare
professionals can use emerging IT competently.
For further information, please contact:
September, 2016
Gemma Hopkins, Senior Public Affairs Officer
T: 020 7383 6287 |E [email protected]
Annex 1.
Social care precept
The social care precept, that enables local authorities to increase Council Tax by up to 2% a year to help
fund adult social care, is unlikely to raise the amount needed to cover costs for social care services. The
IFS (Institute for Fiscal Studies) has estimated that this mechanism would raise £1.7 billion by 2019/20
if used in full and would also need to cover the cost of the new National Living Wage 41 which is estimated
to be £1.4 billion by 2020. 42 Another issue is that the precept will raise the least funding in the areas of
greatest need of social care. 43 The BMA is concerned that this will exacerbate existing health
inequalities.
Annex 2.
Summary of BMA policies in relation to tobacco, alcohol and food and non-alcoholic drink products
Tobacco
• Increase taxation on all tobacco products above the rate of inflation and introduce a minimum
consumption tax.
• Implement a positive licensing scheme to control and reduce the amount of tobacco legally on
sale.
• Introduce a requirement for tobacco companies to report on sales data, marketing strategies and
lobbying activity
• Introduce an annual levy on tobacco companies to provide funding for future tobacco control,
applied proportionately according to a company’s market share
Alcohol
• Introduce a minimum price of at least 50p per unit of alcohol for all alcohol sales.
• Ensure duty on alcohol is increase annually above the rate of inflation and that the tax on every
alcohol product is proportionate to the volume of alcohol it contains.
• Prohibit all alcohol marketing and establish an independent body to provide education about
alcohol and regulate product and packaging design.
• Reduce licensing hours in on and off licensed premises, including restricting the sale of alcohol in
shops to designated areas.
Phillips D (2015). Local government and the nations: a devolution revolution? Institute for Fiscal Studies Autumn Statement briefing.
Resolution Foundation (2015). Care to pay? Meeting the challenge of paying the National Living Wage in social care.
43 Association of Directors of Adult Social Services (2016). ADASS Budget survey.
41
42
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• Implementing mandatory labelling of alcohol products that include an evidence-based health
warning specified by an independent regulatory body.
Food and non-alcoholic drink products
• Introduce a mandatory, standardised approach for displaying nutritional information on all prepackaged food and drink products.
• Prohibit the marketing of unhealthy food and drink products that appeals to children and young
people.
• Review of how the regulation of sales promotions can be strengthened to ensure they favour
healthy options and deliver public health benefits
• Prohibit retailers from displaying and promoting unhealthy food and drink products at checkouts
and in queuing areas.
• Provide local authorities with the power to restrict the future number, clustering and
concentration of fast-food outlets locally.
• Set mandatory targets for manufacturers, retailers and caterers to reduce calorie, fat, saturated
fat, salt and added sugar levels in pre-prepared and processed products.
• Introduce a tax on all sugar-sweetened beverages, which increases the price by at least 20%.
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