Like many others working in health policy, I’m a big fan of a well chosen metaphor. My favourite at the moment is the so-called ‘iron triangle’ – that all health care systems are always looking to achieve quality, access and affordability (the three points of the triangle), but can only deliver two at best.
So why I am obsessing about triangles? It’s all about the signals currently being sent to the NHS, and whether they’re capable of being delivered.
NHS trusts are being told to keep quality high. The Trust Development Authority have been clear on this, saying it is ‘not acceptable for NHS trusts to respond to funding shortfalls by reducing service quality’. Post-Francis, additional focus has been on increasing staffing levels in order to achieve safer care and NHS providers are projected to have spent over a £1bn extra on staff than previously planned between 2013 and 2015 alone.NICE's guidance on safer staffing reinforces this, and we can already log on to NHS Choices to see how our local hospital is faring against their planned staffing levels.
Hospitals are told key access targets are non-negotiable. Too many people waiting longer than 4 hours in your A&E? Expect the chief executive to receive a string of phone calls asking for explanations. Politically, targets still matter immensely – Ed Miliband’s main foray into health over the past 6 months has been to announce Labour would re-introduce the 48 hour GP access target.
And all this needs to be achieved while balancing your books. Not easy when the NHS is in the middle of its longest ever spending squeeze. It is 'essential that chief executives have a tight financial grip and live within their means’ said the Department of Health in June. But of course, choosing not to increase staffing levels or relaxing for a second on access targets is not acceptable.
Going by the iron triangle, something has to give. What has so far?
Evidence from QualityWatch – our joint programme with the Nuffield Trust – shows that overall, quality has broadly held up. Areas such as health care acquired infections and VTE screening have improved very significantly over the past five years. Amidst a gloomy financial outlook, The King’s Fund’s Quarterly Monitoring Report shows some optimism about patient care; 73% of NHS trusts questioned thought care in their area was the same or better over the previous year when asked in June 2014, up from 66% in July 2013.
Access is undoubtedly creaking significantly. For the NHS as a whole to miss the A&E 4 hour target even for a single week in May is unheard of. This year it missed it for 5 weeks in a row. Targets relating to 18 week treatment and cancer waiting times have similarly started to come under severe pressure. The target related to a 62 day wait for first cancer treatment from GP referral deteriorated steadily last year, culminating in missing the target in the final quarter for the first time since it was introduced. While performance has slipped, it certainly hasn’t collapsed – although a harsher winter than last may prove extremely testing.
Which only leaves affordability. There is no hiding the crumbling financial position of NHS trusts. The number of trusts recording a deficit rose by 50% in 2013/14, to 66 from 45 a year earlier. As Anita Charlesworth sets out in her blog, this number is only going to increase this year, and get even worse in 2015/16 as a result of growing pressures, pension changes and the Better Care Fund. While there’s a requirement for NHS trusts (although not for foundation trusts) to break even over a three year period, whether many of these plans are actually credible is a point of debate.
Deficits are the safety valves keeping quality broadly in the right place. That’s okay at the moment, when money can still be found somewhere in the system to keep providers in deficit afloat. But there will come a time – most likely within 18 months – when the level of deficits are so high that the money simply runs out.
At that point, either more money is found from somewhere (reduce the budgets of other departments yet further, anyone?), or trusts have to revisit whether quality and/or access take the hit.
Or we hope the triangle doesn’t prove to be so ‘iron’ after all.