Left column


Since the creation of the NHS, the NAO has been a critical friend. In the run up to its 70th anniversary we have been reflecting on our role in supporting improvements. Resource and the NHS are always discussed together and the additional funding recently announced is not surprising. The health service is under huge pressure […]


A critical friend of the NHS

Posted on June 27, 2018 by

CImage of NAO supporting the NHS
Since the creation of the NHS, the NAO has been a critical friend. In the run up to its 70th anniversary we have been reflecting on our role in supporting improvements.

Resource and the NHS are always discussed together and the additional funding recently announced is not surprising. The health service is under huge pressure – it treats a vast number of patients with finite resources and is a cherished national institution. Throughout its history there are times when budgets are more constrained and those when it is less so, however we have found that the service is not always delivering value for money. Patient experience is often mixed. There is unwanted variation in the quality of care and waiting times are growing. Our experience shows, though, that additional funding will not resolve all of the problems facing the NHS; rather, a different way of thinking and working is required.

Long-term financial sustainability is complicated and remains a challenge. In 2012 when most providers were in surplus many trusts relied on cash support or non-recurrent local revenue support. This was not a sustainable approach, however many of these practices continued until 2014, a point which we raised with NHS England and TDA/ Monitor. In 2015 and 2016 messages hardened as less had been achieved on transformation as sustainability funding was directed to trust deficits and a growing number of clinical commissioning groups were in the red. Ensuring effective financial sustainability requires a stable base. Attempts to transcend these barriers will only succeed where governance and accountability structures work well and there is a determination to achieve change.

The improvement to stroke services demonstrates this. Our two reports: Faster access to better stroke care and Progress in Improving Stroke Care were influential in changing the NHS approach and developing a national stroke care strategy. The move towards are more holistic, coordinated and strategic approach to delivery of services resulted in not only improved quality of care and patient outcomes, but estimated savings of £456 million between 2007 and 2013. The impact is similar for the creation and coordination of the specialist Trauma centres in 27 hospitals.

This different way of thinking is not only important in the way services are structured but also in the way that the NHS interacts with patients and responds to their changing needs. Public health is one of the greatest challenges facing the NHS and the rise of obesity levels is a problem that all western societies are facing. We discussed this in our 2001 report Tackling Obesity in England. The report highlighted that obesity rates had tripled over 20 years resulting in 30,000 premature deaths and cost £0.5 billion in treatments. The NHS must not shy away from these challenges but tackle them head on as it has done so in the past. In 2000 we highlighted the issue of Hospital Acquired Infections and between 2004 and 2008 the NHS was able to reduce MRSA rates by 57%.

The NHS will continue to face challenges and funding will always be an issue, particularly as our population ages and need increases. However, the NHS has shown that it can tackle problems if it has the determination to do so. Local bodies responsible for health and social care must find ways of making this work and national bodies need to look at how they allocate funding, design system rules and support those charged with delivery to prioritise difficult decisions. If these dry, practical but ultimately essential considerations are not thought through, then there is a real risk that little will change in the way that services are designed and delivered. This will impact on patients and make the work of the dedicated staff within the service that much harder. It is also unlikely to deliver value for money. The next ten years need to be better than that.

As always, we welcome your comments and invite you to contact us if you have any queries or would like to discuss any of these issues in more detail.

CImage of NAO supporting the NHSAbout the author: Robert White joined the National Audit Office in 2014 as ​Director – Health (value for money) following a 25 year career in the NHS and independent sector. Educated in Canada and the UK, he worked in the Canadian Health Service prior to his financial roles in the UK. Robert is a Chartered professional accountant (Canada), holds a masters degree in finance and accounting and is a bachelor of commerce. Within the NAO he leads a portfolio of wider health assurance work.


Share this article on social media:


3 responses to “A critical friend of the NHS”

  1. m che says:

    There was a question about the overhead which could be giving variation as much as 55.2 in a presentation given by the insight organisation.Looking up on the bio web lung cancer is top of the list and this is a six month treatment,so the expenditures could well fall into 2 budgets periods and not just one quarter in the accounts.

  2. roger steer says:

    You say “Ensuring effective financial sustainability requires a stable base”.
    The NHS was actually more sustainable when real terms funding was guaranteed prior to cash limits.
    There is not a good argument for restraining healthcare funding. Need is manifest, the public favour increased spending and capping expenditure increases inefficiency.
    Healthcare spending requires a buoyant funding base. The best argument against the NHS is that it has resulted in underconsumption of healthcare in the Uk.
    The NAO has made some positive contributions, notably in trying to get to the bottom of the case for integration of health and social care , but it bears responsibility for turning a blind eye to the unfolding staffing crisis in the NHS and in accepting cash limits as a sensible way to manage local healthcare.
    Correct me if I am wrong but is there any other country in the world who would manage local healthcare according to a fixed budget.
    It is anomalous that the Costs of clinical negligence and NHS pensions are managed through “AME” whilst the flux of healthcare spending has to manage across multiple thresholds and budgetary limits, each increasing inefficiency as decisions are delayed, diluted and denied.
    It feels as though the insights of Enthoven and others have been forgotten.

  3. herrypot says:

    I suspect that the patients in NHS hospitals are fed with privately produced food. To my knowledge, the NHS does not own or run farms that supply food to patients.

Leave a Reply

Your email address will not be published.

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Right column

  • About the NAO blog

    Our experts share their views about issues and common challenges facing government, what public sector leaders should look out for and how organisations have addressed issues. Our posts draw together threads from across our reports, share secrets spilled in events and reveal our experts’ expectations for the future.

    We encourage comments that support the exchange of ideas for improvement, but ask that those posting are respectful of others.

  • Sign up for automatic feeds

    Sign up to receive email alerts:

    RSS IconSubscribe in an RSS Reader