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The NHS at 70 – time for an honest debate about the future

December 31, 2017



5th July 2018 will mark the 70th anniversary of the establishment of the NHS. It remains the most enduring testament of the collective will of the people of this country to tackle the need and suffering of their fellow citizens. As such it will be an occasion which deserves celebration, but I hope it is also an anniversary which provides a focal point for some critical debate about its future.

By this I do not mean challenging the basic principles of the NHS. Britain is not unique in providing universal access to healthcare but it’s system is distinctive and, on the whole, is relatively efficient and fit for purpose. However, the last 8 years of austerity have highlighted weaknesses which, if not addressed, will undermine the sustainability of what is able to be offered for future generations given an inevitable increase in demand with an ageing population and advances in medical technology.

I would highlight five priorities for the New Year.

The first is workforce where we have now woken up to the scale of the short and long-term challenges we face. In the short term the big pressure is numbers, for instance, in mental health, we need 19,000 extra members of staff by 2020/1 to replace staff we are losing and to meet the extra demands of the Five Year Forward View for Mental Health. In the long term there are bigger challenges about reenvisaging the health and care workforce and rethinking career pathways along the more flexible lines which will appeal to a younger workforce less likely to buy the old paradigm of a profession for life.

We also need to be much smarter at looking after the workforce we have got. The recent Farmer/Stevenson report on mental health at work positioned the NHS as one of the sectors of the economy with the highest annual costs of poor mental health at work (estimated at between £2,028 and £2,174 per head). We need more than a sticking plaster approach to addressing this, taking account of the fundamentally traumatic nature of working in healthcare and any remedy must be a fundamental part of the calculations make about efficiency and productivity in the NHS.

The second priority is to be honest about the money. All I have seen in the last couple of years is of a system, which despite some heroic efforts from providers and commissioners, is seriously struggling to keep up with the demand it is facing within the resources available, let alone being able to address key priorities for development and transformation such as those for mental health. I am, of course, not alone in that view with similar opinions being voiced by the Kings Fund and most of the leading health think tanks. While I accept that there are no easy answers to the pressures on public finances there are major consequences of the current position. First there is stress of dealing with the fallout on the frontline staff and who can often feel held personally responsible for the failings of the system. Second a constant focus on short term efficiency distorts priorities, making it harder to make investments in new models of care which often require some element of double running but which, in the long term, are central to the delivery of a sustainable system of care.

These dilemmas have made me a supporter of proposals to take decisions about the long-term funding of the NHS and social care out of day to day political decision making with funding pegged to an agreed proportion of GDP. There would still be difficult choices to be made but, at least, the basis for those choices would be less arbitrary.

My third priority is prevention in its wider sense. It is the most obvious economics that intervening early is less expensive than waiting to deal with issues when they have reached crisis point. However again and again in the years of austerity we have cut those services which prevent demand or help to seriously reduce its impact. Some of this recognises the limited role which health services play, on their own, in improving health outcomes. It also reflects the distortion caused by the short-term nature of funding which can lead to the exclusion of initiatives which deliver a very robust return on investment but where payback will be over years if not in some cases, decades. From my perspective there would be very powerful case for treating elements of public health spending as capital investment with upfront investment justified in terms of its longer-term impact on health outcomes and utilisation.

Linked to this is the need for a much greater sense of urgency in tackling health inequalities which needs to be a much greater focus of national policy making and local commissioning decision. In an era where what we can do is being rationed, either explicitly or implicitly, the impact on health inequalities should be a key criterion for any assessment made by NICE of new treatments.

My fourth point is the need to continue to resist the temptation to default to organisational change as a kind of “magic thinking” to address the problems of funding. I think STPs have, in general, been helpful and the principles of Accountable Care provides opportunity to take a paradigm of integrated care further. But let’s not again make the old mistake of putting form before function. From my experience organisational development is best as a means of supporting and extending those areas which are already well on a journey towards more integrated working and any wider roll out must be justified in terms of clear evidence of benefit in a UK setting. We must also be bold in constructing approaches which go beyond the traditional boundaries of the NHS and ensure social care, housing and the voluntary a key seat at the table.

My final point relates to culture. The NHS has many strengths and it is full of many very committed and inspiring individuals. The way it works together as a system can, sometimes, leave something to be desired.  Part of the problem is the public and political nature of the service and to the way in which it is portrayed in parts of the media, some of it relates to the way in which different constituencies, especially when under external pressure, react to each other.  We need a culture which is tough on problems and supportive of individuals and when things go wrong does not automatically try to find someone to blame.  We need to call time on aspects of the persecution and bullying of staff which sadly remain all too visible in the way the NHS, at times, goes about its business.

So, 2018 will be the time to celebrate the 70th birthday of a remarkable British institution. Its remarkableness, however, will be even more reason for an honest debate about its future.




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