Lord Norman Warner started his presentation by noting that this would not be the most uplifting talk of 2023!
We are witnessing the decline of a national icon close to its 75th birthday. The public no longer bangs saucepans in appreciation of the NHS. Today the NHS treatment backlog is over 7 million patients. Ambulances queue to deliver patients who can wait 12 hours in A&E and then stay in hospital longer than necessary. ONS data shows thousands of excess deaths following delayed diagnoses and treatments. Large swathes of the workforce are on strike over pay. The Government has no credible plan for dealing with this situation.
Norman’s aim was to outline his thoughts on NHS reform based on his memoir and a Social Market Foundation pamphlet published last year. Those ideas are still relevant, though he expressed doubt that they are now sufficient, given how bad the situation is.
The NHS has been in decline since 2010, made worse by the failure to adequately fund social care and the expensive and botched 2012 reorganisation. A decade of inadequate funding averaging about 1% pa and unsustainable pay restraint has made thing worse.
Brexit increased the workforce problems in both the NHS and social care. Covid was the final straw. We now have a drained workforce working in a system that they see crumbling around them with no credible plan for the future. The NHS funding system is being questioned, along with its mantra that it is free to everyone at the point of clinical need. Governments can no longer spend their way out of the NHS’s problems.
We have never faced up to the funding issue. Over its lifetime the NHS has received real-terms annual increases averaging about 3.7%, although this dropped to 1.4% between 2010 and 2018. But throughout NHS history the economy has rarely grown at much more than 2% a year. The result is that the NHS now accounts for about 44% of departmental public expenditure and on present trends this will be 50% by 2030. Since 2019 we have accelerated along this unsustainable path with the 2022/3 budget reaching nearly £180 billion compared with about £106 billion in 2010/11. Unsurprisingly radical reforms in service delivery are on the agenda. Norman’s recent pamphlet for the Social Market Foundation covered some key issues for these reforms.
First the reform of public health and prevention. When Beveridge wrote his report in 1942, he wanted “a national service for prevention and comprehensive treatment available to all.” Adequate prevention has never been delivered. Instead, we have an ill-health service, with the NHS having little influence over factors affecting the nation’s health. The result is a demand-led NHS with little ability to curb demand other than by rationing. The obesity epidemic demonstrates the weakness of public health policy. Governments have never invested adequately or consistently in public health or prevention. More recently these budgets have been cut. Elected Ministers are reluctant to challenge the poor life-style choices of their electorates that fuel NHS demand. Norman has proposed an independent public body, an Office of Public Health, to determine policy and the allocation of resources for public health, nationally and locally. It would have a budget set as a proportion of the NHS budget and report annually to Parliament.
Second, he would increase significantly the proportion of the NHS budget going on community health services and social care and require expensive acute hospitals to do more with less. 15 years ago, a serious attempt was made to move more services out of hospital with a major public consultation and a 2006 White Paper plus pilot schemes and new polyclinics. The acute hospital lobby and nervous Ministers killed it off. But it must now be put back on the agenda and there are signs this is starting to happen.
This approach will require more GPs with a different contract; more community nurses and other staff; new and larger buildings with better access to diagnostic services; better IT with finally an electronic patient record that works across hospitals and community. The private and voluntary sectors and local government will need to play a bigger role as was proposed when he was a Minister. We have to break the inefficient and low-productivity NHS monopoly in many service areas. Prevention and self-care need to play a bigger role, with community pharmacies being paid to do more for patients. We have to fix social care funding with an increase of about £12 billion phased in over 3 years, taken from NHS budgets and uprated in line with NHS increases. These changes will impact significantly on acute hospitals whose high overheads absorb too much NHS funding. For example, it costs about three-times as much to keep someone unnecessarily in an acute hospital as it does in a nursing home. This brought Lord Warner to his third and fourth recommendations.
Third, is to set up a big network of elective surgery and diagnostic hubs with competition between NHS and private providers. This would require longer-term contracts like those he let in the Blair government when new elective surgery centres provided NHS care at NHS prices and extra NHS diagnostic capacity. This gives patients more choice and facilities work longer hours.
Fourth, we should run specialist hospital services on fewer sites as proposed by Lord Darzi when a Health Minister. When specialist stroke services in London were reduced from 32 sites to 8 it saved 400 lives within two years and saved £800 per patient because they recovered quicker. Applied nationally the London stroke services would save about 2000 lives a year. The concentration of specialist services has changed little in 15 years.
The scandals keep coming and the budgets keep increasing because we lack an authoritative clinical appraisal system to drive such a change and take unpopular local decisions out of Ministerial hands. Norman has outlined such a system in his SMF pamphlet.
His fifth main change is tackling the lack of heath and care workforce planning. We have simply not looked ahead and trained our future workforce with the right skill mix. This is extraordinary when health and care is such a labour-intensive industry employing over 3 million people jointly and accounting for two-thirds of the NHS budget. We have relied far too much on oversees recruitment and not done enough to retain the staff we have. The fiasco over doctors’ pensions is one good example. These problems cannot all be laid at the door of Ministers. The top management of DHSC is not held to account for its shortcomings and failure to run the NHS as the large complex business it is.
In conclusion, Lord Warner noted that if he was writing the pamphlet now, he would add more about local and regional autonomy, reducing the number of quangos, downsizing DHSC but improving its business capability and a bigger role for local government and social enterprises.
Lord Warner’s pamphlet, The NHS: Decline and Fall or Resurrection? can be read here.
Click here for the publicity flyer for Lord Warner’s memoir, In Pursuit of Competence: A Life as a Westminster Nomad.