Andrew Haldenby is Co-Founder of Aiming for Health Success, a health advisory firm, and former head of the political section of the Conservative Research Department.
The performance of the National Health Service is unacceptable, in the view of its CEO, and won’t be back to pre-pandemic levels before the general election. Ministers have announced what amounts to a 180-degree U-turn in favour of localism and choice.
The Telegraph and the Times want the NHS to be scrapped in its current form. The editor of this website fears that rising demand for health is inevitable; if so, any hopes of a lower tax future will be dashed.
There is a lot to unpick here. Suffice to say that we are not doomed. The performance of the NHS is a product of a series of poor choices over the years. Putting those choices right will see the Service improve quickly.
But the urgency is great. Whether current Conservative ministers have it in them to change course is the final question.
The annual report of the Care Quality Commission put it well: the NHS is in gridlock. Hospital wards are full because of a lack of available social care. Because wards are full, people are stuck in A&E departments.
As a result, patients wait in ambulances outside of hospitals, and people needing ambulances face unacceptable delays. Difficulties in seeing GPs exacerbate the whole situation.
Taking a longer view, this comes as no surprise. Successive governments have prioritised investment into hospitals rather than social care, primary care and other out-of-hospital services. The Coalition Government decision in 2010 to protect the NHS budget and sharply cut social care set the tone. Since September 2015, numbers of hospital consultants have increased by 25 per cent. Numbers of GPs have fallen by 6 per cent.
Professor Nick Bosanquet has coined the “perverse care law”. Health services can become unbalanced, with much spending on hospitals and little development of out-of-hospital services. The consequence is that patients resort to revolving-door admissions into and out of hospitals rather than getting solid support in the community. It is a very expensive way to deliver poor care.
There have been promises to create these out-of-hospital, “integrated” services – see this good policy statement in 2014. And there are many instances of individual NHS organisations doing the right thing – for example, Leeds General Infirmary using its own budget to buy social care places, solving the discharge problem.
But the promises have not been delivered and the innovative practice has been the exception rather than the rule.
Speaking for the Reform think tank last month, Wes Streeting, the shadow health minister, asked why every NHS organisation doesn’t behave like Leeds General. A key factor is the extraordinary number of performance targets set for NHS managers – “hundreds” according to the Government on Monday – that make it extremely hard for them to try something new. Every review of NHS management warns that NHS leaders look up to NHS England and ministers rather than down to better patient care.
A major new concern is risk aversion among hospital doctors who find it difficult to release patients into the community, even if a social care setting would be more appropriate for them (and less expensive). Last week Dr Adrian Boyle, president of the Royal College of Emergency Medicine, told the Daily Mail that, “Hospitals are like lobster traps – they’re easy to get into and hard to get out of.” The board of NHS Scotland is right to want to change “the risk appetite from what we see in hospitals”.
The situation is grave, but it is possible to improve things quickly. In fact immediate progress is a must both to improve performance and to build confidence in a wider, long-term change of approach.
The priority is to improve outcomes for elderly and high-risk patients, with rapid support at home, so as to reduce hospital admissions. Key steps can include joint commissioning and funding of social care, to make the Leeds General Infirmary experience commonplace.
Out-of-hospital integrated care teams, led by GPs and including nurse practitioners and home carers, are also essential. A particular focus should be deprived areas including parts of the Red Wall. In 2019, A&E attendances per head of population in the least affluent areas were double those in the most affluent.
To reassure the editor, rising demand for healthcare is not inevitable. If outcomes improve, demand falls. It can be done. In the early 1980s it was expected that thousands of long stay hospital beds would be needed for people with HIV/AIDS. A combination of early diagnosis and better treatment have improved outcomes to the extent that the latest NHS target is to eliminate all infections by 2030. There has been similar progress in coronary heart disease and asthma.
An ever-worsening NHS, taking up an ever-greater share of GDP, is only inevitable if we choose it to be so.
Nor should we introduce tax relief for private medical insurance (as one Conservative MP has suggested) or charges for medical treatment (the Times). However well-intentioned, the former would signal the terminal decline of the publicly-funded system. The latter would reduce access to health for the most deprived. The goal of an effective, affordable, universal service is still the right one.
Can current Conservative ministers do it? Certainly their predecessors have made it hard for them. The populist “more hospitals and more doctors” pitch in the 2019 manifesto was the opposite of what the NHS needed. More targets were introduced, not less – see Sajid Javid on face-to-face GP appointments.
I think senior Conservatives became nervous of the NHS in 2011, after the failure of the Lansley reforms, and have left the big arguments on change to NHS England ever since.
But the Autumn Statement was very good: more money for social care, a major review of targets, a reinvigoration of patient choice – all pointing in the right direction. Two years until the election is plenty of time to improve services and to make the long-term case for an NHS that works differently and performs better as a result. I hope Steve Barclay et al can build on their good start.