John Baron is MP for Basildon and Billericay.
We all know that the NHS is in trouble – constituency complaints were on a meaningful increase well before the pandemic.
Despite real-term increases in spending under successive governments, waiting times have deteriorated and outcomes in general remain below comparative healthcare systems. Surgery to save the patient is required.
Part of the problem is that the system is bureaucratic: only half of its ~1.4 million workforce is clinically trained. This is not helped by the myriad of process targets. A narrower focus on outcomes is needed – this would galvanise the NHS while aligning interests with those of patients.
There was a long waiting list even before the pandemic, and the enormous one we currently see will grow before it decreases. NHS staff are exhausted and burnt-out after some very exacting years rising to the Covid-19 challenges.
Meanwhile, the markets have clearly signalled the end of cheap and unrestrained borrowing, while persistent inflation means spending does not go as far as it used to.
This week’s leak from NHS Scotland setting out that its highest echelons are contemplating abandoning Aneurin Bevan’s 74-year promise of universal free healthcare – famously as near a thing the British have to a national religion – is both astonishing and a sign of how much pressure our health services across the UK are under.
According to the King’s Fund, in current prices health spending in England has risen from £124.1 billion in 2009/10 to £173.8 billion in 2022/23. It is clear from this that merely spending more money, as the easy refrain invariably goes, is not the answer. For those of us who support the NHS – as we all do – it is encouraging and significant that even the Shadow Health Secretary recognises this.
Major reform is clearly required, a point starkly illustrated by some extraordinary analysis from the IFS. This showed that the NHS is moving fewer people off waiting lists than in 2019 despite spending being, in real terms, around 12 per cent higher than 2019 levels.
This is also despite the Health Service also receiving around 13 per cent more doctors, 11 per cent more nurses, and ten per cent more clinical support staff when compared to 2019. The NHS urgently needs to up its game and translate these substantially increased resources into greater activity.
There are a number of approaches to solving this problem of productivity and efficiency. One that the All-Party Parliamentary Group on Cancer explored during my nine years at its helm was a greater focus on a small number of outcome measures, such as one-year survival rates, instead of the current plethora of process targets, such as waiting times and the number of operations or treatments.
Measuring how many patients are alive one year after their initial cancer diagnosis encourages earlier diagnosis, as catching it in its early stages greatly increases the chances of successful treatment. It also makes much more likely that any treatment is lighter, less onerous and cheaper; if the cancer is caught in its later stages then treatments tend to be heavier, longer, often lead to a lower quality of life, and are more expensive.
Late diagnosis is a large part of why the NHS continues to lag behind cancer survival rates of other comparable healthcare systems abroad. The Government once estimated that 10,000 extra lives could be saved if we matched the best survival rates in Europe, and in 2013 the OECD confirmed that our survival rates rank near the bottom when compared to other major economies.
Concentrating on outcome measures also has the advantage of not being prescriptive, allowing healthcare professionals the freedom and flexibility to design their own solutions.
This could include running wider screening programmes or better symptom awareness campaigns. It could also include better and more timely access to diagnostic services, and it was encouraging to read that one of the plans to address the cancer backlog is to allow GPs to directly refer cancer cases for diagnostic tests, rather than always via consultants.
However, all too often the Government and health bosses bind the NHS in endless process targets which measure activity rather than achievement – such as the four-hour A&E wait target, which tells you little about the quality and success of care once a patient has been seen. The House of Commons Library identified nine process targets applying to cancer alone – these include the ‘two-week wait’ to see a specialist after a referral and the ‘62-day wait’ from referral to first definitive treatment (which hasn’t been met for many years).
Such targets are only part of the journey when it comes to cancer care, and yet the NHS often cleaves towards these targets because they are invariably the key to unlocking funds. The advantage of outcome measures in this regard is that improved outcomes can only be achieved by improved processes – whilst measuring what really matters to patients and their families, which is whether they will get better or not.
In order to encourage the NHS to focus on outcome measures, I tabled a simple amendment to the Health & Care Act. This was widely supported by MPs and Peers, and to its credit the Government adopted it with a few very minor amendments as Clause Five. This new clause should ensure, if properly used, that outcome measures are put above process targets by the NHS, encouraging it to focus on earlier diagnosis.
There is no reason why this approach should not work for other disease areas, as cancer is far from the only condition to benefit from being picked up in its early stages.
Indeed, one of the reasons Japanese people tend to be in good health is because every citizen has an annual health MOT which aims to nip problems in the bud before they take hold – improving people’s health, quality of life – whilst also leading to a less expensive and more efficient health service.
It is therefore encouraging that the Health Secretary is looking at reducing the number of process targets that bind the NHS. He is quite right to observe that if everything is a priority, then nothing is a priority.
The Chancellor’s announcement in the Autumn Statement that Patricia Hewitt, the former Labour Health Secretary, will lead a review into NHS efficiency is likewise a positive development. The extra £3.3 billion a year in NHS funding must make it to the frontline rather than being swallowed up before it gets that far.
There is also scope for even more radical ways of reforming the Health Service. Any measures which help address the backlog should be considered.
An obvious one would be to reverse, at least temporarily, Gordon Brown’s decision in his first budget to scrap tax relief on private medical insurance premiums for the elderly. This would incentivise those who could afford to go private to do so, freeing up capacity for others to use.
In the longer-term, there is a discussion to be had on whether the whole way the NHS is funded should be reappraised.
There is much to be learnt from other systems in Europe which also offer universal healthcare, which we could adapt to suit British needs. The Dutch put their healthcare system through major reforms in 2006 (so it can be done) and now have some of the best health outcomes in Europe and indeed the world.
We should not let dogma get in the way of a better, more efficient and more affordable Health Service – always bearing in mind the guiding nostrums of Bevan.
It would also be to all our benefit if our healthcare system played a less dramatic role in our general election campaigns – it has been a political football for too long. Calm minds and reality must now prevail.