Ministers should be wary of declaring war on the NHS

Words count – they can motivate or demotivate thousands of public servants and often signal the direction of policy. So the prime minister’s claim that some public bodies have a ‘post-COVID mañana culture’ will baffle hard-pressed NHS workers. The emerging narrative from government briefings – that the health service needs radical reform – will worry them even more.

Backlogs, long waits for treatment and surgery, staff shortages, burnout and low morale all clearly compromise the service the NHS can provide. Some predate the pandemic and show up in relative performance internationally – lower cancer and stroke survival rates for example. COVID-19 hit the NHS hard and public satisfaction has nosedived to a 25-year low, according to the British Social Attitudes Survey. 

Last month also saw the latest round of NHS reforms – in the Health and Care Bill – become law. Dubbed ‘the most significant change to the health care system in a decade’ by secretary of state Sajid Javid, it may not do the trick. 

Health service reforms have usually taken two broad forms. Reorganise, cull bureaucracy and review management. Or the more ideological: either use market-based incentives to improve delivery or centralise state control with targets and regulation, encouraging collaboration over competition. None of these has delivered anything like what was originally intended.

The latest reforms give legal basis to the NHS’s own Long Term Plan: it will set up 42 ‘integrated care systems’ to encourage local collaboration and reduce dependence on hospitals. 

Integrated care is right but will take time and investment. We need faster results, particularly improving access to family doctors and elective care. Government plans for primary care remain unclear, but a COVID-recovery backlog plan is already tackling waiting lists. 

Reforms to social care – critical to freeing up beds and reducing pressure on the NHS – were notably absent, beyond some protection to individuals against catastrophic costs. A review of NHS management, by General Sir Gordon Messenger, reports shortly.

Improving a large system like the NHS demands complex solutions but investment is central to achieving European-style health care. OECD data show the UK spent £3,420 per person a year on health care in 2019, France £4,010, the Netherlands £4,360 and Germany £5,000. Consider how that differential accumulates over decades. Capital spending is less than half that in Germany, Netherlands and Denmark. Germany has 47% more doctors per head, 70% more nurses and over 200% more beds. These reflect political choices, not what is affordable. 

Short-termism is another blight. Amendments to the latest bill requiring independent long-term workforce projections were repeatedly rejected by ministers. Annual budget increases have been unpredictable. This, and costly top-down reorganisations, are also political choices. They hamper innovation and planning as well as day-to-day delivery and accelerate the attrition of experienced staff.

The government’s aim must surely be to get the broad resourcing, organisation and incentives right and stick to them, supporting front-line workers to test technology and other innovations fast. The pandemic proved this possible: we need bold leadership and a consistent sense of purpose to maintain momentum. The priority is increasing access, including shifting care out of expensive hospitals and into the community – safely. 

Instead, we hear empty calls to cull the bureaucrats and torch the quangos. Even to privatise. This rhetoric may be tempting for politicians with thoughts on a nearing general election, especially if NHS delivery doesn’t match expectations around the national insurance levy. Ministers might study recent history and think twice. 

Jennifer Dixon (@JenniferTHF) is chief executive of the Health Foundation.

This piece was originally published in the Financial Times on 23 May 2022.