A big slug of investment has been announced this week for the NHS, as well as extra funds and a reform plan for social care. This has prompted questions from political quarters: will the funding be swallowed up by an unresponsive, bureaucratic and opaque health care system? What will the public see for their money? Calls for reform are never far behind.  

There are precedents. In the 2000s, when the Labour government began the largest and longest cash injection to date into the NHS, major reforms followed.

NHS commissioning bodies were reorganised, new Foundation Trusts were introduced and payment systems overhauled to incentivise hospitals to compete for patients, and allow patients to choose the hospital they preferred to be treated in. At the same time, staff numbers were boosted, and the performance of the NHS was made more publicly transparent and subject to greater centralised oversight and management grip summarised as 'targets and terror'.

This time, the landscape is very different.

First, the NHS has – via NHS England – created its own long-term reform plan and new legislation enabling it is now going through parliament. At its heart, the vestiges of ‘competition’ between health care providers introduced in the 1990s have been replaced by 'collaboration' to improve performance via new integrated care systems across England. This move was in part because a key challenge in the 1990s and early 2000s was to reduce the waiting list, but the bigger challenge now and in the future will be in the prevention and management of chronic disease for which collaboration and integrating services is more effective.

But while collaboration has been demonstrably beneficial during the pandemic, the jury is still out on whether it can in normal times not only improve care, but also prevent ill health and reduce inequalities in health. Evidence to date shows that integrated care takes time to have an impact.

The second difference is the backlog in care created by the pandemic, particularly visible in waiting lists, now more than 5 million. This week’s announcement of extra cash for the NHS means the heat is on for the NHS to make progress. The political risks are high, with the prospect of high-profile cases of delayed care hitting the headlines which can upend governments. On top of that, the damage to services caused by COVID-19 is significant and ongoing, hampering hospitals, GP practices and other services from making progress, and reducing efficiency.

Political eyes then will be on how to reduce the waiting list. The NHS knows how to do this: the remedy as shown in the early 2000s was mainly investment with clear plans, incentives, targets and good performance management. The extra investment announced this week will help, but isn’t likely to be enough according to detailed modelling from the Health Foundation's REAL Centre.

Far from the NHS being a bloated sponge, the hard truth is the UK spends significantly less per capita on health care (and its administration) than most countries in western Europe. And it has done for decades, which is why these countries have far more staff, beds and equipment to cope with the pandemic and its effects than the UK.

So the priority now will be to continue to orientate the NHS towards better preventing and managing patients with long term chronic conditions, as in the NHS Long Term Plan. But at the same time double down on the waiting list using techniques proven to work as we saw in the early 2000s.  

As we head into a likely difficult winter, and as the extra funding for the NHS just announced stretches too thinly, the political stakes will rise. While shrill calls for further ‘reform’ might increasingly circulate among some backbench MPs and associated think tanks, the politicians should hold their nerve: yet more reform would be costly and risky.

Jennifer Dixon (@JenniferTHF) is Chief Executive of the Health Foundation.

Ruth Thorlby (@RThorlby) is Assistant Director of Policy at the Health Foundation. 

This article was originally published by Politics Home on 8 September 2021.

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