Comment Blog 19 January, 2018

Listen to the Lords: if NHS spending is to rise, reform is non-negotiable

So far this year the organisational problems of the NHS, notably the incentives to conduct care in over-crowded hospitals, have been clear for all to see. As Laura Kuenssberg said in the midst of the “winter crisis”, those problems are mounting to the extent that, politically, “something must be done”.  The big question is, what?

Writing in his excellent review last year, Michael Barber noted that political culture tends to focus on money when solutions are needed (full quote at end of this blog). Nick Boles MPmade exactly this case last week, arguing that politicians had to accept “intense and relentless pressure for more public spending on health and social care for many decades to come”. Jeremy Hunt said that, “we will need significantly more funding in the years ahead”. In the same debate, the Opposition spoke of an “all-year-round funding crisis.” Nicky Morgan was a lone dissenting voice, arguing that, “an organisation … for which the Department of Health’s budget has been consistently protected since 2010 (and continues to rise), cannot carry on simply ask for more money as the solution to all its problems”.

In addition, as the Reform / Deloitte report The State of the State found last year, the mood of the electorate has shifted towards a greater acceptance of (somewhat) higher taxes to pay on public services. This is not surprising after several years of very tight budgets or cuts in most of the public sector.

The right approach would be to assess the greatest value to be achieved from any limited extra spending for the NHS. The danger is that the question of value is submerged beneath the wish to expand the NHS budget, as has happened in recent years.

The key reference point is the Wanless Review of the NHS in 2002. This also argued for a big increase in NHS spending, from 7.7 per cent to 11.1 per cent of GDP (on its middle scenario).  It also recommended a major focus on public health and prevention in order to keep the Service affordable.  While some important reforms were introduced in the Blair years, overall, however, the degree of chance was very limited.  In 2007, the Kings Fund concluded that, “thus far the additional funding has not produced the improvements in productivity assumed in the 2002 review”.

This led directly to the efforts to reinvigorate primary care and focus on quality, under Ara Darzi in 2008.  After the interruption of the Health and Social Care Act, the Five Year Forward View (2014) very much carried forward the Darzi ideas.

What is certainly the case is that the Five Year Forward View implementation is moving far too slowly. That is no reason, however, to forget the lessons learnt by the Blair Government. Nick Boles does not say a single word on the better organisation of the Service in his new chapter.

The report by the House of Lords Committee on the Long-Term Sustainability of the NHS does much better. It advocates that the NHS budget should rise at least in line with GDP beyond 2020. It also notes that, “service transformation is at the heart of securing the long-term future of the health and care systems”.

If NHS spending is to increase, the Lords Committee offers the best way to do it.  Rather than abandoning the reform efforts of the last 15 years, it sees them as essential parts of the NHS future.