Rather than 'fixing' the NHS, we need to radically rethink our approach to health
This article originally appeared in Civil Service World on 23 September 2022
When it was established, the National Health Service was visionary: offering high-quality, timely care to meet the dominant needs of the population it served. Nearly 75 years on, with the country facing very different health challenges, it is clear that model is out of date.
From life expectancy to cancer and infant mortality rates, we are lagging behind many of our peers. With more than 6.8 million on waitlists, healthcare is becoming increasingly inaccessible for those who cannot opt to pay for private treatment; and the cost of providing healthcare is increasingly squeezing out investment in other public services. The OBR now describes healthcare spending as the “largest – and most likely – source of long-term risk to fiscal sustainability”.
As demand for healthcare continues to grow, pressures on the workforce – which is already near breaking point – will only become more acute.
Many of the answers to the crisis in health and care are well rehearsed. We need to be much better at reducing and diverting demand on health services, rather than simply managing it. Much more needs to be invested in communities and primary care to reduce our reliance on hospitals. And capacity in social care needs to be greater, to support the growing number of people living with long-term conditions.
Yet despite two decades of strategies and a number of major health reforms, we have failed to make meaningful progress on any of these aims.
That is why Reform is launching a new programme of work entitled "Reimagining health", supported by ten former health ministers from across the three main political parties. Together, we are calling for a much more open and honest conversation about the future of health in the UK, and an “urgent rethink” of the hospital-centric model we retain.
This must begin with the question of how we maximise the health of the nation, rather than “fix” the NHS. It is estimated, for example, that healthcare accounts for only about 20% of health outcomes. Much more important are the places we live, work and socialise – yet there is no clear cross-government strategy for improving these social determinants of health. Worse, when policies like the national obesity strategy are scrapped, taxpayers are left with the hefty price tag of treating the illnesses, like diabetes, that result.
Reform wants to ask how power and resources should be distributed in our health system. What health functions should remain at the centre, and what should be devolved to local leaders, often responsible for services that create health, and with a much better understanding of the needs of their populations?
Of course, access to high-quality healthcare when we really need it will always be crucial. But our current model of delivery is largely the same as the one Bevan introduced in the late ‘40s. It is not a model fit to tackle the challenges of an ageing population and a rising tide of multi-morbidity. At the same time as our care needs have become more complex, our workforce has continued to become more specialised. Between 2010 and 2021, the number of community health workers declined by 20%, while the number of hospital consultants increased by 45%.
We need to rethink our model of healthcare delivery to meet the challenges of the future, rather than simply “optimise” what we already have – not least as continuing on the same path is unaffordable.
Rethinking the model to drive better outcomes is the primary purpose of Reform’s new programme, but a genuinely honest conversation must consider not just the cost of delivering a world-class health and care system, but how that cost is met. Not least because health spending crowds out other forms of expenditure, such as education and housing, which are key to building good health. But, as well as questions of how we raise revenue and ensure generational fairness in healthcare funding, we want to ask deeper questions, like “what do we value in healthcare?” and “how do we create incentives that prize quality and patient-centredness?”
There is a broad consensus on what needs to change – less hospital care, more community and self-care – but despite that consensus, hospital spend as a proportion of health spending has been increasing. We are looking to answer how we can achieve that shift. To do this, we want to engage those thinking deeply about these issues from across the political spectrum – practitioners, policymakers and systems innovators.
We know we don’t have all the answers. But to create a health system fit for the future, we need the courage to start with the right questions.
Patrick King is a researcher for the Reform think tank