The Week

The Week 14 April 2023

Sebastian Rees
Senior Researcher

With parliament in recess and many of us making the most of an extended Easter, it’s been a quiet(ish) week in Westminster. But here’s a few things that may have flown under your radar.

As has so often been the case in recent months, most of the action this week has been in the health sector. Junior doctor strikes have dominated the news, but two other health announcements piqued Reform’s interest. Firstly, NHS England has finally caved to pressure and published data on the number of patients waiting more than 12 hours in A&E before being assessed by a doctor, and either admitted to hospital or sent home. The numbers released on Thursday, for February this year, don’t make for pretty reading. More than 10% of patients waited more than 12 hours in A&E; and in 6 trusts in England, more than 1 in 5 patients experienced waiting times of this length.

Long waits in A&E are not only hugely frustrating for patients, they are also strongly associated with poor outcomes — there is a close relationship between waits of more than 5 hours in A&E and patient mortality, for instance. Sorting out the A&E crisis is vital to getting NHS performance back on track, but as we’ve long noted at Reform, simplistic solutions to this problem (“put more staff in A&E”, “reduce the number of attendances”) won’t cut it. Instead, we need to look at what happens beyond the emergency department and consider the way in which patients flow through the entire health and care system. That’s a truth that’s increasingly being acknowledged, but we’re still waiting for it to really drive NHS strategy.

Secondly, Public Health Minister Neil O’Brien set out his vision for achieving a (almost…) smoke free Britain by 2030. Public health announcements tend to get short shrift when healthcare dominates the headlines, so it’s good to see that acting on the key determinants of poor health hasn’t fallen off government’s agenda. Reducing smoking is still the most important game in town when it comes to our nation’s health — smoking remains the leading cause of premature and preventable death in Britain and it’s closely linked to other drivers of poor health including poverty and unemployment.

O’Brien’s proposals — a national ‘swap to stop’ scheme to substitute smoking for vaping and boosting enforcement of underage tobacco sales — certainly don’t go as far as the recommendations laid out in last year’s smokefree review by Dr Javed Khan. The Khan Review’s flagship proposal, raising the legal age at which tobacco can be purchased each year (a policy adopted in New Zealand late last year), was rejected by O’Brien on the reasonable grounds that public health policy must strike an appropriate balance between the state guiding and incentivising healthy behaviours whilst recognising the importance of personal liberty and responsibility. But the Public Health Minister’s announcements mark welcome progress for the smokefree agenda and are clearly evidence based. Let’s hope that government keeps the momentum going when it comes to the challenges posed by obesity and excessive alcohol consumption…

On to some (non health!) reads…

First, we’ve been reading Diane Coyle and Adam Muhtar’s article on why making a success of levelling up means building institutional mechanisms for learning — and crucially, remembering — what works and what doesn’t to revitalise local places. A top-down, “impositional” model of policymaking in the UK prevents local knowledge being used to effectively inform and update how national economic strategy is set — and that consequently leads to policy churn. This is contrasted with clear, long-term industrial strategies in countries such as Japan and the US, that take a “more regionally-sensitive” approach. Whether in the former’s use of a nationwide network of state-certified management consultants to support SMEs, and feed back into national policy, or the latter’s use of ‘ARPA’ agencies, to help establish local learning mechanisms between industry, academia and government. A compelling read on why closing regional inequalities requires giving careful thought to how local-to-national learning can be incorporated into policy design.

Second up, this great Bennett Institute report (actually from last week!) takes a deep dive into English devolution. At Reform, we’re big believers in the potential of local and combined authorities to take on far more responsibility for designing and delivering public services. And as the report’s authors rightly point out, “By pretty much any measure, England’s governance is now one of the most centralised in the developed world.” However, devolving more power is complicated by the “incoherent and dysfunctional character” of the sub-national layers of government we’ve developed over time. The maps on pages 44 to 46 show the hodgepodge mix of misaligned governance structures we are saddled with. Streamlining these is no easy feat and the report’s authors run through a series of (familiar) policy suggestions to bring about change — an independent commission on English governance, a new English devolution council made up of metro mayors and a new ‘England Office’ in Whitehall to match its Welsh, Scottish and Northern Irish counterparts. These may run the risk of pushing back vital reform and further complicating our crowded governing landscape, but it’s great to see options in this space clearly laid out on the table.