The Week

The Week, 11 March 2022

This week, Secretary of State for Health and Social Care, Sajid Javid, gave his long-awaited speech on NHS reform. He opened by reminding us that the health challenges we face today are “profoundly different” from those that existed in 1948. People are living longer, with a greater number of complex, long-term conditions, and technological change has radically changed the public’s expectations about what healthcare can deliver.

The consequence, Javid says, is a health budget which is already larger than the GDP of Greece, and set to reach 44 per cent of day-to-day public service spending by 2024. Against a backdrop like this, he’s right to say “Reform is absolutely essential”. (Although we can’t help but notice that the words ‘think tank’ have been lost from the online transcript of the Health Secretary’s speech ?.)

Promising to draw on the “reforming zeal” of Nye Bevan, Edmund Burke, Margaret Thatcher and Tony Blair, Javid sets himself a high bar. The approaches that would have guided these thinkers — a healthcare system that is accessible to all (Bevan), resilient (Burke), and maximises freedom of choice and accountability (Thatcher and Blair) — are the right ones. Similarly, the objectives of Javid’s reform agenda (prevention, personalisation, and performance) are spot on — though they have been expressed by his many predecessors.

On prevention, Javid is right that we must avoid building a “national hospital service”. Or in other words, we should focus on keeping people in good health (and therefore out of hospitals) in the first place. The problem, of course, is that most prevention is not driven by the NHS — it is, as he says, “everyone’s” responsibility. The Service cannot ensure high-quality, health-promoting social and physical infrastructure in communities, or access to a good job. These are the “serious trade-offs” that, as Javid says, must be considered when “healthcare takes up an ever-increasing share of national income”.

Nonetheless, taking healthcare out of hospitals wherever possible is a good thing (he reiterated his commitment to community diagnostic centres). And focusing much more on the degree to which the NHS is using it’s resources to prevent ill-health is welcome (the Government will baseline how much is actually being invested into prevention, and ICSs will be required to creates delivery plans with NHSE to cut the prevalence of the biggest preventable diseases); as is making the most of the NHS APP by “making it the front-door for preventive tools and services — like a new digital health check”.

Sajid Javid’s objective for healthcare to become more personalised is also welcome. A large and increasing proportion of the NHS’ work is caring for those with long-term conditions. Better personalisation and more choice should help deliver better outcomes for these patients. The Health Secretary hopes that extending the personal budget programme to more people living with long-term conditions could make a sizeable difference. And we’re delighted to see a commitment to extending the Shared Lives model of support. However, the Health Secretary’s claim, that more personalised care and personal budgeting will constitute “one of the biggest transfers of power and funding in decades: from the state, to the individual and their family” feels a bit of a stretch.

Oddly positioned in the “personalisation” section of the speech, Javid also announced that “long-waiters” (those who have been on waiting list for more than 78 weeks) will be contacted about “alternative provision”, either in a neighbouring trust or the private sector. OK, but that offer should be being made well before someone has been waiting a year and a half for care.

To achieve his objectives, the Health Secretary rightly said “we’ll need one of the most comprehensive reform plans that this country has ever seen”. Yet while there are some encouraging policy commitments, they do not live up to that statement. To achieve his vision of a sustainable and patient-centred health service, he’ll need a much more radical plan.

Our recommended reads from the week...

Adding to truckloads of papers on civil service reform, former Department for Education Permanent Secretary Jonathan Slater this week published his contribution: Fixing Whitehall’s broken policy machine. For those seasoned in the genre, the proposals for reform will sound familiar, but it’s nonetheless worth a read for his candid reflections on his time in Whitehall, and insights on why certain taken-for-granted principles should be rethought. Particularly thought-provoking is his observation that, in the policy profession, emotional detachment is actually cultural disconnect, and the intellectual-orientation of policymakers creates operational disconnect – with both leading to poorer policy. He also has some thoughts on how to improve accountability of officials, including the role of Parliament; and thinks there needs to be much greater transparency of the policymaking process.

Our second read is a report by the Competition and Markets Authority (CMA) on the state of the children’s social care market. The report finds two urgent and alarming failures in the children’s social care market. First, high numbers of children in England are not given access to placements appropriate to their needs. Nearly 40 per cent of children in residential homes, for example, were assigned to settings “at least 20 miles from their home”, with many also separated from their siblings. Astonishingly, the CMA also heard cases of some children with very complex needs placed in settings that were either “unregulated” or “unregistered” — which is illegal. Second, the CMA found that providers of care had been making consistent profits of around 20 per cent from 2016-2020: “materially higher” than would be expected if the market were functioning effectively. This is because highly profitable providers would normally face competition from new entrants into the market and so fear that, by raising prices, they may fail to attract placements from local authorities. As a result, the CMA concludes that these profits show competition “is not working as well as it should be”.

Finally, our friends at Onward have today published The Good Life, exploring how government can act to rebuild the nation’s social fabric. It covers five areas which they argue form the foundations of a “good life”: “Strong human connections; a locus in a thriving place; a place to call home; a job that is secure and rewarding; and institutions that bridge social groups and embed shared values”. Proposals to strengthen each of these areas include introducing a “Family Care Relief” to encourage families to live closer to — and therefore care for — elderly parents; recruiting 20,000 Special Constables and reviving citizen engagement like Neighbourhood Watch; and creating “Charitable Enterprise Zones” to boost giving.