Rob Wilson is a former Minister for Civil Society, and was MP for Reading East from 2005–2017.
An extra £20 billion annually for the NHS should gain the Government some positive headlines amid all its difficulties. Jeremy Hunt comprehensively won his hard fought tussle with the Treasury for a significant uplift in health spending on the basis that it would be accompanied by significant efficiency and productivity gains. Hunt was right to secure extra spending, as the service had reached an impasse where without it the service could not move on; the pressures on NHS front-line services were simply unsustainable.
Unfortunately, Government has been here before – in fact, very regularly. Extra spending accompanied by reform has been a mantra for a number of governments. Most recently with Gordon Brown bringing in private sector companies, and then the 2014 five-year plan. The reality of politics means these plans are never held to account properly or seen through. Hunt has moved on, leaving Matt Hancock to pick up on ten years of huge spending accompanied by a plan undoubtedly written by civil servants and the leadership of the NHS.
Nobody should be surprised that Simon Stevens has outmanoeuvred the politicians again. He delivered very few of his 2014 five-year plan productivity promises, and this plan won’t deliver the efficiency and productivity gains the NHS needs for its long term success. Disappointingly, Stevens is part of the Brown-era legacy that sees spending level (‘investment’, as Brown called it as Chancellor) as a political measure of NHS success rather than patient outcomes.
Anyone who has heard Stevens speak publicly will be impressed by his knowledge of the NHS but concerned by his complacency – particularly his belief that the NHS is already one of the most efficient health services in the world. If you take that view, there is only limited scope for improvement apart from via extra money. That is a significant problem for an experienced Secretary of State, let alone a new one.
If we are brutally honest, the ten-year review doesn’t ask searching questions. The most fundamental is this: is the NHS the best way to run our healthcare to get the best outcomes for patients? Or even: should all the increase in spending come from general taxation (and presumably further borrowing)? Are there lessons we should learn or adapt from other systems, for example where insurance policies are used or co-payments? At the moment the self-pay health market is growing because people with savings are not prepared to wait in the ever longer queues that ration care.
These are big questions, but surely essential ones before huge additional lumps of taxpayers’ money is invested into an inefficient, highly centralised regime. Of course answering them would require a level of honest self-assessment of the current system that no NHS leader would welcome.
Sadly, there is considerable evidence of NHS performance failure, as highlighted by the Kings Fund and others, where the UK ranks well down the international list of avoidable deaths. Despite all the money ploughed into the NHS, the service is paying a little under £2 billion a year in compensation for clinical mistakes. I remember only too well, as Jeremy Hunt’s Parliamentary Private Secretary, that he regularly received reports of major mistakes in hospitals such as cutting off the wrong, healthy, limb. It underpinned his desire to improve standards and quality of healthcare.
To be fair and provide balance, it is also true that within our NHS system there are fantastic examples of world class treatments, breakthroughs, amazing facilities and inspiring doctors and nurses. Even within a poorly performing hospital you can find examples of exceptional and outstanding services or staff. It is a remarkable and frustrating system of the excellent often sitting alongside the awful. It should be acknowledged that the NHS has made some improvements, but they are hard won and slow.
Clearly extra money put into any system will make some difference, even if it is simply relieving existing pressure. But this ten-year plan, with its huge influx of resources, should be able to make a significant difference if delivered effectively, and if it acknowledges that the answer to the NHS’s issues is not simply about putting in more and more taxpayers’ money. For example, Hancock is certainly on to something with his focus on using new technology and its ability to deliver better services and outcomes. Of course the NHS is littered with failed computer projects, but the Secretary of State needs to make technology advances his personal focus. The NHS should not be a place of decades-old technology, such as fax machines and pagers.
Hancock will not be able to push forward on all fronts, so choosing his battles carefully will be the wise thing to do. He will face considerable system inertia and resistance to change. It will quickly become apparent that there are no levers at the centre he can easily pull to get the change he wants. He will gradually be worn down, as his predecessors were, by the bureaucracy, lack of influence, and vested interests that exist everywhere in the system. Additionally, any vision that exists in the ten-year plan will be worn aware by political events until once again, in a few years, more money is again the only solution.
The Lansley changes have meant that substantial reform of the NHS is largely off the political agenda. NHS chiefs are well aware of this and are able to use their considerable knowledge of the system to block or weigh down anything of substance that they do not like. Yet they are at all times helpful, even supportive, of ministers with advice, but avoiding where possible transparency and accountability. Ministers are therefore left to tinker or focus on making a limited impact.
So the ten-year plan will get the NHS by for a few years but do not expect it to deliver much in the way of change, reform, or expected efficiency or productivity gains. Eventually, as health takes a bigger and bigger chunk out of the nation’s wealth without its services or efficiency markedly improving, a political party will get a significant electoral mandate for reform and to allow the hard questions on health service to be asked and answered.