David Hare is Chief Executive of the Independent Healthcare Providers Network
There have been two key healthcare stories in the last week. One was the announcement of a new Health and Care Bill in the Queen’s Speech, the biggest reforms to the NHS in almost a decade. The other was news that NHS waiting lists are now the highest on record with almost five million waiting for treatment.
Drilling down into the numbers we can see that 1.1 million people are now waiting more than six months for treatment and over 400,000 people are waiting over a year for care, up on a little over 1000 in February 2020.
When Covid-19 is behind us, getting these waiting times down will be the public’s number one priority for the NHS. This is hardly a surprise given that one in eight of us are now on a waiting list somewhere in the country.
People will rightly be asking therefore what the plan is to reduce NHS waiting times and it seems from the Government’s framing of the Health and Care Bill that legislation is going to be at least part of the answer, alongside more funding, use of the independent sector, and support for the kind of initiatives set out last week by NHS England.
The problem with linking reduced waiting times with the planned Health and Care Bill, however is that the Government’s recent White Paper setting out the policy framework for the legislation mentions waiting lists just once.
So while the Prime Minister has said that “tackling backlogs and improving patient care will be a critical priority for the remainder of the Parliament”, how will the Government explain how this Bill will help with that, when inevitably they will be judged by the public simply on whether they have timely access to high quality care?
In answering this question it is important to remember that the proposals contained in the NHS White Paper, and which will ultimately be reflected in legislation, have been in development for over two years.
NHS England got the ball rolling in February 2019 with their own consultation on what legislative change was needed to help the NHS better coordinate care for patients.
The Commons Health and Social Care Select Committee ran their eye over the proposals that year and then NHS England made their final recommendations to government. These in turn were noted in the Conservative’s 2019 election manifesto with a broad commitment to implementation during the next Parliament.
At the core of the proposals for the NHS were the desire to better “integrate” care and ensure “it works around the needs of patients rather than institutions”. There was also a desire to repeal the role of the Competition and Markets Authority in the NHS and introduce a new procurement regime to replace that brought in as part of the 2012 Health and Social Care Act.
The proposals to better integrate care were then, and are now, undoubtedly the right thing to do.
Anyone who has come into contact with the NHS, particularly if you have a chronic condition, knows how frustrating it can be when services don’t join up: when your patient records haven’t been shared with your hospital consultant, so you have to repeat your story numerous times; or when you have multiple appointment letters even though you’d rather just manage everything online, like you do with every other aspect of your life.
And the proposals to introduce new “Integrated Care Systems” (ICSs) in the NHS, which bring together healthcare organisations and their partners in local government, should go some way towards achieving this.
But for ministers preparing to strap themselves in to pilot this legislation through Parliament over the next few months, it will be important to stop and reflect on the one thing which has changed beyond recognition since the proposals were first conceived: the aforementioned record waiting lists.
These are, even with yet more inspirational work by frontline NHS and independent sector staff, likely to get considerably worse before they start getting better. For the one thing which we do not yet know but need to consider: how many of the over seven million people that would have presented for NHS treatment since the onset of the pandemic will return?
Even if over half of those people never present, those that do, alongside the normal flow of patients into the system, will put considerable strain on the NHS and return health politics to the debates of the late 1990s: how individuals and their families can access the services that they need.
Re-assessing the laudable White Paper proposals through that lens does give pause for thought, even beyond the fact that there is unlikely to be anything concrete in the legislation which links explicitly to waiting times.
For instance, moving away from a money-follows-the-patient model and replacing it with block payments risks disincentivising activity and reducing throughput and value. ‘Payment by Results’ had many unintended consequences, but one thing which it did well was to incentivise significant volumes of activity – and significant volumes of activity are what we now need.
Equally there is the potential disruption of structural change in the NHS at a time when focusing on recovery and building back better must be the overwhelming priority. Even if these changes are not so big as “to be seen from space”, as Sir David Nicholson, the former NHS Chief Executive, said about the Lansley reforms, any structural changes in the NHS inevitably divert people’s attention towards organisational matters rather than delivering care for patients.
And finally, as the NHS dampens down the split between purchasing and provision which has been a central feature of policy and operational design in the NHS for a generation, is there not a risk that – as Jeremy Hunt, the former Health Secretary, has warned – “cosy local monopolies”, which prioritise provider protection rather than patient care, return?
Over the last year the NHS has stood up to its sternest test, and alongside partners in the private and charitable sectors has been there when the country most needed it.
As the dust begins to settle on that period it is becoming clear that the issues facing the service over the coming years will be different, and indeed more challenging, than anybody could have anticipated when the road to legislation started over two years ago. Ministers must now ensure that the Bill they present to Parliament meets those challenges.