Robert Ede is Head of Health and Social Care at Policy Exchange, and Prize Director for this year’s Wolfson Economics Prize.
Away from the fallout of the local election results, the chatter in Westminster over the past few weeks has related to levelling up. The appointment of Neil O’Brien as an adviser to the Prime Minister, and the commitment to publish a White Paper this year, demonstrates a desire to define and deliver on what has been an ambiguous slogan.
There continues to be a debate in Number 10 about what levelling up means in a healthcare context. But many of us on the outside see it as an opportunity to elevate arguments around healthcare inequalities in Whitehall policymaking.
Plenty of evidence backs this up. The ‘red wall’ areas contain some of the most deprived areas in England with the worst health outcomes. In the 48 seats which switched from Labour to the Conservatives in 2019, women have four fewer years of healthy life compared to their counterparts living in core Conservative areas.
Many of the factors which drive these disparities are preventable: 23 per cent of people smoke in Blackpool compared to just five per cent in Ribble Valley, while analysis from the Health Foundation has found those in the red wall tend to live closer to fast food outlets and have higher childhood obesity rates.
So when the White Paper is published later this year, how can NHS and social care spending be used to further the levelling up vision?
One obvious opportunity is healthcare infrastructure. The Government and NHS are already showing signs of ambition, with two separate, but interrelated building programmes.
First is the new hospital programme. A central manifesto pledge, the commitment to construct 40 new hospitals by 2030 has not been without critics, many of whom argue that another round of hospital building goes against the grain of modern healthcare trends.
But the case for investment is clear. Take Derriford Hospital in Plymouth – where residents have been campaigning for a new A&E for decades, or the decrepit Hillingdon in north London, which had to close its paediatrics department due to subsidence two years ago. In reality, 17 of the 40 schemes are rebuilds of existing sites; perhaps an attempt to atone for a “frugal” approach to NHS investment over successive years.
Regardless, there is a huge opportunity to ensure that these rebuilt and new hospitals deliver for patients who deserve the best possible care and for staff who deserve high quality workplaces.
This is a popular policy. Polling undertaken by Policy Exchange in 2020 found that new hospitals were the most highly ranked infrastructure commitment – far ahead of new houses. In battleground regions such as Yorkshire, the North East and the South West, more than half of respondents chose it as their top priority. By comparison, when asked about levelling up, the public’s response is far less clear.
But while popular, the hospital building programme is not guaranteed to be a success when it comes to levelling up. As other commentators have observed, the current list of schemes proposed is concentrated in Southern England. Levelling up should not solely be about the red wall of course (not if the Conservatives want to avoid repeats of Worthing) but opportunities – and cash – do need to be spread around.
There is also no guarantee that the programme succeeds on its own terms. Hospital building in the NHS has a chequered history. The last major programme under Labour from 1997 to 2010 delivered 51 schemes, but relied upon PFI money and saw significant delays, with the average hospital taking seven years to be designed, constructed and commissioned.
This Government clearly does not want to wait that long. In a bid to speed up delivery, the Department of Health and NHS England are proposing much more centralisation, with guidance to emphasise repeatable design and greater standardisation of plans across sites, hopefully accelerating delivery.
That might work, but there is a danger of prioritising speed over innovation. If taxpayers are going to invest billions, we need to build hospitals that will serve us for decades to come, not just hospitals that can go up fastest.
With this in mind, this year’s Wolfson Economics Prize, hosted in partnership with Policy Exchange, hopes to create a springboard for new ideas; offering a £250,000 prize for the best proposal to radically improve hospital planning and design. Perhaps hospitals should be built around green spaces – as is being trialled by NHS Scotland. Or they could have affordable housing for healthcare workers designed into a “village” campus.
But even if we can find the right design and can speed up delivery, few of the new hospitals will be welcoming patients by the next general election. There must be healthcare infrastructure improvements that can be delivered quicker.
This is where the second new policy comes in: Community Diagnostics Hubs. Following last Autumn’s review of NHS screening services led by Sir Mike Richards, NHS England plans to introduce new ‘one stop shops’ in the community. All too often, patients have appointments for routine scans cancelled as an emergency case takes precedence; separating urgent care from planned diagnostic activity should prevent that.
The sensible clinical rationale makes for good politics, too. Positioning diagnostic centres nearer to the public – for example, in vacant spaces in town centres – will make them immediately accessible and contribute to a sense of local renewal. As Rachel Wolf has outlined, the ‘High Street test’ will be one of many ways in which voters at the next election judge whether their areas have benefitted from a Conservative Government.
As part of a bigger piece of work to be launched in the coming weeks, Policy Exchange will argue that there is the potential to go further, taking advantage of the recent changes to the planning use classes to provide additional healthcare services on the high street. Rather than proposing the slightly technocratic sounding ‘Community Diagnostic Hubs’ why not create ‘town health centres’ which would deliver diagnostics but also a broader set of services?
Taken together, the new hospitals programme and new high street healthcare facilities could make for a compelling offer towards levelling up: improving the specialist and acute care in hospitals; speeding up diagnosis; providing local amenities and, in the longer term, tackling health inequalities.
There is a real opportunity, but we have been here before. In the late 2000s the Labour Government promoted the use of ‘polyclinics’ – expanded GP-led health centres. Ultimately the business case failed to demonstrate how polyclinics would improve patient outcomes, whilst the concept faced resistance from both hospitals and general practitioners, unwilling to see their role (and thereby budget) reduced. Together this led to the rollout being paused by the Coalition Government in 2010.
We now find ourselves at a more favourable point in the political cycle. The Government’s majority should mean that legislation to enable better integration of local healthcare bodies will pass into law. This may go some way to tackle the cultural tensions within the NHS that have prevented providers from working in patients’ interest.
Much has been written about levelling up already. Yet it is in bricks and mortar of our healthcare buildings where the clearest manifestations of slogan are likely to be found.