Andrew Haldenby is co-founder of Aiming for Health Success, a new health research body, alongside Professor Nick Bosanquet.
Today, following in the footsteps of Gordon Brown and Tony Blair, the Government is expected to increase National Insurance to fund greater health and social care spending.
Ministers will see this as a new beginning – a reset moment for the NHS. They want the service to make much faster progress on tackling the backlog in hospital treatment as result. This may happen, but it is not guaranteed. It very much depends on how the new money is spent.
Ministers will be very tempted to follow through on the rest of the Blair agenda – i.e: see the waiting list as a national problem; set national targets for hospital waiting times, and set up special Whitehall units to direct local leaders. This may give Ministers a sense of being in control. But what Blair found is that such an approach distorted the development of the NHS, made it less able to cope with modern healthcare needs, and left it financially unsustainable.
Modern healthcare seeks to reduce hospital activity and increase the ability of primary care and “integrated” services to manage growing numbers of patients with long-term conditions. The Blair government achieved the opposite: an NHS dominated by a much bigger hospital sector, only affordable in years of well-above-average economic growth. He did reduce waiting times, but the NHS he created has failed to do that, or balance the books, since financial reality required more reasonable spending increases after 2010.
Blair himself learnt from this experience. In a valedictory interview in 2007, he said: “The purpose should be so that public services can adapt and adjust naturally – self-generating reform – rather than being continually prodded and pushed from the centre”.
Today’s Ministers can learn from his mistakes. The first step is to give local health and care leaders full responsibility for reducing waiting in their area. Each local NHS area needs a crisis team consisting of the area’s lead GP, the local hospital Trust’s medical director and a council lead on social care.
While Whitehall sees one waiting list, local areas see 50 or more, and these local lists vary by region by specialty. A study this week showed that, adjusting for population, 550 people have waited for orthopaedic treatment for more than a year in Norfolk and Waveney, compared to 36 people in North East Lincolnshire. The clinicians who put people on the waiting list should have the responsibility for setting priorities and brainstorming on extra capacity. The locals know best.
These leaders can make the hospital sector much more productive, copying the success of high-volume treatment centres such as the South West London Elective Orthopaedic Centre, the largest hip and knee replacement centre in the UK and one of the largest in Europe.
GPs and social care leaders are needed as much as hospitals. GPs should contact every person on the waiting list to assess their situation and prescribe medication, or other services such as physiotherapy, as necessary. This personal contact can also identify those people who need immediate treatment.
This activity will greatly boost the development of new, close-to-home services that significantly reduce the demand for hospital treatment. Ministers should be thinking about the future waiting list as much as today’s. The 2019 NHS Long Term Plan rightly set a goal of reducing outpatient admissions by a third in ten years. The NHS should now set the same goal for inpatient and A&E admissions.
Given the current priorities, the Government’s programme of refurbishment of 48 hospitals looks out of touch. It would be relatively easy to revise the programme, since very little building work has started. A much better use of the funds would be to support new hubs for GPs and other close-to-home services, including diagnostics, particularly in deprived areas.
These ideas will also defend the position of social care. Ministers seem to want a general fund of £10 billion a year, paid for by the National Insurance increase, which will be targeted at the NHS backlog to begin with and then redirected to social care. The problem here is that the lobby groups for hospital leaders are insatiable in their demands for extra resources. The Government should ring-fence funding for social care and make clear that the goal of policy is not an ever-expanding high-tech hospital sector.
Done right, the new spending can help to build a more productive NHS that operates without regular emergency funding boosts. Get it wrong and manifesto-busting health tax increases could become a regular event.
The Government has a choice. Local solutions with limited funding – or £10 billion on centralised non-solutions.
Aiming for Health Success’ report on NHS spending, “Realistic or utopian?”, is available here.