Well intentioned, top-down reorganisations have been a regular feature of government policy with regard to the NHS. Too often they prove to be both costly and disruptive, and end up distracting, rather than supporting, clinicians in their core task and vocation of providing care to their patients.
There is particular risk in the timing of their proposed new reorganisation, given that the country and the NHS has been buffeted by the covid pandemic. The battle against the pandemic and the hard work to relieve the backlog of non-covid clinical procedures and treatments will last for at least the next two or three years.
Yet, it is also the case that the health and care system in the UK, even before the pandemic, was in need of reform given two particular ‘crises’. In the first place it was creaking at the seams evidenced by the pressure on A&E departments, the difficulty in some areas in getting GP appointments, hospitals regularly running at over 90 per cent capacity utilisation, and so on.
Secondly, the ageing population and the increase in chronic diseases had exposed the often deadly cracks between health (NHS) and social (local government) care.
So, given that the announcement has been made, the key question now is ‘how can we make sure that the benefits of change coming out of the process outweigh the inevitable disruption that any change programme entails’?
If the changes can bring about four outcomes, then the process will be worthwhile. This will require an increase in the ambition of the White Paper as none of these is currently fully addressed in that document.
- Public health is addressed in the white paper. The covid pandemic has highlighted the poor state of health of much of the UK population. Sixty five per cent of the population is overweight/obese, and this has sometimes proven deadly. Public health, both in terms of promoting healthier lifestyles and protecting against pandemics, has been poorly resourced heretofore. A step change improvement in public health would be a good outcome from this White Paper.
- The White Paper could also prove helpful in tidying up the currently disjointed nature of health and care jurisdictions that make integrated decision-making around individual patient care extremely difficult. The move to Integrated Care Systems, long overdue, will hopefully be accelerated. However, the government needs to go further and properly integrate health and social care by merging adult social care with the NHS into truly integrated care systems. This is not a takeover of local government by the NHS nor vice versa, but a recognition that the system should be organised around individual patient needs and not around increasingly arbitrary divisions accidentally implemented in 1948. The White Paper also needs to make a clear call on authority within these bigger healthcare systems: is it the NHS-centred ICS or the local government-dominated Health and Care Partnerships, or (the best solution) a merger of the two equals. Moreover, the change process has to be bottom up rather than imposed from the top, and managed by responsible clinicians and managers on the ground. Politicians can set high level objectives for the Integrated Care Systems, but should not be allowed to play party politics or to make ill-informed, distant interventions or, worst of all, run the risk of being accused of pork-barrel politics.
- The White Paper makes no mention of funding. The new Integrated Care Systems need to be allocated funds on a two-year rolling basis within a rolling 10 year budget. Social care needs an immediate injection of £10 billion just to get back to the needs-adjusted per patient rate that pertained in 2010. More innovative and sustained ways of funding health and social care are required. There are many options ranging from the type of social insurance systems that Germany and Japan operate, through to a hypothecated tax that integrates both health and social care funding. The government has been promising a solution to social care for many years, most recently in the 2019 General Election, and it has still not been delivered. This is the opportunity to finally fix social care, and to do that in the context of integrating it with the NHS, and finding ways of resourcing both of them adequately.
- This predictable and increased funding should support a long-term workforce plan that trains more doctors, nurses and care workers. Again, this is not addressed in the White Paper and it is especially urgent given the strains that the pandemic has placed on a workforce that, in both health and social care, was under-resourced by at least 10 per cent going into the pandemic.
If these four outcomes can result from a re-defined and more ambitious White Paper (professionally and smoothly implemented), then this government has the opportunity to make the biggest improvement in the UK’s health system since it was set up by Nye Bevan in 1948. In doing so, we can do justice to Bevan’s vision:
‘We shall of course find from time to time that alterations and adjustments have to be made. We are not ridden by doctrine; we are a nation very largely of visionary empiricists, able to adjust things where necessary, and between us we shall have a standard of health service that will be the envy and admiration of the world.’’[i]
[i] Foot, M., 1962. Aneurin Bevan. London: Davis Poynter. Book 2, p. 193.
