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3 days ago
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The British government’s 10-year health plan is still some months off. So is the multi-year spending review that will set the parameters around funding. But the three themes around which Labour plans to build its NHS reforms are set. Each involves a change in emphasis: from treatment to prevention, hospital to community and analogue to digital.
As health policy is devolved, these plans apply directly only in England. Their impact, though, will be UK-wide, since the largest health system is bound to influence the others, and what happens to the NHS is so crucial to the UK government. In 2025 – Labour’s first full calendar year in office since 2009 – there is arguably no area in which the party is more urgently in need of results.
What would a good year look like? The NHS app has 34 million users so far, and people booking appointments, ordering prescriptions and checking results online should free up staff to do other things – contributing to the 2% productivity boost that was promised with £22.6bn of new funding in October’s budget. Ministers and health bosses need to ensure that the app does not add to digital exclusion. Unless analogue means of accessing services are retained, the health inequalities they have promised to tackle will be exacerbated. But an app-supported boost to efficiency looks achievable – and has the advantage over some other ideas that it can be summed up in a sentence.
Restoring the 18-week hospital treatment target was a compromise between advocates of top-down targets and those prioritising primary care. The commitment to 92% of patients waiting no longer than 18 weeks by the end of this parliament will challenge a system strained by workforce shortages and industrial action. In England, the waiting list has already topped 7.5m cases (representing 6.3 million patients), with even more waiting in Northern Ireland, Scotland and Wales.
Funding for a ‘broken’ system
Politically, it is not hard to see why ministers felt the need to offer voters something concrete. But to the question of whether it is possible to slash waiting lists while simultaneously re-engineering the nation’s health system in the direction of preventive public health, many experts think the answer is no.
Health has done relatively well in funding terms since Labour took over, and is expected to be among the winners in the spending review. But owing to self-imposed fiscal constraints, as well as the weak economy, spending on the NHS does not look likely to increase at anything like the rate at which it did the last time Labour was in power, when it rose by an average of 5.5%. This makes the kind of improvement that can be delivered by rapid investment – for example, in staff working overtime – impossible. But public awareness of the depth of the crisis could buy ministers some time, as Wes Streeting, the health secretary, appears to have calculated when he declared the system “broken”.
Despite problems on the frontline and the widely recognised demographic challenge of an ageing population with high rates of chronic illness, at least there is a broad consensus on structure. Integrated care is the name given to the plan for 42 regional NHS bodies (which spend around two-thirds of NHS England’s £168bn annual budget) to work in partnership with councils and the voluntary sector to make local populations healthier.
It sounds simple. But two years in and, as Lord Darzi noted in his review for ministers, there is already variation in the way that integrated care boards (ICBs) and partnerships interpret their responsibilities, including “how and at what level they should tackle population health”. What, for example, is their role in tackling social determinants of health such as bad housing?
If overreach is one risk – with ICBs set up to fail as mini welfare states that are meant to fix everything – the bigger one is that ministers will not let go of the reins at all. It’s not hard to see why a return to centralised performance management feels like political sense for ministers fearful of voters’ judgment. Politicians know how high a value people place on hospitals. But the announcement of the 18-week target plus league tables, with rewards for successful hospitals and special measures for failing ones, runs counter to empowering local boards. Regional health bosses panicking about whichever data points will decide the fate of local hospitals will not be able to focus on building the services that the government says it wants in order to prevent people from becoming ill in the first place.
Questions on the new model
Whether this power grab by the centre continues may be influenced by the government’s listening exercise to reshape the NHS. There is a good chance that mental healthcare will benefit from growing public concern. But integrated care is unlikely to emerge as a theme of public consultation, not least because the concept remains so vague. One question that the 10-year plan will need to answer is where, and by whom, the new-model community healthcare is to be delivered: are GPs the key figures, or health visitors and district nurses? How about schools? How will strong leadership and an open culture be supported? What principles and rules will govern the involvement of the private sector? The rapid advance of private-equity-backed businesses into social care is something that everyone involved should be wary of.
A recent report by Patricia Hewitt, who was one of Tony Blair’s health secretaries, concluded that local boards should be bound by no more than 10 national targets, while the share of health spending on prevention should rise by 1% each year. Much now depends on whether Mr Streeting chooses the advice of Alan Milburn, another Blairite former health secretary now with a desk in Whitehall, over that of Ms Hewitt, who chairs an ICB.
There is no question that devolution and autonomy require courage. One risk when local organisations pursue their own priorities is that demands for equity and consistency can trump support for innovation. One person’s localism is another’s postcode lottery. Joint commissioning by the NHS and councils brings technical complications that will have to be resolved on the ground.
The danger is that allowing them this freedom, along with the rest of the integration agenda, is too much at odds with the centralising instincts of the British state. But Mr Streeting should not allow this prejudice, or nostalgia for the New Labour years, to colour his judgment. If the health service is as broken as has been claimed, the government must seek solutions to fix it.
