Wes Streeting, the new health secretary, faces a big dilemma. English NHS performance is objectively poor, and the Labour government will be expected to improve the health service – fast. One of his first acts has been to launch a full investigation, led by Lord Ara Darzi, the surgeon and former adviser to Gordon Brown and Tony Blair. Darzi will report back in the autumn.
But he doesn’t need a report to tell him the most brutal facts of all: that between 2010 and 2019, the NHS had its lowest period of budget growth as a real-terms share of GDP in its history. This decade of financial restraint was largely achieved by holding down staff pay, the legacy of which was widespread NHS industrial action. But the new government has not come in under the same sunny economic conditions as the Blair administration of 1997. The outlook for growth is much chillier. Streeting will have to make improvements, but on a tight budget. How can he do it?
Streeting will have to ride two horses simultaneously, which doesn’t sound comfortable and probably won’t be. He will need to establish the root causes of NHS performance problems and effectively address them, while also developing strong regional bodies with real bite and rewarding organisations that improve by giving them greater freedom.
The problems that Streeting confronts in 2024 are very different to those that Beveridge and his colleagues faced in the 1940s when he drew up his report. Back in 1948, communicable diseases were major killers and disablers, most notably tuberculosis. Vaccinations and antibiotics made huge inroads in suppressing it. Polio, diphtheria, tetanus, whooping cough, measles, mumps and rubella were all virtually wiped out during the second half of the 20th century, via childhood vaccination giving herd immunity.
While TB was largely eradicated, heart disease and cancer remain the two biggest killers nowadays – just as they were in 1948. But the big two killers’ proportions have swapped. Deaths from heart disease have halved since 1948: those from cancer have doubled. Deaths from heart disease and strokes have fallen by 40% since 1948 (despite population growth). Medical advances and improvements in housing and nutrition have driven this progress. More statins and less smoking have helped.
But in other areas, recent progress has been less convincing. The Office for National Statistics’ latest data on life expectancy, from January, confirms that life expectancy improvements “have been slow for the last decade, after 40 years of generally increasing: improvements have been primarily because of reductions in mortality at older ages driven by advances in healthcare, and better living and working conditions. Since approximately 2011, the rate of increase in life expectancy has slowed.”
In 2020, the Institute of Health Equity, led by the distinguished epidemiologist Sir Michael Marmot, reported that “for the first time in more than 100 years life expectancy has failed to increase across the country, and for the poorest 10% of women it has actually declined. Over the last decade health inequalities have widened overall, and the amount of time people spend in poor health has increased since 2010.”
It noted “an increase in the north-south health gap, where the largest decreases were seen in the most deprived 10% of neighbourhoods in the north-east, and the largest increases in the least deprived 10% of neighbourhoods in London”.
“The more deprived the area, the shorter the life expectancy,” the report stated, adding that “mortality rates are increasing for men and women aged 45-49 – perhaps related to so-called ‘deaths of despair’ (suicide, drugs and alcohol abuse)”.
Which tells us that what makes us healthy is not only healthcare. Studies suggest that clinical care accounts for about 20% of health outcomes; while social and economic factors and physical environment contribute around 50%.
And yet, the state of the health service is clearly important. Ipsos polling has put the NHS as the public’s second-most important issue, just behind the economy. It found that 64% of respondents expect the NHS to get worse in the next few years, with a further 19% thinking it will stay the same.
The hospital treatment backlog is well over 7 million, and that’s not all due to the pandemic: it was already 4.4 million in January 2020). It is almost a decade since the major national English NHS targets were met.
The public often still find it hard to get GP appointments, despite a rise in GP activity since the pandemic. There has been no increase in the number of GPs. Fortunately, the NHS had massively increased activity and reduced waiting lists during the 2000s, but that was funded by significant economic growth, which isn’t on the current horizon.
What do we need to do about all of these problems? To start with, one thing we know doesn’t work is “re-disorganising” the NHS. Andrew Lansley’s attempt at reform, which became the 2012 Act, may have put people off major NHS legislation for a generation. Lansley believed that competition would make the NHS a self-perfecting machine. He also reduced NHS management by 45%, and created the world’s biggest quango in the operationally independent NHS Commissioning Board, later rebranded NHS England.
To put it mildly, this wasn’t successful. When the full chaos of the Lansley reforms became obvious, the Cameron-Osborne leadership begged former New Labour health special adviser Simon Stevens to come back from his lucrative work running UnitedHealth in the US to fix the mess. Stevens had been hugely influential on New Labour’s NHS reforms of the 2000s.
But despite his work, and despite the increased resources and staff provided since the pandemic, NHS productivity has not risen. It’s hard to argue that the current management model is effective. Streeting will have to find ways to “hack” the current system to make it work more effectively and efficiently.
His first step must be to accept that, even for a highly centralised government like the UK’s, the current version of the NHS is insanely centralised – this is a major cause of its cultural problems. When all you’ve got as a means of system management is shouting at local NHS organisations from Whitehall, every problem is simply met with more shouting.
It wasn’t always so. Past versions of the system had stronger regional bodies, whose leaders were major figures. This could, and did, lead to regional cliques, but also to genuine localism in some areas and usually the best-performing ones. It also produced credible leaders who could be candidates for senior national jobs.
The creation of semi-autonomous NHS foundation trusts, high-performing organisations that elected local governors, was one of New Labour’s good ideas. While they still exist, technically at least, no new trusts have been created for years, their regulator was merged into NHS England and their autonomy was reduced. There are times when the NHS needs to be nationally run in a top-down way – the pandemic being the clearest example. But having money and power as centralised as they are now in NHS England is infantilising and damaging.
Massive centralisation of power also makes the centre arrogant and unwilling to accept bad news. Some of these dysfunctions are replicated in local NHS organisations: this cultural imitation is one of the drivers of the NHS’s incessantly shabby treatment of whistleblowers.
Medical training also needs attention. There is currently a mismatch between the number of people who want to study medicine and the number of training posts being made available. So too is the poor treatment of junior doctors, with problems ranging from pay (low, late) to rostering and where people will be allocated their training posts.
During the 1990s, doctors’ medical training changed and the consultant-led paternalistic “firm” structure came to an end. That old structure, where doctors trained in one team in one organisation, was replaced by the current system of frequent rotations of trainee doctors through various trusts around the country. This is not only hugely disruptive for the doctors in training, but also discourages organisations from making real efforts to improve their trainees’ experience as they aren’t there for long enough.
Morale among medical staff has declined, and has scarcely been helped by the clumsy introduction of a range of new “associate” roles. While the basic concept of new staff with lower training requirements to take on some of the most routine work makes sense, its introduction has been over-hasty, at times deceitful, and it clearly enjoys little confidence in much of the medical profession. This scheme needs to be rethought and redesigned.
Management also requires improvement. When the Lansley reforms cut 45% of NHS management resources, the work done by those managers did not suddenly vanish: it just started being done by doctors instead of managers. That tends to be a poor use of doctors’ time. Secretarial resources available to doctors have also shrunk. The loss of expertise in waiting-list management and patient pathways through the system has been apparent in the subsequent performance deterioration.
While the 6% real-terms year-on-year cash growth of the NHS budget between 2000 and 2010 is clearly not coming back, the system needs to re-design itself. Trying to get the system to run faster in its current operating mode will not work.
But – beware tech utopianism, which in healthcare is pretty widespread. This is partly because the NHS has not resourced technology adequately: most hospital doctors are wearily familiar with computers that take over five minutes to boot up. The former chancellor, Jeremy Hunt (previously the longest-serving health secretary in the NHS’s history), announced a big increase in tech funding. That was good, as NHS IT infrastructure indeed needs major improvement. The bit of the health system that got tech first and best was primary care: this happened because GPs, being small private businesspeople, could see that having effective IT systems would save them time, space and money.
During the pandemic, the NHS Datastore became a key resource. This managed to link up data from NHS organisations with working IT systems, but since the end of the pandemic it appears to have been largely abandoned. The need to improve NHS management is largely about the use of data. Giving clinicians actual timely evidence of their performance happens in well-run NHS organisations. Linking up data within an organisation could help to hasten the end of those “bed meetings” you see in TV documentaries, where staff discuss bed capacity over a speakerphone, using a whiteboard. This is a ridiculous way to try to run a health service.
And as for artificial intelligence, it is the latest centre for healthcare tech utopian hype. AI is already a fantastic resource for diagnostics: its ability to “learn” from diagnostic scans and tests will be an increasingly vital resource. It will probably also become highly important in drug development.
But people are developing magical beliefs that AI is going to transform everything in healthcare very soon. It isn’t: most of us use significant healthcare resources during the first two years and last six months of our lives. Most of healthcare involves dealing with very old, frail people and people with long-term conditions. Tech can help greatly (as continuous glucose monitoring has revolutionised diabetes care), but there is no AI magic on its way for frailty.
And while we wait for the AI revolution, simply saying “I heart-symbol the NHS” won’t achieve anything. It is the “live, love, laugh” sign of public policy and is a strong emetic. I don’t heart-symbol the NHS, because I want to be able to think about it clearly. Clarity is important because more healthcare is not always better.
Linked with this, we also need a Campaign for Better Deaths. The late serial killer GP Harold Shipman probably did more to set back the cause of improving the quality of life as people approach death than anyone else. The cultural response of the NHS has been to become considerably more cautious over the use of morphine. Most of us understand the physical process of death poorly, if at all. That’s reasonable: most of us want to defer it, so denial is always likely.
We have made progress with understanding how to discuss and record care preferences later in life, with advanced care directives and powers of attorney. But we do need to go further to avoid vexatious over-medicalisation of the end of life. Dying in hospital sounds really lousy.
But before that stage, we need to improve the nation’s health. The very worst argument for doing this is that it will “save the NHS”. The best argument for doing it is that being ill is horrible, and consuming healthcare usually involves a lot of waiting and hanging around with other sick people.
The university-educated middle classes are probably broadly fine. We need to get to the least healthy bits of the population. We need to talk to them in and on their terms: this will best be done by people who are from those backgrounds, who know much more instinctively what the barriers are to having better diets, doing some exercise. Often, the barriers will be resources: sometimes it will be access, and sometimes education.
Improving the nation’s health literacy will be a long-term project. Some could be done in schools, but perhaps the system should look for other “learnable life moments”: decade birthdays; pregnancy; retirement; first major illness or long-term condition onset.
The new health secretary should keep in mind what several of his predecessors have found – that shouting at people to be healthier won’t work. As is the case throughout the entire NHS, we need to understand the barriers, and remove them. This will be slow work.
Andy Cowper is the editor of Health Policy Insight
