When the NHS celebrates its 60th birthday in 2008, it will be in its best ever health. On any objective test, the NHS has climbed a mountain in the last decade. This turn-around will best be symbolised by the achievement in its anniversary year of maximum 18-week waits from GP to hospital treatment.
It will be a solid platform from which Labour can fight the next general election. The facts will demolish Tory claims that the investment has been wasted. Instead, our investment and reform is providing patients with its best ever service, improving and saving lives.
But, for our part, the 60th anniversary must also be a time for reflection. We need to acknowledge that getting the NHS to this position has been difficult and learn the lessons from the reform process. Meeting challenging targets has put staff under pressure. As some trusts struggle to bring overspends under control, staff have been left uncertain about what the future holds and about where Labour is taking the NHS in the long term.
This mood of uncertainty explains the ‘perception gap’. As individual patient satisfaction rises, so does collective pessimism about the state of the system. Put bluntly, NHS staff have achieved great things in recent years but they don’t feel good about it.
And the difficult reality is this: having just scaled one peak, another is rising up in front of us. For the next decade will be the most challenging yet for the NHS. A combination of the following pressures will test the capacity of the system to deliver:
1. An ageing population: Every five years our average life expectancy is increasing by one year. It’s likely that the first person to live to 150 has already been born.
2. Chronic disease: In the same time, the number of people living with a chronic disease will double.
3. Obesity: Rising levels of obesity will significantly increase related conditions such as hypertension, diabetes and stroke.
4. Medical advances: Advances in pharmaceutical technology, such as the new generation of pharmacogenomics, will add hugely to the existing pressure on the NHS.
5. Rising expectations: Amongst all this, the NHS will have to cope with the fast-rising expectations of younger generations for more things to be done more quickly.
So despite the progress of the last decade, we haven’t seen the back of the debate over whether we can afford our NHS on the current basis. There will be more calls to restrict services, introduce top-up payments or introduce an insurance system.
What will be the response of the progressive left to this debate? At present, the signs are not encouraging. There is a real danger that we’ll focus on the differences between us – arguing about the need for, and pace of, further reform – and lose the big argument.
We need to be united in facing down calls for rationing and insurance and argue that the NHS model is the fairest and most efficient way of delivering healthcare now and in the future. But this will require give and take from all sides.
For the government’s part, we will need to recognise the limits of top-down reform and targets, to listen to staff and shape a reform programme that has broad ownership and support. For opponents of reform, there has to be an acknowledgement that further change is unavoidable if the NHS is not to be overwhelmed by the challenges it faces. The Labour movement can’t afford to see reform as a threat to the NHS; rather it is the only way to ensure the NHS keeps pace with the times and secures its future role.
So what are the challenges we face? The most difficult will be service reform to ensure that funding is spent in the right places.
The NHS remains too much of a ‘pick-up-the-pieces’ system. It is superb in an emergency but less good at spending money to keep people out of hospital in the first place. But coping with the pressures outlined above will mean it has to change.
Putting in place the right services at the right level may mean painful reconfigurations and new providers. We’ll certainly need to ensure those who have the most direct contact with patients in their own homes – GPs, community nurses, mental health teams and paramedics – operate in a much more integrated way, possibly with the support of consultants and specialists working out of hospitals and in the community.
I would also mount a strong case for the NHS at local level working in much closer partnership with local government, possibly with pooled budgets and joint teams. This certainly applies to social services, but also to other departments such as children’s services and leisure services. It is time for the NHS to take a few more risks and to spend creatively at a local level to keep people healthy, happy and out of hospital. For instance, if a council in an area with high levels of ill health is unable to fund free swimming for the over-60s, there is a strong argument for PCTs helping out.
By definition, this means switching the way money is spent and more change to the established way of doing things. It won’t be easy or comfortable. And it will need a sea change in the political debate around health reconfiguration.
We urgently need to move on from the assumption that the closure of a hospital ward or hospital bed is by definition bad news. We need to stop seeing all proposed changes through the prism of financial pressures. The starting point for all debates about health reconfiguration should be whether or not they achieve health improvement and human progress.
If we can agree, as all the evidence shows, that on-going reform is inevitable, the question is how we can learn to manage it better.
I believe difficult changes are far more likely to be accepted if developed locally by professionals and the public together. This means ministers and Whitehall having the confidence to let go. This will require a change of culture.
For all its strengths, the NHS has always had a top-down culture of management and for good reasons. In 1948, a top-down system was necessary to impose basic national standards on a patchwork system. Even 50 years later, these top-down levers were needed to put an early sense of focus and priority into a failing system, and set out a clear set of priorities to guide the funding that would soon arrive.
But, in 2008, a different approach will be needed. National mechanisms, such as NICE and the healthcare commission will always be needed as part of the glue that binds a national health service. In addition, national targets have worked, but we are reaching the limits of what can be achieved by top-down management of working practises. They can bring focus, but do not help unlock innovation or creativity and, over time, create a feeling of disempowerment and frustration at the front line.
There is a debate to be had about what this means in detail. But I would argue that the direction of travel for the NHS from 2008 to 2020, a time in which it will face huge pressure, should include a combination of the following:
· More operational independence for the NHS.
· More power and ability for staff to make changes and innovate.
· Fewer targets and a new lighter-touch system of regulation focused on outcomes.
· Local decision-making and more public involvement in commissioning.
· The NHS working in much closer partnership with local government.
· NHS values and principles set down.
Now that the NHS is performing at a much higher level, politicians can have the confidence to stand back from the system and allow much greater freedom at a local level. It would be a sign of strength, not weakness.
Our vision for the NHS should be a system in which the funding and the policy framework is set centrally by ministers but the service has more operational independence at a local and regional level to carry through necessary changes. Decisions on the shape of local services, and the range of providers to be used, should be taken locally. That should mean the freedom for commissioners to use new providers, in the public or private sector. Strong commissioning is the key to this new vision, backed up by transparent information on the quality and safety offered by providers that can guide patients choices.
The key question in this debate will be the balance between public and private provision. Devolving the decision to a local level will make such questions what they should be: a question of pragmatism rather than ideology. The public sector NHS will continue to be the bedrock of the system. Where independent providers can add to or support what the NHS does, they should be used. If they can’t, they shouldn’t. But those should be local decisions.
But greater operational independence for the NHS will only work with two things: more local accountability of commissioners to the public and a stronger national framework.
Despite the furious debate, there is growing evidence that foundation trusts are showing the way. There has been real engagement by the community in decisions about the provision of healthcare. But if local decision-making is to work, we need to address the other side of the coin and bring much greater public influence and involvement in the decisions of PCTs.
It is this model of full local engagement in decision-making – with both providers and commissioners – that is the only way to change the terms of the local health debate from its current sterile position to one where communities feel in control and work their way through difficult choices.
But one of the lessons of recent years is that the drive to reform has been interpreted in some quarters as a wish to dismantle. There is a sense that ministers have a back-pocket plan that is being achieved by stealth.
This is a problem to which we need a convincing response. If staff and the public are to have the confidence to make change and think innovatively, they need to know the parameters. In changing times, we need a much firmer and unshifting landscape in which debates about further NHS reform can take place. The lack of such a framework at present creates an impression in which everything appears up for grabs, thereby adding to instability and uncertainty.
One way to give permanent reassurance about our enduring values without stifling local innovation may be an NHS Constitution, perhaps along the lines proposed by Will Hutton in his book New Life for Health: The Commission on the NHS. This would set out the values and principles we share and that are not up for debate, while providing the framework within which any changes could take place. In a similar way to the BBC Charter process, the NHS Constitution could be renewed every 10 years through a wide-ranging and inclusive debate about what we want our NHS to be in the future.
Much of the detail has to be worked out, such as whether a legal constitution would cause practical problems to the NHS. But such a package has the potential to unite the coalition that believes in the NHS. Staff are embracing change and new thinking, but they are also passionate about the values of the service they work in and for. So are we, but we need a better way of communicating to staff our commitment to the same enduring values. Health arouses such strong emotions that, in the future, change will have to come bottom-up.
So, today, there is a stark challenge facing the progressive left, and more broadly all those who wish to see the NHS survive. We can either let our divisions polarise us. Or we work on both sides to reach a better consensus around the shape and style of the reform programme needed to carry the NHS forward.