A 30-year consensus on how to run the NHS is coming to an end. The centre-left now needs to focus on new ideas, rather than returning to old ones, argue Richard Bourne and Steve Iliffe

Inadequate funding has consequences as we see with our social care system. But simply increasing funding is not enough. It is time for progressives to set out clearly their ideas about what a 21st century care system should be like; and the role of the National Health Service within it.

In its recent editorial, The Strange Death of the NHS Market, the Centre for Health and Public Interest (a thinktank which was set up with the explicit intention of questioning market orthodoxy) claims that the NHS changes initiated by the Health and Social Care Act 2012 have ground to a halt.

A year ago in our paper on the ‘third era’ of the NHS, we argued that the era of markets and competition in the NHS (era two), dating from the mid-1980s, was over and we welcomed the possibilities for the third era. Whatever follows in era three will not be a leap backwards and a return to 1948 and the first era, as some on the left are advocating, but an opportunity to think more radically.

This is a major challenge for the progressive thinkers of the left; once we abandon the easy simplicity of attacking the market and privatisation we have to think far more about what the NHS is actually for and how it sits in the bigger picture of the kind of society we want. We also need to reflect on evidence. Fortunately we have a lot that is valuable – from the Lords Sustainability review to the Barker review to the commission on Whole Person Care to the outputs of the King’s Fund, the Nuffield and the Health Foundation. Just by looking at Wales and Scotland, which have different health care structures but very similar outcomes and problems, we can see how organisational forms and structures are not as relevant as many have argued.

One argument worth exploring is how to position the NHS within an overall system where the state acts collectively to ensure all its citizens are enabled to enjoy the maximum wellbeing with the right to care and support when they need it. This broader view ensures housing and disability support (as examples) are factored into how we think about hospital and out-of-hospital care. So in the third era the NHS ceases to be its own separate island.

A good start then is to define a set of principles for an enabling state; a contrast perhaps to the welfare state or the regulating state.

We know the basic founding principles of our NHS – universal, comprehensive, free at point of need and funded from general taxation – remain even if all are bent at the edges. But as we look at social care, at housing or at ‘benefits’ we see that these NHS core principles are not common – in fact there is no common set of principles. The question as to why social care is not free like health care has no sensible answer apart from political history.

We have to accept that even if the financial issues are addressed then the NHS still faces three major weaknesses. (In part the marketised NHS of era two was intended to address some of these issues, but it failed to do so.) They are: accountability; fragmentation; and equity.

Accountability

The democratic deficit is a major issue; the principle ought to be that important decisions about allocation of funds or setting of priorities or configuration of services are made by people democratically accountable in some proper way.

We also have to address the issues of personal accountability; personalisation of care may not just be another route to privatisation, and personal budgets may actually be important to some.

Then we add dilemmas around local decision making – will this produce a post code lottery or count of evidence of listening to communities?

Accountability cannot exist without a culture of genuine openness and transparency. Once the market concept of commercial confidentiality is dumped then everything must be in the public domain and subject to real consultation and engagement. This in itself creates a major force – the power of voice, derided by those who forced the market upon us but now ready for rehab.

Fragmentation

The NHS has never been a single service. It has always been a muddled confederation of vested interests. Gaps between various NHS tribes are as great as the NHS/social care divide. Poor experiences of care are as likely to be due to lack of joined up services within the NHS as around the boundaries. Initiatives such as ‘Get it Right First Time’ suggest professional autonomy may be a cause of unhelpful variation. Put another way, quality of care will depend, in part, on co-ordination of services.

While every service everywhere cannot be above average we ought to know what variations exist and ask for reasonable explanations; linking again to a culture of openness and transparency.

The new fragmentation introduced by market thinking has to be undone with the return to the idea of all public services collaborating and cooperating to best effect; but it should be undone without massive organisational upheaval.

Finally the separation of the NHS from the rest of the public services like social care and housing has to be addressed; a single strategy and plan for wellbeing for large geographical areas (sub-regional planning) looks to be one way forward, and is prefigured by the Sustainability and Transformation Plans, but could be fraught with huge obstacles created by vested interests.

Equity

The drive must be around prevention, earlier intervention, and earlier diagnosis, and this will involve challenging the acute sector domination that sucks funding away from public health.

Conclusion

We know the NHS compares well internationally on a number of measures including efficiency, affordability, equity and some aspects of the process of care. We know it does this on levels of funding around the EU average (but less per capita than the better services). But we also know the NHS does not perform well enough in terms of outcomes -arguably the thing that is most important. How much improvement is dependent on addressing fundamental weaknesses in the principles is debateable and should be debated

It is time the progressive left found a rational voice. Currently it can only respond with incoherent hostility to anything new. It is unsure whether the NHS is the best in the world (as the Commonwealth Fund suggests) or on the edge of collapse. It is unsure if the NHS has already been sold off or is just about to be. The NHS in Scotland (free of markets) is either brilliant as there is no market or rubbish as it is overseen by a right wing SNP. We have heard that we have 24hours/one week/one election to “save the NHS” so many times it is amazing that it has held on. It is time for new ideas.

–––––––––––

Richard Bourne has worked in senior roles across the NHS and local authorities for many years and been involved with policy development since 2010.

Steve Iliffe is Emeritus Professor of Primary Care for Older People at University College London, and co-editor of Health Matters magazine.

Photo