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Should we have a royal commission on the NHS?

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1621 (Published 06 April 2017) Cite this as: BMJ 2017;357:j1621
  1. Maurice Saatchi, Conservative member of the House of Lords1,
  2. Paul Buchanan, patient editor2,
  3. Nigel Crisp, independent member of the House of Lords3
  1. 1London SW1P 3QL
  2. 2The BMJ
  3. 3London
  1. Correspondence to: Paul Buchanan pbuchanan{at}bmj.com, Nigel Crisp crisp{at}parliament.uk

A high level inquiry could detoxify the radical changes needed and command wide support, say Maurice Saatchi and Paul Buchanan; but Nigel Crisp thinks that a less formal, more flexible and collaborative approach could be quicker

Yes—Maurice Saatchi and Paul Buchanan

Never has there been a better time or a more compelling reason, as Brexit is negotiated, for a considered and politically neutral review of our health services. The fiscal implications of dealing with the projected numbers of people with diabetes alone, for example, are enough to prompt a rethink of the whole system and of how society needs to change.

Political football

But the NHS has become a political football. People disagree even on whether it has a problem, let alone the possible solutions. We need an honest broker, a peacemaker: we need a royal commission on the NHS.1

Royal commissions are public inquiries at the highest level, called to look into matters of utmost importance, and few issues are more important to the future of our country than the health and wellbeing of our citizens. Their many advantages include the ability to secure the vital cross party support needed to embed lasting changes and to detoxify reforms that otherwise may be too politically dangerous to pursue.

Royal commissions are independent—governments cannot interfere once they have started—and therefore sit outside politics. They are also powerful and can compel people to produce documents and other evidence in their inquiries.

And we will need the power to ask difficult questions of experts from all sections of society. We must challenge what we think we know about the problems the NHS faces today. We must think beyond the structures and institutions of the previous century.

Is the NHS no longer fit for purpose? If so, what is that purpose? Is the system in crisis? If so, what is the real nature of the crisis? Is it simply a lack of funding? Or are citizens bringing it to breaking point through lifestyle choices?

We need the power to ask difficult questions of experts from all sections of society. We must challenge what we think we know about the problems the NHS faces today

In a society increasingly prone to chronic conditions, from obesity and diabetes to depression and stress, is the NHS in its current form capable of providing for people’s needs?

Such an inquiry can and must include the voice of the patient: reform of the NHS must be co-designed by those it is meant to serve. What sort of NHS do patients want and need for the future, and how must we redefine our relationship with the NHS?

What should be the social contract between the NHS, healthcare professionals, suppliers, and patients? And what role should the private sector play?

The big picture

A royal commission could look dispassionately at the big picture—an ageing population, social care, funding, the growing prevalence of financially draining chronic disease, the impact of poverty on health outcomes, the effects of Brexit on labour supply, the cost of innovation, the private sector’s role, mental health, public health, and prevention.

The alternative of a shorter, cheaper, more manageable public inquiry may seem attractive at first sight. However, the Saville inquiry into Bloody Sunday cost £195m, and the Francis inquiry into the Mid Staffordshire trust produced a 4000 page report with 290 recommendations, five years after poor care at the Stafford Hospital was first exposed.

Royal commissions have declined in popularity in recent decades, with only three reported since 1990. But they can be effective if their length and remit are well defined. The unfocused recommendations of the 1976 commission into the NHS, for example, stand in contrast to much more successful examples such as the 1991 royal commission on criminal justice, which established the Criminal Cases Review Commission in an effort to reduce wrongful convictions.

The prime minister has rightly said that unfairness and injustice are her top priorities. We want an NHS that is accessible, fair, and sustainable, and the public supports a royal commission.2 The former health secretaries Norman Fowler (Conservative), Stephen Dorrell (Conservative), and Alan Milburn (Labour) have said that they support this approach, as has the current Liberal Democrat health spokesperson and former health minister, Norman Lamb.

Now is exactly the right time for a royal commission to examine forensically what that means today for healthcare, for citizens, and for society—and to deliver a non-partisan, politically independent report.

No—Nigel Crisp

The relaxation of waiting time targets is, like the crisis in social care, another aspect of the financial difficulties facing the NHS.

The UK’s approach to health and care needs a thorough rethink that goes far beyond financial issues and service changes in response to current problems, taking advantage of scientific and technological breakthroughs. A new approach must also consider the responsibilities of different sectors, including employers, educators, and patients, in creating a healthy—and health creating—society. And it must consider the important economic role of health in boosting productivity and supporting the biomedical and life science industries.3

Formal and restrictive processes

A royal commission has some merits in being above politics, authoritative, and open in its deliberations. It would potentially command wide support. However, these commissions are semi-judicial public inquiries, with formal and restrictive processes for taking evidence and consultation. They are also very expensive and can be lengthy: the last royal commission on the NHS was set up in 1975, and implementation began seven years later with the abolition of area health authorities.

The biggest argument against a royal commission, however, is that we have better options for rethinking the NHS. We need a far more flexible, quicker process that directly involves—indeed, is driven by—people from all parts of the health and care system, including patients, families, and carers.

People working in and with the health and care system should be engaged in its redesign: they shouldn’t simply give evidence to a judge led inquiry and then wait for it to finish its deliberations

We can follow examples. In 2000 the secretary of state for health created six working groups, each including clinical, managerial, academic, voluntary sector, and patient organisation leaders, to review areas of critical concern. Their findings were merged into a comprehensive NHS plan. The process took less than nine months from its start to the beginning of implementation and led to major improvements in premature mortality, service delivery, and public satisfaction over the following years.4

In Portugal in 2013, the Gulbenkian Foundation established similar groups that reported to an independent commission and created a new plan for health within a year.5

These more flexible processes involved as many as 100 people discussing, debating, and negotiating with each other as part of the process. They were informed by wider public consultation. People working in and with the health and care system should be engaged in its redesign: they shouldn’t simply give evidence to a judge led inquiry and then wait for it to finish its deliberations.

Today we need many clinicians, scientists, businesspeople, and social entrepreneurs globally, who are already creating the future, to be central to the process.

Global pioneers

Examples of such global pioneers include ParkinsonNet, a collaboration of more than 2700 health professionals; the Buurtzorg model of home care in the Netherlands; and the innovative Aravind eye surgery and Narayana cardiac hospitals in India.

UK pioneers include the St Paul’s Way Transformation Project, which brings public sector and private organisations together in a deprived London community to develop new approaches to health, alongside improvements in employment opportunities, education, and housing; and the New NHS Alliance, which engages practitioners and community organisations in developing new ways of promoting health and providing services.

Both NHS England’s and Public Health England’s strategies point to a future where today’s hospital and illness based system is replaced by a patient centred and health based one.67 The government must accelerate this transformation with the public’s full involvement while also setting up the sort of process described above.

Led from inside the government or by an independent body such as the Royal Society, this approach would develop the radical strategies needed to maximise the NHS’s contribution to improved productivity and supporting the biomedical and life science industries. And it would engage other sectors, including employers, educators, architects, and designers, in creating environments that encourage communities and individuals to flourish.

The NHS and its partners show enormous creativity and energy. We mustn’t put everything on hold while waiting years for a royal commission to opine.


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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