Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Health policy advice in the new number 10

BMJ 2019; 366 doi: (Published 04 September 2019) Cite this as: BMJ 2019;366:l5309
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

Just before taking up his post in Boris Johnson’s new support team, health policy adviser William Warr made quite a splash in a Daily Telegraph column.12

Generally, special health advisers in number 10 or Whitehall fly under the radar. Few people outside the healthcare policy and communications bubble would know their names or hear what they think. But in that column, Warr set out his views for public consumption.

Early reports on the new administration indicate that it is being run with control and strategic focus. Although Warr was not yet in post, I can’t believe he was just sounding off. This was surely a tactical decision to get some ideas into the public domain, while keeping the new prime minister’s hands clean.

So what did Warr say? Here are some worrying lowlights.

He told us that more money was not the solution to the NHS’s problems, that the service was “hopelessly ill equipped” (to deal with chronic diseases) and a “highly centralized” “monolith,” and that attempts to introduce new technology had been “feeble.”

He attacked “traditional public health policies” as treating “everyone the same, regardless of lifestyle or risk” and criticised measures like food or drink levies as “sin taxes.” “The only way to prevent is to predict,” he said. This reinforced health secretary Matt Hancock’s push for widespread genomic testing to identify people at high risk of diseases and annual health checks focusing on individual choice.34

Despite the lack of established evidence to show that genomic testing or digital solutions can drive improvements in population health, quality of care, or service efficiency, Warr is pushing a magical thinking narrative based on future potential, above better evidenced, but less shiny, solutions. If you want to predict early onset of diseases and premature death, for example, postcodes are a better bet than genes.

His comments fly in the face of expert evidence in public health around the effects of socioeconomic inequalities, pricing policy, and environments on health.567 They ignore the impact of sustained attacks on public health funding or drug and alcohol services.89 They also reinforce a narrative that blames citizens for personal lifestyle choices and advocates less state interference.

As for the NHS’s structures, the service has, since its inception, undergone continuous evolution and sporadic reform to adapt to new circumstances and policy fads. Big destabilising reforms have rarely delivered. We need to learn from history. There is no “clean slate” as we need to keep current services on the road.10

Current configuration and re-disorganisation of the NHS has been overseen by Johnson’s own party since 2010, despite Warr claiming that the NHS had been “brainwashed by the financial targets introduced under Blair.” This includes “any qualified provider” legislation, devolution of service leadership, and now workforce planning into 45 local integrated care systems.1112

Despite the prime minister’s warm words and gestures towards the NHS, the agenda set out by his adviser and by the health secretary is clear: smaller state and more responsibility for individuals. This agenda deliberately bypasses inconvenient evidence and credible expertise wherever it conflicts with the neoliberal narrative, upsets industries with vested interests, or requires more government intervention in social policy. All this is coupled with an evangelical deification of digital and genomic technologies, destined to benefit their manufacturers.

As for becoming less “centralized” and less “monolithic,” this looks like a precursor to more private insurers and providers taking over parts of a service whose ethos and model are being talked down and undermined.