What needs to be done to make the NHS fit for the future?

Sajid Javid, secretary of state for health and social care, served up a dish made up of politics, economics, and healthcare in his speech on the NHS at the Royal College of Physicians of London on Tuesday 8 March. The dish included ingredients from previous health secretaries in a wide ranging review of what needs to be done to make the NHS fit for the future.1

Politics loomed large in Javid’s public commitment to the founding principles of the NHS and his vision of a state “that is small but strong; empowering not constraining.” Economics appeared in his reminder that healthcare spending will comprise 44 per cent of all public spending by 2024 compared with 27 per cent in 2000 and that growth on this scale cannot continue. Health care permeated his argument that the NHS must embrace reform centred on three “Ps”—prevention, personalisation, performance.

Prevention was given a special place in Javid’s speech. He argued that too much time is spent dealing with symptoms and not enough on the causes of illness, adding that if this continues “we will end up with an ever expanding state and even worse health.” In his view, responsibility for prevention is everybody’s business (echoes of Barbara Castle’s 1976 green paper of the same title) and must recognise the role of families in supporting people to make the right choices.

Alongside prevention, Javid outlined a commitment to personalisation involving an expansion of personalised care for people with long term conditions and personal health budgets. Personalisation includes giving people a “right to choose” where to be treated, building on Virginia Bottomley’s Patient’s Charter and Alan Milburn’s market based reforms. Choice will start with those facing the longest waits and the NHS will cover the costs of people using the private sector or an NHS hospital outside the area in which they live.

The third “P” was performance. By this Javid meant ensuring that standards are raised across the NHS with unacceptable variations in performance reduced. Teams and organisations with a track record of solving long-standing service issues will be expected to share learning across systems to bring about improvements in care. Without giving detail, the speech promised “more freedom and support for system leaders and frontline innovators to partner and to deliver,” a nod in the direction of Andrew Lansley’s ambitions to liberate the NHS.

The most important omission was recognition that delivering the three “Ps” and sustaining the NHS for future generations requires an investment in capacity that was shown to be lacking during the pandemic. Capacity includes hospital beds, intensive care facilities, diagnostic equipment, buildings and above all health and social care staff. Failure to develop a fully funded workforce plan undermines the credibility of the commitments in the speech and will act as a brake on progress.

The melding of politics, economics, and healthcare is a reminder of the difficulty of increasing spending on health and care and the inevitability of governments making hard choices between competing claims. These choices have become even more difficult in the context of the war in Ukraine. Demands to increase spending on defence will surely grow as will the need to support families faced with rising energy and food bills.

Given the pressures on the public finances, the assumption must be that the NHS will be expected to live within spending plans already announced. Not only does this mean that there will be no extra funds for the workforce plan when it eventually appears, but also the NHS will have to find resources for the ongoing costs of covid from within its budget. The challenge this presents is how to increase productivity in sectors like health and social care that are labour intensive and suffer from “the cost disease.”2

If the speech was intended as an appetiser, then it just about does the job. But if it was meant to be the main course, it falls far short of what is needed. Much will depend on the white paper on health disparities promised for later in the year and the commitments it contains on improving the population’s health. Is the government willing to tackle the commercial drivers of ill health in the food and drinks industries, and is there an appetite for cross government action on housing, education, and the wider determinants of inequalities?

The government also needs to go further in explaining how performance will be improved as the provisions of the Health and Care Bill are enacted. How exactly will system leaders be given more freedom and support and how will front line innovators be empowered to lead improvements in care? Will ideas such as “academy trusts,” floated in recent weeks, be pursued, and will the lessons from the pandemic, when clinical teams and managers seized the initiative, be acted on?

Claims of “a revolution in the supply side and demand side of healthcare” at the end of the speech are at odds with the substance of what was proposed and beg the question of what “a huge transfer of power and funding from the state to the individual and family” really mean. Conspiracy theorists will seize on these words to argue that the government’s real agenda is to privatise funding and provision even though Javid was explicit in his rejection of the United States model. We may need to await the next course to find out.