Rhetoric about NHS reform is misplaced
BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p54 (Published 11 January 2023) Cite this as: BMJ 2023;380:p54
The NHS in England is in crisis. The health service entered the new year—as it did the last one—with several NHS trusts declaring critical incidents,12 which means they may not be able to provide urgent or safe care. In November 2022, people with emergency conditions such as heart attack or stroke waited over 48 minutes on average for an ambulance3; 1 in 10 waited over 105 minutes. Routine care is being disrupted too, and the hospital waiting list has grown to 7.2 million.4 These big numbers are made up of people whose lives may now end early or contain unnecessary pain and suffering as a consequence of delayed NHS care.
What should be done? The government’s approach to improving the NHS is hard to identify. The health service in England has just been reorganised under the Health and Care Act 2022, which established 42 regional NHS bodies, called integrated care systems, to plan services and manage spending. The changes are based on the idea that better collaboration between different parts of the health system—hospitals, general practices, social care, and others—is needed to improve care.
But these changes were introduced under Boris Johnson’s government. Two prime ministers later, Rishi Sunak and his health secretary, Steve Barclay, are emphasising patient choice of provider and “radical transparency” on performance as ways to improve the NHS.56 A review of integrated care systems is already under way.7 And the NHS must somehow cope with spending growth well below the long term average.8 Plans have been promised on improving access to general practice, NHS staffing, and recovering urgent care services. But it’s not clear when they will arrive—a workforce plan, for instance, has been promised for several years—or whether they will be matched with additional resources to make them happen.
Meanwhile, the crisis continues, and calls for more fundamental “reform” of the NHS grow louder. On the right, the target is often the NHS’s funding model. Sajid Javid—health secretary under Johnson in 2021-22—suggests government looks at alternative ways of funding the health service, like social insurance.9 David Davis, another Conservative MP, says the same.10 And so do commentators in newspapers such as the Telegraph and Times.11121314
This is a bad idea. How countries fund healthcare is shaped by history, context, and values. The distinction between Beveridge (tax funded) and Bismarck (social insurance) systems has blurred over time, and high income countries with social insurance schemes increasingly rely on additional government spending.15 There is no clear evidence that one model performs systematically better than the other.16171819 And the way the NHS is funded—mainly through general taxation—is an efficient and equitable way of raising revenue, with strong public support.20 Switching funding models would be a monumental waste of time and money. A better lesson from our European neighbours would be how much they choose to spend. UK health spending per person would have been £40bn higher every year over the past decade if it had matched the EU14 average—which includes countries such as France, Germany, and Sweden.21
Labour is calling for reform too. Wes Streeting, the shadow health secretary, says the NHS must “reform or die.”22 His prescription is “modernisation”: more staff, a greater focus on prevention, and new ways of delivering care.23 But details on how to achieve this are thin. One of Streeting’s proposals is scrapping the general practice partnership model in favour of GPs becoming salaried NHS employees.24 There are good reasons for giving GPs options for how they organise in future,25 but it’s not clear how a big bang shift would solve the major challenges, such as GP shortages, facing general practice right now.26
Unglamourous solutions
Rhetoric about fundamental reform is a distraction. The NHS is in deep trouble, but it doesn’t need a big idea to save it. The problems are plain to see: a decade of underfunding, weak capital spending, staff gaps, neglect of social care, a tangled web of priorities and incentives, and more. The fixes are mostly unglamourous and well known: adequate investment and staffing, skills and capacity for improving services, clear and coherent national priorities, and the right blend of policy levers—such as targets, payment systems, regulation—to help achieve them. The experience of tackling long waiting times in the 2000s shows it can be done.2728 And evidence from a long line of top down NHS reorganisations since 1990 should be a clear warning for politicians dreaming up another round.29 Instead, policy makers should recognise the value of the NHS’s single payer structure for testing and evaluating innovations in care.
Reforming the NHS is often touted as the route to improving the nation’s health. Life expectancy has stalled over the past decade, and gaps in health between richer and poorer areas are widening.30 But health and health inequalities are fundamentally shaped by social and economic conditions outside the NHS’s control, such as income, education, and housing.3132 Public services beyond the NHS have faced substantial real terms cuts over the past decade,33 and some—like social care—are ripe for reform.34 Politicians looking for radical solutions to improving health could perhaps start there instead.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The author declares no other interests. Further details of the BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf.
Provenance and peer review: Commissioned; not externally peer reviewed.
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