Intended for healthcare professionals

Opinion Acute Perspective

David Oliver: Short term health policy decisions have long term risks that we should anticipate and mitigate

BMJ 2024; 384 doi: (Published 07 February 2024) Cite this as: BMJ 2024;384:q282
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

Whether in the private, public, or third sector, most organisations of any size include risk assessment, risk rating, and risk management as part of good corporate governance. This includes government departments and arm’s length bodies responsible for health and social care policy and leadership. Once risks have been assessed and their likelihood and severity rated, a standard framework (embraced by the government itself) involves the “4 Ts” of terminating, tolerating, treating, or transferring them to other parties.1

The strengths of UK health systems include being universal, needs based, free at the point of care, efficient, and relatively free of upfront payments that can deter people from seeking help, while allowing a component of central planning and national initiatives, datasets, and improvement incentives. But they also attract criticism for being overly centralised and top-down, with decision making not sufficiently devolved to local service leaders or communities, and—by virtue of being tax funded and politically accountable—being subject to the short term whims of the political and electoral cycle and too reluctant to use institutional memory around discredited approaches and failed initiatives.234 Longer term planning and cross party consensus have been rare.

Some consequences of policy decisions made or ducked are unforeseen, at least partly. Context may change. We might put the impact of Brexit into that category, although Brexit itself came with plenty of risk assessment and warnings about foreseeable harms to healthcare provision56; or the covid pandemic, even though we hadn’t been without pandemic preparedness exercises and then chose to ignore recommendations78; or rapid inflation, although even this can be factored into risk rating and contingency planning. But plenty that has happened in the NHS in recent years—to paraphrase the legal tests for clinical negligence—was “a breach in the duty of care leading to a harm that was foreseeable and reasonably preventable.”9

I’ll give a few examples. Andrew Lansley’s 2012 Health and Care Act was heavily criticised at the time, especially after pre-election promises of “no more top-down organisational change.”10 Indeed, the NHS chief executive of the time, David Nicholson, said that the “changes were so big they could be seen from space.”11 The government resisted all pressure to release the internal risk register, from both parliament and the information commissioner.1213 What followed was a massively damaging and disruptive re-disorganisation, now largely swept away, in a service that had been performing at its highest level for years before Lansley took office.1415

Serial failings across several parliaments to find a sustainable solution to the funding and provision of adult social care have left services in a precarious position and hundreds of thousands of people short of support.16 This was compounded by deliberate decisions from 2010 onwards, taken as part of austerity policy, to slash central government support for local authorities—and by the impact of Brexit and new points based immigration rules on the social care workforce.1718 These consequences were warned of at the time.19

Ongoing crises

Over the past three decades we’ve seen the loss of around half of our hospital beds, even as demand has risen and the population has grown and aged. The lack of access to social and community health services outside hospital has put ever more pressure on the 100 000 or so acute and general beds we now have for the 57 million people in England—the lowest per capita bed base in industrialised nations.20 No wonder hospitals are crammed daily, with front door waits and overcrowding.

We’ve also seen an ongoing failure to put sufficient capital into built NHS facilities or equipment such as IT or diagnostics. The UK’s spending has been far lower than in other developed nations21—with the predictable result of crumbling or unsafe hospital buildings and IT that isn’t fit for purpose, alongside sticking plaster announcements like the mythical “40 new hospitals.”22

Finally, we have the current workforce crisis. Allowing the real terms pay of doctors and other clinical groups to fall so far behind other sectors over the past 10-15 years has contributed to crises in morale and retention, as have changes to the GP contract that make general practice increasingly unsustainable, struggling to appoint or retain staff. Serial delays in producing the eventual long term NHS workforce plan,2324 and the complacent reliance on international recruitment, have not helped.25 Nor, initially, did the removal of nursing bursaries.26

Planning major increases in undergraduate medical school places without allocating the funds to subsidise more students from the UK, or expand postgraduate training pathways, has proved short sighted. So has the initial push to create more physician associates and other medically associated practitioner roles without considering scope creep and the impact on postgraduate medical training—as the very public disputes over this issue illustrate.2728 More diligent risk assessment and mitigation, with far better public communications and engagement with the professions, could have stopped or significantly modified many of these initiatives far sooner.

You could put it down to incompetence and short termism. But, if you like a conspiracy hiding in plain sight, it would be hard to avoid the conclusion that some of these decisions had been quite deliberately careless of the potential risks and harms a few years down the line, in the cause of more immediate goals and in the knowledge that they’d become someone else’s problem to solve.