Robert Ede: Another brick in the wall? Investment in healthcare could be central to levelling up

21 May

Robert Ede is Head of Health and Social Care at Policy Exchange, and Prize Director for this year’s Wolfson Economics Prize.

Away from the fallout of the local election results, the chatter in Westminster over the past few weeks has related to levelling up. The appointment of Neil O’Brien as an adviser to the Prime Minister, and the commitment to publish a White Paper this year, demonstrates a desire to define and deliver on what has been an ambiguous slogan.

There continues to be a debate in Number 10 about what levelling up means in a healthcare context. But many of us on the outside see it as an opportunity to elevate arguments around healthcare inequalities in Whitehall policymaking.

Plenty of evidence backs this up. The ‘red wall’ areas contain some of the most deprived areas in England with the worst health outcomes. In the 48 seats which switched from Labour to the Conservatives in 2019, women have four fewer years of healthy life compared to their counterparts living in core Conservative areas.

Many of the factors which drive these disparities are preventable: 23 per cent of people smoke in Blackpool compared to just five per cent in Ribble Valley, while analysis from the Health Foundation has found those in the red wall tend to live closer to fast food outlets and have higher childhood obesity rates.

So when the White Paper is published later this year, how can NHS and social care spending be used to further the levelling up vision?

One obvious opportunity is healthcare infrastructure. The Government and NHS are already showing signs of ambition, with two separate, but interrelated building programmes.

First is the new hospital programme. A central manifesto pledge, the commitment to construct 40 new hospitals by 2030 has not been without critics, many of whom argue that another round of hospital building goes against the grain of modern healthcare trends.

But the case for investment is clear. Take Derriford Hospital in Plymouth – where residents have been campaigning for a new A&E for decades, or the decrepit Hillingdon in north London, which had to close its paediatrics department due to subsidence two years ago. In reality, 17 of the 40 schemes are rebuilds of existing sites; perhaps an attempt to atone for a “frugal” approach to NHS investment over successive years.

Regardless, there is a huge opportunity to ensure that these rebuilt and new hospitals deliver for patients who deserve the best possible care and for staff who deserve high quality workplaces.

This is a popular policy. Polling undertaken by Policy Exchange in 2020 found that new hospitals were the most highly ranked infrastructure commitment – far ahead of new houses. In battleground regions such as Yorkshire, the North East and the South West, more than half of respondents chose it as their top priority. By comparison, when asked about levelling up, the public’s response is far less clear.

But while popular, the hospital building programme is not guaranteed to be a success when it comes to levelling up. As other commentators have observed, the current list of schemes proposed is concentrated in Southern England. Levelling up should not solely be about the red wall of course (not if the Conservatives want to avoid repeats of Worthing) but opportunities – and cash – do need to be spread around.

There is also no guarantee that the programme succeeds on its own terms. Hospital building in the NHS has a chequered history. The last major programme under Labour from 1997 to 2010 delivered 51 schemes, but relied upon PFI money and saw significant delays, with the average hospital taking seven years to be designed, constructed and commissioned.

This Government clearly does not want to wait that long. In a bid to speed up delivery, the Department of Health and NHS England are proposing much more centralisation, with guidance to emphasise repeatable design and greater standardisation of plans across sites, hopefully accelerating delivery.

That might work, but there is a danger of prioritising speed over innovation. If taxpayers are going to invest billions, we need to build hospitals that will serve us for decades to come, not just hospitals that can go up fastest.

With this in mind, this year’s Wolfson Economics Prize, hosted in partnership with Policy Exchange, hopes to create a springboard for new ideas; offering a £250,000 prize for the best proposal to radically improve hospital planning and design. Perhaps hospitals should be built around green spaces – as is being trialled by NHS Scotland. Or they could have affordable housing for healthcare workers designed into a “village” campus.

But even if we can find the right design and can speed up delivery, few of the new hospitals will be welcoming patients by the next general election. There must be healthcare infrastructure improvements that can be delivered quicker.

This is where the second new policy comes in: Community Diagnostics Hubs. Following last Autumn’s review of NHS screening services led by Sir Mike Richards, NHS England plans to introduce new ‘one stop shops’ in the community. All too often, patients have appointments for routine scans cancelled as an emergency case takes precedence; separating urgent care from planned diagnostic activity should prevent that.

The sensible clinical rationale makes for good politics, too. Positioning diagnostic centres nearer to the public – for example, in vacant spaces in town centres – will make them immediately accessible and contribute to a sense of local renewal. As Rachel Wolf has outlined, the ‘High Street test’ will be one of many ways in which voters at the next election judge whether their areas have benefitted from a Conservative Government.

As part of a bigger piece of work to be launched in the coming weeks, Policy Exchange will argue that there is the potential to go further, taking advantage of the recent changes to the planning use classes to provide additional healthcare services on the high street. Rather than proposing the slightly technocratic sounding ‘Community Diagnostic Hubs’ why not create ‘town health centres’ which would deliver diagnostics but also a broader set of services?

Taken together, the new hospitals programme and new high street healthcare facilities could make for a compelling offer towards levelling up: improving the specialist and acute care in hospitals; speeding up diagnosis; providing local amenities and, in the longer term, tackling health inequalities.

There is a real opportunity, but we have been here before. In the late 2000s the Labour Government promoted the use of ‘polyclinics’ – expanded GP-led health centres. Ultimately the business case failed to demonstrate how polyclinics would improve patient outcomes, whilst the concept faced resistance from both hospitals and general practitioners, unwilling to see their role (and thereby budget) reduced. Together this led to the rollout being paused by the Coalition Government in 2010.

We now find ourselves at a more favourable point in the political cycle. The Government’s majority should mean that legislation to enable better integration of local healthcare bodies will pass into law. This may go some way to tackle the cultural tensions within the NHS that have prevented providers from working in patients’ interest.

Much has been written about levelling up already. Yet it is in bricks and mortar of our healthcare buildings where the clearest manifestations of slogan are likely to be found.

The Deal in Detail 7) Health

2 Jan

Robert Ede is a Senior Research Fellow in Health and Social Care at Policy Exchange.

In April 2016, the UK Government sent every household in the UK a leaflet entitled: Why the Government believes that voting to remain in the European Union is the best decision for the UK. Ahead of writing this blog I dug out this controversial pamphlet to compare the health elements to the Brexit deal agreed on Christmas eve.

What were the biggest perceived threats then, and how does this compare against the situation we find ourselves in, four years on? Were the supposed doomsters and gloomsters proved right in the end?

Unfortunately, my search did not yield much: the document makes only a couple of short references to health. It highlights the benefits of reciprocal healthcare sharing arrangements across members states, whilst referring to the 136,000 people employed in the pharmaceutical and chemicals industry, and the strength of exports to the EU from the life sciences sector.

In these areas, the deal agreed between the Prime Minister and Ursula von der Leyen stacks up. Those travelling to the EU and vice versa will still benefit from reciprocal necessary treatment, with the European Health Insurance Card (which 27 million Brits hold) to remain valid until expiry when it will be replaced by the new Global Health Insurance Card. This is a win for the consumer, who can feel reassured that they will be looked after if they fall ill whilst on the Continent.

On top of this, the deal appears to allow for UK citizens to seek treatment in the EU if the NHS cannot deliver the procedure or treatment within a ‘medically justifiable’ timeframe. It also extends to covering the costs of planned treatment – for example the 30,000 people who are on dialysis in the UK can now plan holidays to Europe knowing that they can arrange for the NHS to pay for their dialysis sessions in advance, without any upfront costs.

And whilst there has been important attention paid to the possible disruption which may be caused by new customs and border arrangements, there will be no quotas on the import and export of the 45 million packs of medicines which move from the UK to the EU, and the 37 million which go back the other way. The interdependency of medicine supplies has been underlined in the context of the current vaccine rollout – with the first batches of the Oxford/AstraZeneca vaccine to come from the Netherlands and Germany before the UK manufacturing centres come on stream later this year.

The UK has also agreed to pay an association fee to take part in the Horizon Europe research programme, enabling British researchers to bid for funding from an overall €85bn pot up to 2027, on more or less the same basis as their EU counterparts. Many working in the British science sector were pessimistic about this being achievable, but in reality there was a helpful precedent with a number of non-EU countries such as Israel and Switzerland being associate members of the predecessor programme.

This continuation will bring benefits for the EU too, who will be able to continue to fund world-leading scientific discovery. UK research already accounts for 12 per cent of all life sciences academic citations (second only to the USA) and has been central to the global scientific response to Covid-19. Two of the most critical breakthroughs, namely the discovery of Dexamethasone as a cheap and effective treatment and the development of a flexible vaccine candidate, both originated in the UK.

Beyond this, the deal gives the flexibility to diverge from current EU regulations. One obvious example is medicines licencing and approval, where the British regulator will be able to take a different path to the decisions made by the European Medicines Agency when a two-year extension period concludes in January 2023. There has already been some evidence that the MHRA will use this to take advantage of emerging trends in healthcare – such as the use of biosimilars, meaning that patients can access these treatments sooner.

So, this agreement will provide certainty and mitigate some of the most immediate risks that a no-deal Brexit could have posed. But things get a little murkier when it comes to assessing other longer-term impacts.

One point up for debate is whether Brexit will lead to the UK taking a less stringent approach to public health interventions – for example to tackle air pollution or to target the pricing and advertisement of tobacco and alcohol. The deal makes little consideration for these areas, and it is fair to question whether air quality measures will be introduced with the same vigour in a post-Brexit Britain, given that much of the original legislation was driven by Brussels.

But on subjects such as tobacco and alcohol regulation, the EU has often spoken with intent but failed to translate this into meaningful policies. The UK’s introduction of plain packaging for cigarettes required authorisation from the EU but was done unilaterally, whilst attempts to coordinate activity on alcohol related harm across Member States has been mired by disagreement and the pervasive influence of lobby groups. It would be naïve to assume these issues will get an easier ride in Westminster than Brussels, but it is similarly blinkered to believe that EU membership automatically enhanced our capability to tackle non-communicable diseases back home.

And for all the strengths of the deal, it does not help the NHS address its number one issue: the lack of staff.

It has been clear for several years that free movement of labour would end, but the consequences of this change feel especially sobering as the NHS tries to plug so many vacancies. There are 67,000 EU nationals already working in the NHS, representing around 5.5 per cent of the workforce. Without them, the health service would be even more stuffed (to use the technical term) than it is now in responding to the current crisis. Boris Johnson chose to highlight that he was cared for in St Thomas’ by Luis Pitarma, a critical care nurse originally from Aviero in Western Portugal.

Doctors and nurses will qualify under the new points-based system, however they will encounter fees and additional bureaucracy in doing so. Will this deter other Portuguese nurses from coming to work in the NHS?

Evidence since the referendum shows that the overall proportion of EU NHS Staff has remained relatively static, whilst there are hopes that the new rules will be accompanied by redoubled efforts to train staff domestically. There are already 14,000 more nurses working in the NHS than a year ago, but the Government could go further – for example by removing the need for NHS Trusts to ‘back-fill’ the costs of hiring staff to cover for those taking nurse degree apprenticeships when at college.

Back in 2016, the NHS played a central role in both the Vote Leave and the Stronger In campaigns. With the separation now delivered, the relationship between the UK and its European counterparts on health is different and less close, but perhaps more similar and more familiar than the ‘doomsters and gloomsters’ predicted.