Chris Thomas is a senior research fellow at the Institute for Public Policy Research.
Over the last forty years, there has been a remarkable consistency in health reforms under both Conservative and Labour governments. In different ways, each has reflected a common core triplet: drive quality through competition; maintain financial sustainability through efficiency; and ensure popularity by focusing policy and funding on the NHS.
More recently, Boris Johnson’s government has indicated a willingness to break from this path. February’s health white paper – Integration and Innovation – gestures towards three, potentially seismic changes. First, a shift from competition to collaboration; second, a shift from NHS-centrism to a more holistic vision of health; third, a shift from short-term efficiency to long-term innovation.
Each is a welcome aspiration. But, at the moment, the white paper only constitutes a statement of ambition. It will take far more than some proposed top-down legislation to reflect these ambitions in practice and to deliver lasting change. And indiscriminately throwing money at the NHS won’t help either.
The Government has recognised that business as usual won’t be good enough on health following the pandemic. Achieving pledges like “build back better” will rely on delivering a more collaborative, holistic and long-term approach to health. And that means putting forward a plan to fully substantiate the rhetoric.
From competition to collaboration
Strikingly, the Government’s proposals contain a fundamental ideological shift. Instead of a system fragmented into provider units and forced to compete with each other, it envisions larger integrated providers working together and collaborating to improve the nation’s overall health.
It is the right decision. Competition and the internal market fragmented the health system and made our Covid-19 response noticeably more challenging. But after years of fragmentation, it will take far more than a single, centralised decree to create lasting collaboration.
Bottom-up integration has flourished during the pandemic. When I ask professionals and local health leaders, they almost always put this down to the centre removing artificial barriers – be they financial, regulatory or bureaucratic. Out of Covid-19 necessity, health leaders have been given more freedom, and with that freedom they’ve moved to collaboration by default.
The challenge for the Government is to maintain that new way of working and to replicate the conditions for integrated, local “system working” after the pandemic.
System working means redefining the role of the centre – from commander to enabler. That necessitates a stronger focus on culture change and working with the regulators to align incentives to boost health service integration and population health. It would also mean cultivating a common sense of purpose and mission.
And creating more networks and forums for cross-sector collaboration. Some of these, like the cancer network, were disbanded during the last decade, but forums to meet and discuss are vital for increasing integrated working.
From NHS-centrism, to the primacy of place
A second key shift indicated by the white paper is the Government’s recognition of the “primacy of place”. Again, this is the correct course – recognising that the places we grow-up, live and work define our health throughout our lives.
It also challenges the widespread assumption that health is synonymous with only the NHS. Reflecting this fact in practice will depend on the cultivation of thriving local partnerships – between the NHS, social care, public health, community services and the voluntary sector. In turn, that means addressing just how bad things have got for many non-NHS health service providers.
The social care system is a case in point. While it struggled during the pandemic, the truth is it needed fundamental reform long before 2020. The political consensus is growing behind free personal social care, free at the point of need and funded through general taxation. The Government should act fast to enact this and end the decades of prevarication.
Similarly, public health is in need of a reboot. Despite covering preventative local services such as stop smoking initiatives, sexual health services and healthy living schemes designed to prevent underlying health conditions, the public health grant has been cut by almost £1 billion since 2014. Those cuts have fallen disproportionately on lower income parts of the country and on the North of England. We need a funded, functional public health system to make the primacy of place a reality.
Simply put, place-based health and care means extending political engagement, resource and reform far beyond the NHS and brick and mortar hospitals, ensuring every community has the local health services needed to lead healthy dignified lives.
From efficiency to innovation
The white paper’s reforms are designed, ultimately, to support innovation. By making all health leaders jointly responsible for the total health of the population, the Government hopes to uncork the power of health innovation. New treatments, medicines and best practice can significantly boost health outcomes and the economy.
Covid-19 demonstrated what’s possible when it comes to the spread of innovation. The shift to digital in general practice for instance has been an aspiration for years, but finally happened at pace during the pandemic. However, if the Government want its reforms to make fast innovation the norm, it will once again need more that legislative changes and top-down diktat.
Much more importantly, it will need to change the fact the NHS is currently run to the top of its capacity – all through the year. In healthcare, austerity suppressed supply, even as health demand rose. This has left the healthcare providers with little headspace, time and bandwidth.
More bluntly, healthcare professionals just do not have the time they need to adopt, adapt and champion innovation. Change will rely on a bold strategy for ending burn-out, driving recruitment and improving retention rates. Evidence indicates an effective, immediate strategy would combine a pay rise, more leave, a right to flexible working, stronger professional development and more extensive action on institutional racism in health.
Innovation is only possible in a system at the top of its game. That is the reason austerity represented short-termism. It is time to invest in health capacity and professionals, to boost productivity and deliver globally leading outcomes.
Meeting an uncertain future
When it comes to health, we face an uncertain future. Analysis by IPPR and the CF health analytics company shows that due to the pandemic we can expect an additional 4,500 extra deaths from cancer this year; 12,000 extra heart attacks and strokes in the next five years; and two million more mental health referrals. On top of that, there is a continuing risk of future health shocks. Pandemics are becoming more likely and resistance to anti-microbials is growing.
A vision for health and care based on a collaborative health system, healthier places and rapid adoption of innovation could help meet those challenges. If the Government gets it right, it could launch a new health consensus and define the agenda for decades. But that will only happen if it combines welcome aspiration with sustained, funded and evidenced health policy.