My prescription for a healthier NHS
Published by The i paper (8th February, 2021)
Matt Hancock overseen a string of fatal failures and one big success since the arrival of Covid-19. Now this ambitious politician, enjoying rare plaudits for his vaccine triumph, seems to think he is just the chap to take more control over the National Health Service. He complains that when he pulls the machine’s levers, little seems to change. This is perhaps unsurprising: he oversees a vast, complex organisation spending £130bn a year in England with 1.2 million highly-trained staff. Yet the health and social care secretary, an economist by training, is using the cover of the pandemic to mount a massive power grab.
A leak of Hancock’s proposals exposed his scheme to take “enhanced powers of direction for the Government.” This led to a hasty spin operation in the weekend media, claiming the biggest health crisis for a century showed desperate need for drastic reform. This spin is nonsense. Hancock has talked about such reforms from the moment he entered office, with some ideas floated in the last Tory manifesto, while his co-conspirator Sir Simon Stevens, the head of NHS England, has been clawing back Whitehall’s control over the system for several years.
Any major shake-up raises valid issues over another bout of bureaucratic shuffling in an organisation battered by pandemic, filled with staff left shattered on the frontline. The timing is really driven by politics: the Government’s desire to get reforms through quickly, so any fuss dies down before the next election. The Tories remain haunted by their bungled last attempt to grapple with this beast nine years ago. David Cameron later confessed his changes were badly handled, drained political capital and missed key issues of crumbling social care in an ageing society. Hancock aims to unravel the impact of botched reforms that devolved power and fragmented local services.
Politicians will always be held ultimately responsible for the NHS. As its founder Nye Bevan famously said: “If a bedpan is dropped in a hospital corridor in Tredegar, the reverberations should echo around Whitehall.” Hancock’s move is merely the latest in the long struggle between politicians and bureaucrats at the centre, and an army of staff delivering diverse local services, over how to deliver efficient and effective care with limited resources. Every rich nation is confronting similar dilemmas as demand soars.
Now the British pendulum is swinging back to more centralised command, a reflection of the 1974 reorganisation, after decades trying to drive improvement through different tactics. The Cameron reforms, after all, simply extended an edifice built by both Margaret Thatcher and Tony Blair. Hancock seeks to rally public support with a populist pledge to roll back privatisation. Yet the problem is not the profit motive in healthcare, as proved in parts of the NHS and European systems with better patient outcomes. It lies in bad commissioning, poor operators, disempowered patients and inadequate politicians. Hinchingbrooke Hospital in Huntingdon, briefly handed to a private firm, is routinely held up as an example of failure, yet it offered valuable lessons in innovation, procurement and staff empowerment.
Yes, there has been an explosion of terrible private provision in psychiatric services, with fat-cat firms fleecing the state and delivering atrocious care – but ministers have not used their existing powers to thwart them. The pandemic has also seen big contracts doled out to cronies with a scandalous lack of accountability. These are political, not structural, failures. Hancock’s desire to speed up the drive towards greater cohesion among local care and health services is correct. Yet there are grounds for caution. Social care needs to retain its own, localised character, not simply be subsumed by the NHS. There is also a danger in politicians having too much control, since they will play their self-serving tribal games.
Likewise, there was good reason to break the stifling and unaccountable grip of Whitehall by diverting more power to providers on the ground. If the Government really wants to build back better after the pandemic, I would suggest there are three more important reforms.
First, the urgent need for deep social care reform, not mere tinkering to stop middle-class citizens selling homes to fund their support. We have a corroded system, one that breaks rather than helps families. This was exposed again by the pandemic, along with the shameful and deadly lack of concern from politicians for a second-class public service. We need profound change that delivers decent services, drives out fat cats, ensures proper pay for staff and hands control to the users of services. This would relieve considerable pressure on the NHS. Instead, we have had Boris Johnson lying about his mythical plan for reform.
Next, we need to rectify persistent staff shortages in the NHS. This is always low down the list of a politician’s priorities since the impact of reform occurs long after they have left office when it takes seven years to train a doctor. One smart idea is for an independent agency like the Office for Budget Responsibility to provide analysis and forecast for future needs. The issues are not always simply down to funding: billions are blown each year on costly agency staff. Many doctors also collect a fat pension in their fifties, then sign on as locums to pocket more hefty chunks of cash, so be wary of vested interests even if they carry a stethoscope.
Finally comes the issue that should be at the heart of any health service but often gets overlooked: the need to focus on quality and safety, not just quantity and statistics. The NHS performs poorly on too many health metrics and outcomes, with worse life expectancy than some competitor nations, lagging survival rates for several key diseases and lower “amenable mortality” figures (when people die from potentially preventable conditions).
If Hancock really wants to take control, then he should stop the spin and start offering solutions to the damaging failures of social care, staffing, patient safety and psychiatric services.