The Guardian’s take on Labour’s NHS reform: structural change and reducing waiting lists is a big ask | Editorial
TThe British government’s ten-year health plan is still several months away. This also applies to the multi-year expenditure evaluation that will determine the parameters surrounding the financing. But the three themes around which Labor wants to build its NHS reforms have been identified. Each requires a shift in emphasis: from treatment to prevention, from hospital to community and from analogue to digital.
Because health policy is devolved, these plans only apply directly in England. However, their impact will be across Britain as the largest healthcare system will undoubtedly influence the others, and what happens to the NHS is so crucial to the UK government. In 2025 – Labour’s first full calendar year since 2009 – there is unlikely to be an area where the party needs results more urgently.
What would a good year look like? The NHS app has 34 million users to date, and people booking appointments, ordering prescriptions and checking results online should free up staff to do other things – adding to the 2% productivity improvement that was promised with £22.6 billion of new funding in the October budget. Ministers and health bosses must ensure the app does not contribute to digital exclusion. If analogue access to services is not maintained, the health inequalities they have pledged to address will worsen. But an app-enabled efficiency improvement seems feasible – and has the advantage over some other ideas that it can be summarized in one sentence.
Reinstating the 18-week in-hospital treatment goal was a compromise between proponents of top-down goals and those who prioritized primary care. The commitment that 92% of patients will have to wait no longer than 18 weeks by the end of this parliament will test a system under pressure from labor shortages and industrial action. In England the waiting list has already been reached 7.5m suitcases (represents 6.3 million patients), with even more waiting in Northern Ireland, Scotland and Wales.
Funding for a ‘broken’ system
Politically, it is not difficult to understand why ministers felt the need to offer voters something concrete. But when asked whether it is possible to shorten waiting lists while simultaneously redesigning the country’s healthcare system toward preventive public health, many experts think the answer is no.
Healthcare has done relatively well in terms of funding since Labor took over and is expected to be among the winners in the spending review. But due to self-imposed budget constraints and the weak economy, spending on the NHS appears unlikely to rise as quickly as the last time Labor was in power. increased by an average of 5.5%. This makes the kind of improvement that can be achieved through rapid investment – for example in staff overtime – impossible. But public awareness of the depth of the crisis could buy ministers some time, as Wes Streeting, the Health Secretary, appears to have calculated when he declared the system ‘broken’.
Despite problems on the frontline and the well-recognized demographic challenge of an aging population with high rates of chronic disease, there is at least broad consensus on the structure. Integrated care is the name given to the plan for 42 regional NHS bodies (which spend around two-thirds of the NHS’s expenditure in England). Annual budget of £168 billion) to work with municipalities and the voluntary sector to make local people healthier.
It sounds simple. But two years later, and as Lord Darzi noted in his judgement for ministers, there is already variation in how integrated care boards (ICBs) and partnerships interpret their responsibilities, including “how and at what level they should address public health”. For example, what is their role in tackling social determinants of health, such as poor housing?
If overreaching is one risk – with ICBs set up to fail as mini-welfare states meant to solve everything – the bigger risk is that ministers will not loosen the reins at all. It’s not hard to understand why a return to centralized performance management feels like political sentiment to ministers who fear the voters’ judgment. Politicians know how much people value hospitals. But the announcement of the target of 18 week plus league tables, with rewards for successful hospitals and special measures for failing ones, goes against the grain of strengthening local authorities. Regional health bosses panicking over the data points that will determine the fate of local hospitals will not be able to focus on building the services the government says it wants to prevent people from getting sick in the first place.
Questions about the new model
Whether this power grab by the center continues may be influenced by that of the government listening exercise Unpleasant reshaping the NHS. There is a good chance that the mental health sector will benefit from the growing public concern. But integrated care is unlikely to become a subject of public consultation, not least because the concept remains so vague. One question the 10-year plan will have to answer is where and by whom the new model of community health care should be delivered: are GPs the key workers, or health visitors and community nurses? What about schools? How will strong leadership and an open culture be supported? What principles and rules will govern private sector involvement? The rapid advance of private equity-backed companies into social care is something that everyone involved should be wary of.
A recent report by Patricia Hewitt, one of Tony Blair’s health ministers, concluded that local authorities should stick to no more than ten national targets, while the share of health spending on prevention should increase by 1% every year. Much now depends on whether Mr Streeting prefers the advice of Alan Milburn, another former Blair health secretary, now with an office in Whitehall, to that of Ms Hewitt, who chairs an ICB.
There is no doubt that decentralization and autonomy take courage. One risk when local organizations pursue their own priorities is that demands for equity and consistency may trump support for innovation. One person’s localism is another’s postcode lottery. Joint commissioning by the NHS and municipalities brings with it technical complications that need to be resolved on site.
The danger is that allowing this freedom, along with the rest of the integration agenda, is too much at odds with the centralizing instincts of the British state. But Mr Streeting should not allow this prejudice, or nostalgia for the New Labor years, to color his judgement. If the healthcare system is as broken as it is claimed, the government needs to find solutions to fix it.