The National Health Service is close to breaking point. It is in the worst state I have ever seen. Millions of patients languish on waiting lists and staff shortages are endemic. Hope is in even shorter supply.
On top of the hospital waiting list challenge, the NHS is being battered by the competing demands of the ongoing pandemic, the unknowns around Long Covid, a surge in mental health referrals, the fragility of the social care system, and the need to address the deep health inequalities that Covid has so cruelly exposed. Inevitably, questions about whether the NHS can survive in its present form are surfacing. Stage right, the whispers grow louder that the current funding model – paid for through general taxation – has to give way to more people paying more privately.
The NHS’s problem is not how it is funded. It is how it is organised. Nations across the world with very different methods of funding their healthcare all face a similar challenge: how to reorientate their care systems away from episodic care in hospitals to one based on improving health. The ever-growing tsunami of chronic disease like diabetes, arthritis and dementia means that over 70 per cent of NHS costs go on dealing with these types of conditions, and as society ages the figure will balloon still further.
But the NHS is not properly set up to deal with these problems. Hospitals absorb most NHS cash when what is needed is a system geared to help keep patients healthy and out of hospital. One in four patients don’t need to be in hospital in the first place providing their condition can be diagnosed and treated soon enough. One in five emergency hospital admissions are potentially preventable. So what is needed to make that happen?
Firstly, the NHS should harness the technology revolution now taking place worldwide in healthcare. Machine learning and artificial intelligence have already reduced unnecessary surgery by one-third in some hospitals. The lessons learned during the pandemic from remotely monitoring Covid patients through virtual wards – with hospitals being able to double capacity and reduce readmission rates by one-third – should be made universal.
But this is just the tip of the technology iceberg. The alignment taking place between data analytics and genomic science opens the possibility of a new type of care system – one that is less about diagnosing and then treating illness and more about being able to predict and prevent ill health. It won’t just happen: it requires leadership and a 10 year plan for change – to how staff are trained, how infrastructure is procured and how services are provided.
Second, patients should be given far more choice and greater control. Every NHS patient on a waiting list should be able to choose faster treatment – paid for by the NHS – at those hospitals, public or private, with the shortest wait times. More patients should be given their own personal health budgets to let them choose the treatment that is right for them. What patients do to manage their own condition – their lifestyle, diet and exercise – can positively impact both their health and NHS costs. So using the NHS App to let people manage their own waiting list journey should be the start of a bigger drive, using technology, to shift the NHS focus towards earlier preventative action and the empowerment of patients.
Third, empowerment should be extended to those providing care. There is no shortage of ingenuity or innovation in the NHS. But today local clinicians and managers are battling an edifice of top-down bureaucracy and a spaghetti soup of new organisational structures. Of course the system should have to meet national standards and targets, but improvement only happens when those in the frontline of care can create solutions that are right for the communities they serve.
I formed NHS Foundation Trusts for that reason, but new legislation gives the Secretary of State powers over their finances, the shape of local services and even appointments to boards. Seeking to run the NHS from an office in Whitehall is a fool’s errand. It will not work. Instead the best NHS Foundation Trusts should be given extra freedoms to run local community and primary care services, and the way money moves around the system should be reformed to give more to the hospitals and systems that achieve the most.
Without fundamental change, the NHS will become unsustainable. It is easy to forget that, even before the pandemic, waiting times had been growing for a decade. So doing more of the same will not turn the situation around. New approaches are needed.
More investment on its own will not do the trick either. I speak from experience. It was only when far-reaching reforms were introduced – to give patients more choice, make the system more transparent, tie payments to hospitals more to performance, and create more competition – that waiting lists and times began to fall in the early 2000s. In other words, reform was the key that unlocked a better NHS. What was true then remains so now.
Alan Milburn was a Labour MP from 1992 to 2010, and Health Secretary from 1999 to 2003. He is a senior advisor to PwC
