The General Election is approaching with polls consistently showing the state of the NHS as the most salient issue for voters. The recent British Social Attitude survey reveals an unprecedented decline of public confidence in our most loved national institution. It is hardly surprising we are seeing a steady stream of health-related policy proposals.
There are common themes among many of these proposals, like better integration and moving investment ‘upstream' into prevention, primary and community care. But occasionally something more controversial grabs the headlines. So it was for a recent pamphlet from think-tank Reform. It argued for the abolition of NHS England and the transfer of much of the running of the health service to local government.
Significantly, the production of the paper was overseen, though not endorsed, by a panel whose membership included former ministers Lord Norman Warner and Sir Norman Lamb (also a current NHS Trust chair) and Professor Paul Corrigan, once a ministerial special adviser and now known to be informally advising the person most likely to be the next secretary of state, Wes Streeting.
The document is an important contribution to the debate about the future of the NHS. It correctly describes the English health service as the most centralised in the developed world. It argues convincingly, as did Patricia Hewitt in her review last year, that the structures of control have made it difficult so far for Integrated Care Systems to live up to their mandate. It shows how the separation of national systems of funding and accountability between the health service and local government have made service integration and the task of redirecting investment into prevention, primary and community care more difficult.
But is Reform's prescription right?
First, in saying the NHS' biggest structural problem is centralisation, Reform describes only half the problem. The other is the failure of government to have a joined-up strategy for the nation's health.
As chief medical officer Sir Chris Whitty argues, in the face of population ageing and rising morbidity, the current model of health care is simply unsustainable. We need to redirect focus and investment from a model of health that prioritises caring for very sick people to one that helps people stay healthier longer. But the latter requires action beyond the NHS, in areas ranging from the regulation of food to tackling poor housing and insecure work.
If a future health secretary spent more time co-ordinating a national health strategy and less telling NHS England how to micro-manage the health service, then not only might we help make the NHS' job more manageable, but we could give NHS England a chance to be the more strategic, consistent and empowering body its leaders want it to be.
Second, the recommendations of the Reform paper would require a major structural reorganisation of the health service.
As we know from both the 2012 and 2022 Health and Care Acts, parliamentary bills on health and care inevitably turn into compendiums of proposals impacting most aspects of the service. Such a weapon of mass distraction is the last thing the NHS needs now. Reform's preferred option would also require huge changes in the structure of local government.
Third, many of the changes Reform wants to see can be achieved through incremental change:
- Fewer national targets and a set of objectives that focus more on population outcomes and less on acute sector activity
- Long-term funding models that incentivise a shift upstream, enabling more combined authorities to increase collaboration and joint funding between local government and the NHS. All of this is possible within existing legislation.
An important forthcoming report on health and devolution from the NHS Confederation and the Local Government Association will show how we could make important progress now without waiting years for new legislation.
The NHS suffers from several assumptions popular among national policy-makers. One is that central micro-management works. But another is that meaningful change requires pulling everything up by the roots. Neither is correct. The tools are there for better joining up nationally and locally. We need a government that wants to use them.
Matthew Taylor is a public policy expert, former adviser to Tony Blair while Prime Minister and currently chief executive of the NHS Confederation
X – @ConfedMatthew
