As the Secretary of State said in his speech at our London building last week, the challenges facing the NHS today are significantly different from those in 1948.
Our rapidly ageing population and ever more apparent climate change were things we knew were coming, yet, far from preparing, the government made decisions that have rendered us less able to respond to them. In recent years we have cut funding to initiatives and services that prevent people becoming ill – the government cut the public health grant by a quarter, or £1 billion, between 2015/16 and 2021/22 - and failed to plan the NHS workforce based on likely demand for care. It’s unsurprising then that we have seen rises in obesity that are higher than anywhere in Europe, stalled rates of smoking after decades of improvement, increases in sexually transmitted infections and a persistently high rate of death due to alcohol.
The Secretary of State said that small states are pre-emptive ones. By this he meant that governments that act before something becomes a problem have to do (and spend) less in the long run. For example, if you take action to stop aggressive marketing of unhealthy food now, you won’t have to foot the bill for ill health as a result of obesity later.
But he recognised that the government has tried to reduce the size of the state simply by reducing the amount of money it spends, rather than taking pre-emptive action that will lead to a smaller state. This means there is less for prevention and less to manage the ill health that we didn’t pre-empt. As well as seeing the best of Britain, on his tour around the country Mr Javid will have seen the great disparities in health that exist as a result.
The Secretary of State identified ‘how to deal with an unsustainable financial trajectory while backing the brilliant people who work in health and care’ as one of the long-term challenges facing the NHS. The RCP will always make the case that investing in the health service is a price worth paying, but the acknowledgement that there will be no additional funding at least brings clarity on the resources we have for the road ahead.
So, we were glad to hear that there will now be more focus on prevention, which will ultimately save money. As an example, overweight and obesity related conditions alone currently cost the NHS around £6bn a year. Reversing the disinvestment in prevention and public health will over time reduce avoidable pressure on the health service and bring down the cost of medical interventions. Although Mr Javid said nothing about money and this week’s decision not to keep free flu jabs for young people of secondary school age, against the advice of the Joint Committee on Vaccination and Immunisation, doesn’t exactly herald a preventative focus.
We also agree that an organisation the size and importance of the NHS should always be evolving and responding to immediate challenges. And while moving patients around the country is far from ideal, we should do it if it will help people receive the care they need quicker and help us reduce waiting lists. While it won’t be right for everyone, we know many patients and doctors will be comfortable with patient initiated follow-up (PIFU) as routine appointments are too often unnecessary. The increased use of electronic records will help us deliver better and faster care. Community diagnostic centres make sense. And an improved NHS App could help more people manage their own health, if only to know how long they have to wait for care.
The change of the kind the Secretary of State is advocating requires planning, particularly when it comes to the size and nature of the NHS and social care workforce. Yet last Tuesday’s speech confirmed that while plans to tackle NHS shortages will be published by the end of the year, they will be funded from the £36bn already pledged over the next 3 years. The £12bn that will be raised each year from the rise in National Insurance (NI) from 6 April 2022 is significant, but without extensive ongoing investment we simply can’t attract and keep hold of the people we need, and without them we don’t have the time to make the improvements we want.
We have known this for some time, yet not acting on it meant we were ill prepared to deal with the pandemic. We were able to create the Nightingale hospitals virtually over night, but we weren’t able to find enough doctors, nurses and others to make use of them. We have just about enough capacity to provide routine care or deal with a national emergency, but not both. The Secretary of State confirmed that backing health and care staff is one of his priorities, but we’ll need to wait for detail on how he will do that.
So what should happen next? If there is no new money for workforce investment, the money that has already been pledged must be spent as effectively as possible. The only way to do that is to know what we’re facing and plan accordingly. That is why we hope the government doesn’t try to reverse the amendment made to the health and care bill by the House of Lords two weeks ago which will set out independent assessments of how many staff we need now and in future based on projected demand. Without knowing the likely health and care needs of the country, how can we plan to meet them? As Chris Hopson, chief executive of NHS Providers, said to the Health and Social Care Committee earlier this month:
‘The Treasury is forever saying to us, “You have a responsibility, the NHS, to maximise taxpayer value for money.” The answer is that at the moment we are spending billions of pounds that we do not need to spend on agency and locum staff instead of the full-time staff we desperately need. We have reached a pretty absurd and extraordinary position where the NHS is saying, “We need this long-term workforce plan to maximise taxpayer value for money, but the Treasury is stopping us and preventing us from doing so.” That cannot make sense.’
Ultimately, we need a wholesale change of approach to ensuring the good health of the country. Following the Secretary of State’s speech, we need a clear statement that the prevention of ill health is going to be put at the heart of government.
The forthcoming disparities white paper is the opportunity to announce intentions to increase funding for prevention and make sure it is spent as effectively as possible. It should also lay out how information about inequality in access and outcomes collected by integrated care systems (ICS) will be used to improve prevention, particularly with respect to the Core20PLUS5 approach to reducing health inequalities.
But the NHS and the Department for Health and Social Care can only do so much. ICSs and the Office for Health Improvement and Disparities can’t stop poor quality, cheap food being sold. They can’t stop the air being polluted by industry, vehicles and unnecessary wood burning fires in affluent homes. They can’t stop tobacco being widely available.
Along with ICSs, prevention of ill health should be central to the way we judge the performance of government as a whole. Otherwise ICSs are going to be forever focused on trying to counter the forces that cause ill health.
If we want to shift power to people as the Secretary of State said, we need to recognise that people do not control their environment. They don’t control what food is sold at what price. They don’t control the levels of pollution that are put into the air by industry. They don’t control what vehicles are sold and how polluting they are. They don’t control the availability of tobacco.
As I said at the end of last year, if we really want to level up the extent to which we all share in the country’s economic success, if we want to build back better – and fairer – we need to be honest about what causes economic growth. It is people, and we must put people first. Healthier communities flourish, and flourishing communities are healthier.
If the prime minister wants the UK to flourish, and I believe he does, then he needs to free people from poor health.