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Wednesday 20 September 2023

A long game with hard choices

By Sir Chris Ham

The NHS will be a key battleground at next year’s general election. As the party conference season gets underway, Sir Chris Ham sets out the challenges facing the UK’s political parties as they draw up their NHS policies, and argues that the multiple crises facing the NHS can be overcome with honesty, realism and political will.

Sir Chris Ham pictured in Summer 2023

As the party conference season opens, the challenges facing the NHS continue to attract political attention. On almost all indicators, NHS performance is either at or near an all-time low, as a result of the failure of the coalition and Conservative governments since 2010 to provide sufficient funding to meet rising demand for care. The Covid-19 pandemic added to the pressures built up during the previous decade of austerity, and industrial action has hampered efforts to deal with care backlogs accentuated by the pandemic. Failure to fund social care adequately and agree how it should be reformed have added to the challenges confronting the NHS.

Research by The King’s Fund and the Nuffield Trust shows that that public satisfaction with the NHS has fallen to its lowest level since the British Social Attitudes survey began in 1983. Despite this, support for its founding principles remains as strong as ever. As the Health Foundation found, most people still believe that the NHS should be be free at the point of delivery (90%), provide a comprehensive service (89%) and be funded through taxation (84%). They also feel that the NHS needs more funding.

Decline is not inevitable

The improvements in the NHS during the decade to 2010 demonstrate that decline is not inevitable. Multi-year funding increases and a series of reforms resulted in much shorter waiting times, increases in staffing, investment in buildings and equipment, and measurable improvements in areas of clinical priority such as cancer and cardiac care. Through a combination of investment and reform, the then Labour government set the UK on a path to match the care standards of the best-performing EU countries.

In a joint letter to the party leaders in England in June, the chief executives of The King’s Fund, the Nuffield Trust and the Health Foundation argued that long-term policies are needed now to support innovation, boost productivity and provide the resources, capacity and technology the NHS requires. They also called for a cross-party commitment to deliver the NHS Workforce Plan, reform social care, and agree action to improve the health of the population. “Promising unachievable, unrealistically fast improvements without a long-term plan to address the underlying causes of the current crisis is a strategy doomed to failure,” the think tank leaders warned.

Investment lagging behind

The adversarial nature of British politics makes political consensus unlikely, but the need for a long-term plan is self-evident. International comparisons show that the UK has below-average health spending, lags behind on capital investment, and has fewer resources including CT and MRI scanners and hospital beds. The UK also has fewer doctors and nurses and is heavily reliant on foreign-trained staff. This lack of capacity was exposed during the Covid-19 pandemic and must be addressed in coming years if we’re to respond effectively to future threats.

There is a strong case for targeting extra investment at primary care and community services to promote independence and offer alternatives to hospitals. We also need a sustained commitment to prevention and early intervention, both in the NHS and other public services. This includes restoring public health funding to local authorities and agreeing a cross-government plan to tackle the wider determinants of health and tackle health inequalities. The effects will not be felt immediately but it will lay the foundations for improving population health over the long-term.

Equally important is social care reform, which remains stuck in the ‘too difficult’ box after a succession of failed initiatives. The most urgent priorities are addressing gaps in the social care workforce and additional public funding to better meet the growing needs of the population. Politicians must work towards a sustainable funding model which aligns social care and healthcare entitlements, and which enables social care services to support people’s independence and aid their recovery in partnership with the NHS.

Hard choices

None of this will be possible unless the next government is willing to make hard choices on tax and spending. The improvements in the NHS during the 2000s were possible in part because the then Labour government increased national insurance contributions to support extra spending. The Conservative government recently came close to doing the same with its proposed health and social care levy, but changed its mind late in the day during a period of instability and division within the governing party.

The current state of the public finances will be a major constraint on whoever forms the next government. With taxes set to account for a growing share of national income, the cost of servicing government debt rising, and increasing pressure for higher public spending, it would be a brave politician who promised rapid improvement in any public service. This is why opposition politicians like Keir Starmer and Wes Streeting are being cautious with their commitments on the NHS.

In his recent book on Britain’s finances, Follow the Money, Paul Johnson, director of the Institute for Fiscal Studies (IFS), argues that politicians often avoid hard choices because they are scared of voters. This is one reason why tax reform has been neglected for so long even though, the IFS argues, it could offer fairer and more efficient ways funding public spending. If politicians are unable or unwilling to confront hard choices, they must be honest with the public about the consequences.

Honesty and realism

For the NHS, honesty means revisiting commitments on waiting times for care, and the scope of services covered. Some political parties may consider encouraging greater use of the private sector to support the NHS in delivering its commitments and to take pressure off hard-pressed public services. This is happening already, as more people pay for private health care to avoid long waits for NHS diagnosis and treatment – but private choices rather than overt political decisions are causing this shift.

An obvious way of stemming the flow of care to the private sector would be to redouble efforts to improve NHS productivity. This includes extracting greater value from existing budgets by tackling unwarranted variations in clinical services, reducing services which offer little benefit to patients – for example, treatment at the end of life – and delivering efficiencies in procurement and use of temporary staff. Cutting waste in the use of medicines is another priority.

If the next government can be confident that public support for the NHS remains high, it should be under no illusions about the scale of the challenge it faces. Much depends on supporting staff to perform to the best of their abilities, filling gaps in staffing through renewed attention to retention, recruitment and the expansion of training, and showing that staff are valued and have the support they need to improve and innovate. Clinicians and managers have a vital role in making change happen by building on the NHS’s response to the Covid-19 pandemic.

The public should be sceptical of politicians who promise to make the breakthrough by adopting radical new ideas. Progress is more likely to result from the accumulation of many small improvements in care that, over time, will make a tangible difference to staff and patients. Often these improvements focus on better co-ordination of care and the widespread adoption of established best practices. Now is the time to support the NHS to reform ‘from within’ instead of relying on targets and performance management from above.

  • Professor Sir Chris Ham is co-chair of the NHS Assembly, emeritus professor of health policy and management at the University of Birmingham, and a former chief executive of The King’s Fund. His report The Rise and Decline of the NHS in England 2000-2020, published in April 2023, is available from the King's Fund website.

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