The standout observation for me as the NHS reaches 70 is just how much but how little has changed over that time.
Everyone agrees it remains a uniquely popular cherished “National Treasure” in the best sense. It is today more politically and publicly unassailable than ever before. The institution remains an expression of the best British social political and civic values. So far so good, but as ever with birthdays it is a time for reflection (and planning the next 70 years); what comes next? Let’s look at it through a few lenses as patients, as taxpayers and as “owners” of the NHS organisation.
What comes next?
The changed demography of the UK population means the patient mix today is almost unrecognisable from 1948, and that divergence is only set to increase. People will soon be routinely living into their 90’s. The challenge is not just the affordability of those extra years, but the pattern of care needed to deliver that extended care. That care has to include social care as all health leaders have been furiously signalling during the last few weeks. Without a functioning integrated health and social care system, the health bit of the system, the “in” hospital not the “out” will not survive; winter pressures are already becoming all year pressures. More subtly there has to be much better (not necessarily expensive) public health to keep the whole population fitter, healthier and happier.
Smoking has been replaced by Obesity as the biggest whole population challenge, and that will require all the skills of nudge theorists and PR engagement to manage. So while patients will and must remain at the centre of care, where that care is delivered, and what the focus of that care is, has to change.
What about the taxpayer view?
Well the voracious appetite of the NHS to absorb all sums thrown at it (and like Oliver keep on coming back and asking for more) remains one of its few unchanging themes. Apart from insatiable patient demands, new technology, new individually tailored drugs new models of care, and the incentivisation of a brilliant but sizeable workforce will all continue to push the 3 to 4 % funding growth needs of health, for as far as my eyes can see into the future. Politically the pressure on politicians to find more money for health has been irresistible, it has always been at the head of the queue for any extra funds going.
Can it stay there? We have seen the past masters of defence spending lobbying, rattling their sabres again over recent days, but they stand alongside education, welfare, police and the environment – all in a post Brexit world vying for a share of the wealth our own national pot can deliver. Will other funding routes be needed e.g. co-pay, hypothecated taxes, means testing? None of them are popular but when you look at the increases in health spending, when all other branches of public spending have suffered real terms cuts, you have to ask, how long can it continue?
Finally can the NHS find a new sustainable organisational form?
The Lansley convulsions may have been the last and greatest new form change over the last decade (in scale if not achievement), but the truth is the NHS has always been, and probably always will keep changing. We are already seeing STPs morphing into ICS and ICP models; Vanguards sinking or swimming, integration and collaboration replacing competition, no wonder the public is confused. Will anything stick from the Lansley era? Well to me, having an independent voice for health outside the DH(SC) has been a good thing. That DHSC/NHSE relationship is still settling down, but a bit of healthy tension about the future of this critical national public service is, I would argue, long overdue. Whether the eventual amalgamation of separate regulators will ever deliver the slim, streamlined, co-ordinated (cheaper) safe stable, sustainable etc framework for management of the NHS is pretty unlikely.
Outside national structures, the future of local and regional provider and commissioner organisations is at a greater scale than at present, with more integrated providers, larger scale commissioners and more local co-ordination involving social care at least. The more radical question is whether moving the current deckchairs of Acute, Mental Health, Community Primary, Ambulance Social and Public Health around, can ever deliver the new service models needed to meet future patient needs. Now that will take real bravery inside and outside the NHS, let’s hope there is the time to pluck up the courage for that vital discussion.
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