Why we should be more upbeat about health reform

22 Jun 2018 Nick Garbutt    Last updated: 22 Jun 2018

Picture: Natanael Melchor, Unsplash

Most health experts in England were scratching their heads this week at Theresa May’s much trumpeted £20 billion anniversary present to the NHS.


At first glance it looked like very good news indeed, and her speech was a fine one which contained all the right words. But probe a little deeper and the announcement falls apart.

There was some cynicism when Professor Raphael Bengoa told an audience in Belfast last week that Northern Ireland was ahead of the pack in terms of health reform. Mrs May speech on Monday unwittingly served to reinforce that.

There are lessons for us in a close analysis of what the announcement means.

She said that NHS funding “will grow on average by 3.4 per cent in real terms each year from 2019/20 to 2023/24.”

That translates into £20.5 billion by 2023/24.

It is a high figure but it is lower than the 4% per annum that the Independent Institute of Fiscal Studies and the Health Foundation estimate is necessary just to keep things as they are.

And note that the money is for NHS England ie front line services - it does not apply to vital areas of health spending such as staff training, capital investment and public health. Given the huge current disparity in access to mental health it is also hard to fathom how the funds will plug that gap. This is compounded by the fact that many English health trusts are seriously in debt as a result of austerity and will be required to balance their books.

Given all this it seems remarkable that in her speech Mrs May said: “So these are my five priorities: Putting the patient at the heart of how we organise care; a workforce empowered to deliver the NHS of the future; harnessing the power of innovation; a focus on prevention, not just cure; and true parity of care between mental and physical health.”

She presumably thinks that some of this will come from “efficiency savings”: “So in return for this increase in funding, the government will agree with the NHS later this year - a ten year plan for its future. This must be a plan that ensures every penny is well spent. It must be a plan that tackles wastes, reduces bureaucracy, and eliminates unacceptable variation, with all these efficiency savings reinvested back into patient care.”

So her anniversary gift turns out to be insufficient to keep things as they are and she states she wants a new plan with the NHS which will deliver a better workforce, a focus on prevention and parity between mental and physical health and some kind of war on waste. Her speech contains no evidence of the achievability of this most admirable vision.

To compound this social care which is not full integrated with health in England and currently funded by local authorities is not part of this – it is being separately reviewed. Given the interdependence of the two this seems curious.

Yet she still speaks a language which is very familiar to health reformers here: “everyone deserves the right care, in the right setting, at the right time.”

Mrs May has managed to cloak an announcement which gives health services less money than they need in the language of a passionate advocate of the NHS dispensing largesse. She uses the language of a health reformer without outlining the actions required to bring it about. And the very fact that social services are not covered serves to reinforce the segregation from health that she and everyone in the sector want to break down.

So those of us who are frustrated at the lack of progress in Northern Ireland can at least content ourselves in the knowledge that we are much further ahead than England.

When Bengoa spoke last week he told his audience that he was just back from a meeting with politicians from all parties. Before the government collapsed there were already signs that Sinn Fein and the DUP had a working understanding that reforms were necessary and needed to be put beyond politics. Alliance has always had sound health policies, the SDLP and the UUP both accept reform in principle.  

There is at least room for optimism that if and when we have a government again health reform will command a high level of cross-party support, albeit conditional on local concerns around hospitals which require reconfiguration.

That is a much sounder foundation than at Westminster where the NHS is and always will be a political football. And the problem with that, as May’s announcement so vividly illustrates, is that the political arena is one for sloganeering and manipulation of statistics rather than mature debate and reflection. Both Labour and the Conservatives have a long track record of putting short term political advantage over long term health policy needs.

As we pointed out last week there is a public perception of overpaid “suits” excessive bureaucracy and mismanagement in the health service. You even hear some people arguing that we should reduce their wages or scrap them altogether and leave it all to the doctors. Whilst May’s comments about waste do nothing to dispel this, Bengoa makes the counter argument. He states that reform is essentially a management challenge. It is about breaking down the silo mentality between different parts of the health service  and social care. It is hard to dispute this.

For sure there will be waste in the system, but change will only come if we are prepared to accept that what we need is good, strong “suits” prepared to show leadership. And falsely characterising them as wasteful and incompetent paper pushers is not helpful in this regard.

Again in Northern Ireland we have an advantage. Our Programme for Government is specifically designed to combat silo working, to enable colleagues from different arms of government and from the voluntary sector to work together to make progress against the outcomes laid down.

The challenge should not be under-estimated because the new thinking runs counter to the prevailing culture within government. Progress will inevitably be slow but as it would be impossible to realise the ambitions within PfG without changing to this type of working, incentives are high.

There is no such approach in England.

Furthermore health and social care is already integrated in Northern Ireland, so the task is more straightforward – it involves making services fully integrated in practice, again this is easier said than done but there are already many examples of effective “multi-agency” work. Everyone in the system knows what needs to be done. It is the quiet revolution that puts people at the centre of care and involves them in it. It is now for their leaders to make sure it happens.

It is worth noting that as part of Mrs May announcement Northern Ireland could receive an additional £500 million. For us that could be very good news indeed – more in the pot for what we need to do providing it is used to free up more investment in reform.



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