Let’s talk about the NHS 2: when was the golden age? #Health

The 3 Es: employment, ‘ealth and education

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Lord Darzi’s 2024 report is an honest analysis that cuts through complexity to lay bare the NHS’ parlous state.  I believe it is spot on with the symptoms, if a little optimistic in its medical history and diagnosis.

In this narrative, it all went wrong with the Health and Social Care Act 2012 (I wasn’t a fan for other reasons). This ended a golden age that dawned with the Wanless Report 2002. So, the noughties were good.

Is that golden age the right place to start?  Surprisingly, I think it may be!

In later posts, we’ll ask:

• Why have hospitals so successfully harvested ever more of the budget?

• How many honest conversations can we have?

• How realistic is a health-wealth cycle of benefit?

• How close are we to truly integrated care?

With the NHS short of cash on so many fronts, where are we?  The 2024 IFS Report, The past and future of UK health spending sets a broad context.  Using the downloaded figures from its figure 1:

In terms of GDP, it looks like this (again, IFS figures):

Darzi’s analysis does not flinch from unpleasant truths: that hospitals have remorselessly sucked funding from other services, including primary care; that with rising supervision and regulation there are now 80 people ‘at the top of the system for each NHS provider trust’ (Darzi, p123): or the significant increases in staffing. The unsayable has been said!

“Given the very significant increase in resources in acute hospitals, it is implausible to believe that simply adding more resource will address performance.” (Darzi, p 91)

In 2002, Sir Derek Wanless was commissioned to provide a long-term view of the NHS. One of his scenarios, ‘seems to rather presciently capture the situation we are in today.’ (Darzi, p 22). Wanless and Darzi have produced reports fairly early in the life of governments elected in a sea change. For me, Wanless was not fully understood and so the easy parts of his message were seized upon while its less obvious warnings languished until they were overtaken by the next seismic upheaval and the unfortunate events of 2012. In a sense, Darzi’s challenge is to finish what Wanless started.

What Derek did

Faced with an existential, complex and virtually unbounded – often called a wicked – problem, he did what any mathematician, engineer, scientist or financier would do: he built a model, a computer that showed what happens to NHS costs under a variety of decisions.

In his cover letter, he notes that the findings are ‘very sensitive to the assumptions’ and explains some of the limitations of the model – for instance, that the data came from England.  It also reflected current practice, so it could only be scaled up using factors that had to be estimated (Wanless, para 2.57, p26) as, for instance, more people were added to the workforce (Wanless, para 2.67, p 28). It also assumed reductions in hospital admissions and average length of stay over 20 years against the 2002-03 baseline since, it was hoped, care would improve.

Thus, care would be delivered over the coming two decades according to how it was already being delivered. This provides a hidden rachet, because the only way to get more or get better is to spend more.

However, it was an entirely appropriate approach, undertaken with considerable care, and it recognised it was not possible to predict the potential of delivering care in radically different ways: ‘[i]t is outside the scope of this Review to make recommendations on the precise configuration of staff required over the next 20 years.’ (Wanless, para 5.56, p 91). That said, reshaping the workforce was clearly on the agenda: ‘before the end of the decade, there needs to be considerable progress on skill mix and pay modernisation to avoid capacity constraints‘ (para 5.57, p 91).

Finally, Wanless called for – but could not deliver at the time – whole systems modelling, which connected Social Care to Health. How far beyond that the report intended to go, is hard to say although there are strong hints in his definition of ‘integrated.’

Wanless’ legacy and how it was spent

Wanless left a vision that healthcare should: be patient-centred; offer safe, high-quality care; provide comfortable accommodation as needed; and deliver within reasonable waiting. 

Crucially, this required, ‘an integrated, joined up system,’ by which he means, ‘a hassle free service where there are effective links and good communications between the different parts of the service and beyond.’ (Wanless, para C.39, p 148-9)

My reading is that Wanless gave the NHS until the end of the decade to reform the many issues that he could only make assumptions about: proper measures of productivity, workforce, skills mix, pay, technology, and creating an integrated system. The fact that one of his scenarios has played out so eerily correctly surely reflects the limited progress on these fronts in the intervening two decades.

So, funding had generally risen throughout the noughties.  The big IT programme (and Wanless was keen on IT) had come and gone, but resourcing was in the best shape it would be for some time.  The global financial crisis had not yet been followed by austerity, and the 2012 Act was still in the future.

Had the NHS been able to use the financial respite afforded by Wanless, and it made some efforts that didn’t quite come off: had it reconfigured the workforce by redesigning care, the end of the noughties might have provided a good comparator for us now. As it was, having seen health spending rise from around 5.5% of GDP to around 7.5% in short order (it has recently tipped 10.5%), the NHS was looking for its next uplift.

Going forward

Today’s challenge is to return to the Wanless 5 characteristics of a good system: patient centred, safe, high quality; low waiting; good accommodation; and, of course, integrated.

Meanwhile, the world around has moved on.  To understand the relevance of what else has been happening over the past 50 years in business and industry, see: 21st Century Healthcare: why the details really matter to the NHS, 2022.  To exploit the discoveries of the e-world, we know that the key to better performance is to use better information to drive better performance and better performance to drive better information – as shown in our chart (which now includes the Wanless 5).

The problem is that cash desperately short.  However, compared to the noughties we start with a health service consuming nearly twice as much GDP as Wanless started with.  That headroom has gone!

We must find innovative ways to rein in spending after an initial investment. I propose a single bolus of funding – a large injection around £10Bn – after which it is essential that the virtuous vortex is spun up to make continuous year on year savings.

This is laid out in the recent  series, Fixing the NHS (Fixing the NHS: the bite-sized story in 6 charts and linked articles).

The unsayable has now been said.  It’s time to do what has not yet been done.

Professor Young: researching for 40+ years; in healthcare for 25; and using NHS limbs for 50+.

The series

Let’s talk about the NHS 1: we need a common language (12 September 2024)

Let’s talk about the NHS 2: when was the golden age? (19 September 2024)

Let’s talk about the NHS 3: why have hospitals so successfully harvested ever more of the budget? (26 September 2024)

Let’s talk about the NHS 4: how many honest conversations can we have? (3 October 2024)

Let’s talk about the NHS 5: why health probably won’t create wealth. (10 October 2024)

Let’s talk about the NHS 6: how close is an integrated NHS? (17 October 2024)