Health policy goes round in circles. In the words of ex-health secretary Stephen Dorrell, “there is nothing new under the sun in terms of the issues which health secretaries have to deal with.” That we are on such a policy hamster wheel may seem futile and depressing. But the silver lining is that such circularity provides a rich tapestry for politicians and policymakers to learn from when seeking to solve current NHS problems
With this in mind, the Health Foundation, an independent charity working to improve the quality of healthcare in the UK, has created the Policy Navigator website as a tool to be used by policymakers and enthusiasts to see how our current policy landscape has developed and to provide insight from the past. The Navigator website seeks to build an accessible repository of health policy developments grouped by theme, including provider landscape, adult social care and integration, choice and competition and commissioning.
Let’s have a quick recap of the NHS’s to-do list and how it is faring: deliver totemic access targets (not great: the latest data for the four-hour A&E target was the worst November since 2010); raise efficiency to unprecedented levels (weak: efficiency grew by only 0.4% a year between 2010-11 and 2013-14 in NHS acute hospitals, against a target of 10 times that); all of this – and much more – to happen while delivering NHS financial balance (no chance: 76% of NHS trusts are in deficit).
It is clear that overall NHS performance is way off target, and requiring radical action. The latest plan to do this, the NHS planning guidance published at the end of 2015, reignites one of the longest-running themes in health policy history: the power wielded by the national “centre” versus the autonomy of local organisations.
This tension was hardwired into the NHS from its inception. Whereas Rab Butler’s Education Act of 1944 invested power in local authorities, Nye Bevan’s NHS Act of two years later put power “to promote the establishment of a comprehensive health service” in the hands of the national minister for health. The implication was that, as Bevan is often quoted, the bedpan dropped in Tredegar should echo in the corridors of Whitehall. Was this what Bevan actively wanted? As was argued by Nick Timmins in Glaziers and Window Breakers, published last year by the Health Foundation, it’s likely the words were spoken more out of frustration than pride.
The past 30 years of health policy has seen a number of attempts to move power to the local level (at least as regards how hospitals are run; workforce policy remains stubbornly national). From Ken Clarke in 1989 to Alan Milburn in 2001 to Andrew Lansley in 2010, the emphasis has been placed on local NHSorganisations “looking out” at their populations not “up” at their political masters.
The NHS planning guidance for 2016-17 reintroduces a level of central control unseen since the “targets and terror” era of the mid-2000s. Organisations are asked to agree five-year plans for their local area (in itself, perfectly sensible), which need to be submitted to national bodies for approval. Get the wrong answer? “Sanctions” will be applied, and funding withheld to a level that, in effect, would bankrupt a local system.
Whether such threats are credible is beside the point. What’s clear is that restoring the NHS’s fortunes is being pinned to using national “grip” rather than relying on organisational autonomy. The lesson from history is that high levels of national pressure can introduce serious perversions into local priorities. Robert Francis saw that failings at Mid Staffs were in some part caused by a system where“finances and targets were often given priority without considering the impact on the quality of care.”
If history is to repeat itself, the limitations and harm that can come from over-assertive national control will once again be exposed. Positively, it appears local leaders are running ahead of national policymakers: when surveyed by the King’s Fund , the main concern of NHS finance directors is not their deficit, but the morale of their staff. There’s hope that, by listening to leaders and staff, policymakers can avoid the pitfalls of the past and break out of this cycle.