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Gavin: Hello, welcome to The Lancet Voice. I'm Gavin Cleaver. And
Jessamy: I'm Jessamy Bagonal. The LSE Lancet Commission on the Future of the NHS is published today, May 6th, 2021, in The Lancet. In 70th anniversary of the NHS, this commission was formed to take stock and objectively consider the future of the UK's health system.
It featured commissioners from various disciplines, and to find out more about the commission, which you can read now for free at thelancet. com We spoke with two of the commissioners, Michael Anderson and Emma Pitchforth.
Gavin: So we're very pleased to be joined by Dr. Michael Anderson, who's a health research officer at LSE, and Dr.
Emma Pitchforth, who's a senior lecturer and senior research fellow in primary care at Exeter University. And they're two of the lead authors of our new commission, which is The Future of the NHS. relaying the foundations for an equitable and efficient health and care service after COVID 19. Michael and Emma, thank you both so much for joining us.
I guess we should probably start off by talking about the elephant in the room whenever we talk about healthcare at the moment right now, which is COVID 19. This commission was already largely in process before the COVID 19 pandemic hit, and changed the landscape of healthcare in the UK.
How much did the pandemic change your aims at the time?
Michael: No, you're completely right. So the commission, it was convened in November 2018 and it was all, we were finalising it actually when the pandemic hit. But I think what it did is made us think about two different questions. So first of all, so it shifted the focus of the commission towards how could the NHS develop?
That's a long term resilience and sustainability. And then also the second question is we identified a series of chronic weaknesses and strengths of the NHS that have been persistent for over several decades. And we reinterpreted what that meant in relation to the pandemic.
Emma: In some ways, it didn't shift the aims altogether.
Aim was to look to a 10 year horizon or so for the NHS and we had identified these more chronic issues. It just it just played us in a very strong position in order to then analyze the response to COVID in light of those underlying strengths and weaknesses of the NHS.
Gavin: There's been a lot of reports on the NHS, it's something that's well covered in the literature and in fact you, you discussed this in the commission and you talk about avoiding calling for another structural change.
Why was another report necessary and why is this one different?
Emma: I think it was a critical time to consider the NHS. When we started it was, on the back of the NHS turning 70, but also with realisation that it was under significant strain as a system and we needed to think about what the future of the NHS was going to be.
I think our report is different because we bring in both international analysis, so we look at how the NHS and how health and outcomes in the UK compare to other countries, high income countries that we might want
we take a look across the UK. So importantly, the NHS is different in the UK countries, but I think, and this has been strengthened through COVID, there's a need to think across the UK when we're thinking about the health system, we still have a lot more in common than with other countries in terms of the health system that we have in each of the countries.
And we have a very common challenges that we're trying to face. We essentially share. a pooled workforce. And, the pandemic showed us that we need to coordinate, we need to work across countries. So very few reports bring in bring in that element I think.
Gavin: So I guess then the crux of the matter is what priorities for the NHS did you identify in your commission report?
Michael: So we focused on seven key areas. So we focused First of all on the funding for the NHS, social care and public health. So we outlined how much the funding needed to increase at what rate and how to raise the revenue. We talked about principles in spending the money and outlined some recommendations at national, local and treatment level.
And then talking about the workforce, we outlined a series of recommendations for workforce strategies across the country, the four UK countries and workforce planning. And then we also argued for a renewed focus on prevention. and outlined recommendations related to cross government strategies to promote health as well as investment in preventative activities.
To improve the UK's poor health outcomes in terms of life expectancy and cancer and cardiovascular disease, we outlined a vision for diagnosis over the next decade. with a series of recommendations about investment in diagnostics and novel routes to diagnosis. In terms of data, we outlined a series of steps for how the NHS and social care in each country can become a learning health and care system, maximizing the use of data routinely to improve policy and planning.
And then finally, probably the biggest challenge revolves around integration. We argue against any short term structural reorganization of the NHS because past benefit has taught us that this is often disruptive instead of producing benefits. So we outline a series of system barriers that need to be removed to move towards a direction of travel into completely integrated care by the end of the decade.
where there'll be one body responsible for health and care delivery for geographically defined populations.
Jessamy: I just wondered whether we could talk a little bit more about the funding. So you come up with this figure of 4%. I was just wondering how we, how you derived at that and whether it's even enough and what it compares to over the last 10 years in terms of spending.
Michael: We, we NHS funding has increased by on average 3. 7 percent per year in real terms. And then over the last decade, increases have been closer to a percent since 2010, although for the last couple of years it's increased at a higher rate. So the last decade in particular, the NHS has emerged from a significant period of austerity.
So we identified the 4 percent figure based on a review of projections done by the Health Foundation, the Institute of Fiscal Studies, the LSE focused on social care. And the Institute for Public Policy Research. There's consensus amongst these projections that to meet demand and to make improvements to services, funding needs to increase by at least 4 percent per year in real terms.
Now, is this even enough? That's actually a quite pertinent question in current times. So these long term projections give a good idea of what the government needs to commit to over the next decade. They don't include the funds that are needed to respond to the pandemic or address growing waiting lists.
So in reality, we do, we're completely transparent in the report that It's possible that in the short term high levels of funding may be required.
Jessamy: And Emma, I wondered whether I might ask you a little bit about universal health coverage and how, the NHS is this sort of originator of, if we're being pompous about, about of universal health coverage.
What we've seen through COVID 19 is that having universal health coverage didn't, doesn't protect against a poor response of COVID 19. And why would it, in many ways, but I suppose what I'm interested in is what does that tell us about how we need to consider universal health coverage and whether it needs to be broader and how that links into, potentially global health security and other ways of us making sure that the NHS is resilient rather than efficient.
Emma: I think there's a number of points there. So I guess the first one to make would be on the flip side. So imagine if we didn't have universal healthcare coverage, what would the response to COVID 19 have been? And we're seeing that now from other countries that are in a bad way. And I think also, there's been poor elements of the response to COVID 19 and we highlight these.
Much of the response from the health system can be highly commended in terms of how we have been able to respond in terms of workforce. We have, and then where we've done things, we have been able to drive out change nationally. And very efficiently, so some of the response comes from a broader, government level and the kind of decisions that were made there, and so it's not just the the health system.
I think it tells us that in terms of universal health coverage that you can't drive a system so hard that it has no. No extra capacity. It has to have something to be able to respond whether now, in this case, it was to a pandemic, but any kind of future health shock. So I think, the evidence of terms of where the NHS was and going into COVID was there being driven, very hard, in terms of, efficiency.
We ran hospitals, extremely high capacity. We're struggling in terms of workforce, in terms of retention and recruitment and so on. So the fact that we've been able to do in some ways, what we've been able to do, given that context has been perhaps remarkable in some ways, I think in going to, so if we think about what universal.
health coverage means. I think it reminds us that we have to think about the full spectrum of care. So it takes us from prevention and health promotion treatment and through to to end of life care. And I think going forward, we need to think of keeping that comprehensive care within the health system going forward.
And I think it tells us that we have to be. Prepared so we can't become complacent with having such a strong system in some ways in terms of universal health coverage, we have to be prepared for future health shocks. We have to believe that they're going to happen to us and to plan to be able to respond to those.
And I think it just also reminds us that you don't necessarily see the benefits of universal health coverage. So particularly if you've grown up in the NHS, We don't day to day think the health system's providing me financial protection, it's unseen generally in everyday life, but it just has brought home the importance of that, I think.
Jessamy: What's difficult is disentangling the sort of politics and the performance of the aid. the health system and that, they're both so linked, but at the same time, the politics influences how the NHS is responding. And we're speaking like we're over it, but obviously we're not at all.
We're still in the middle. And it might be that actually the NHS comes out with an overall very good response because the vaccination program has thus far been, very successful.
Emma: And it could be, I think we have to think about things about the sustainability and resilience going forward. So things like, you could argue that workforce response has been remarkable in terms of people were able to bring back into the NHS at the start as well.
But I think there's concerns about. Sustaining the workforce, promoting the well being of the workforce, there's indications that there's an intention to leave from a fairly high number of workforce once the pandemic pans down. So yeah, I think it shows us that it's a long term impact for the health system.
Gavin: I wanted to ask you a little bit about basically every time Jessamyn and I talk to someone involved in health and care planning. in the UK. What's really striking, and of course, we're talking anecdotally, we've spoken to a few people, what's really striking is the kind of sweeping agreement that the care system is in dire need of reform.
And of course, successive governments now have basically said this, that one of their priorities is to have a major reform of the care system in the UK as it currently stands. What sort of sweeping changes do you think are required and why hasn't more progress been made on this front?
Michael: I completely agree with you.
It's it's interesting how successive governments have in their manifestos Put social care as a priority and despite that has Little progress has been made just to demonstrate. So the eligibility criteria and for social care has been unchanged for a decade in England. So with inflation, that means that with every year passes, there are less and less people that are eligible for publicly funded social care.
So in addition to just the eligibility criteria, the funding levels are in real terms have been declining. Whereas in the for NHS funding in real terms, it's been it's been more stagnant. So the social care funding situation is more extreme. And then also I really liked Simon Stevens when he was asked, so the 70th anniversary of the NHS, he used that as an opportunity to try and raise the agenda of social care politically.
Rather than emphasizing the successes of the NHS because of the impact that this continues to have on the NHS, why is it, why has it not happened? So far, I think there's a number of reasons. I think it hasn't been high on the political agenda because there's been other things going on. So specifically Xi of course, and then the pandemic, and then also I think it's a politically difficult thing too.
to implement because inevitably reforming social care. So there's two aspects. So there's the funding. So we argue that the threshold to pay for your own care needs to be increased from 23, 000 to 100, 000. And there should be a cap on care costs of 75, 000, which is in line with the social care. The Conservative Manifesto of 2017, so that, that will cost money.
So we, we argue it costs 3. 2 billion per annum to implement that. So I think it's from a fiscal perspective, it's difficult to implement that policy. And then from the integration perspective, there's no simple solution to that. There's no one policy. I think it's a direction of travel that needs to take place gradually.
There needs to be continual evaluation. and review of what system barriers exist to hindering integration and develop locally implemented policies to overcome them.
Emma: I think progress has been made, and I think at a local level people can work together very well. I think looking across the UK countries who are perhaps further ahead and in terms of perhaps legislative change in Scotland, for example, to promote integration, it helps and makes a difference, but it doesn't.
There's still the kind of historic ways in which people work together, the way in which budgets flow that mean there's still ongoing challenges in terms of how people work together. But there's, yeah, a need to think about what do we mean by What is integration and good integration that we're looking for, and then can we reduce some of the things in the system that perhaps don't promote that?
Michael can pick up on points of, can we think about ways of which we pay providers, for example, that actually align with these broader aims of integration and so on and don't work in the opposite direction.
Michael: And then just the last thing I want to say about integration is when people think about integration they sometimes think that there is a national solution.
And actually that's harmful to the process of integration because the only thing that seems to push integration forward is the relationships between local actors. So whether that's a GP developing a relationship with a district nurse or the district nurse developing a relationship with a social worker.
And when the government implements. Cross country policy to try and push integration forward. Then sometimes that ignores the power of these locally developed initiatives and policies, and actually it could be harmful to the process.
Emma: Yeah, so we were very resistant in coming up with a model that would, suggest that's a blanket model that would across work across the board, I
Gavin: think.
Thinking a little bit more about structure and integration, the NHS has always had a kind of interesting relationship between public health and their primary care and preventative health. What have we learned? What do you talk about in the commission in relation to this kind of more proactive rather than reactive approach to public health?
Emma: Yeah, no I think what we highlight is that lack of priority or lack of stability for public health there has been in the system. The 2012 Act, moved public health more to local authorities than the NHS, which isn't necessarily a bad thing in terms of what you want to achieve through public health and who you want to work with, but it coincided with decades of austerity, significant grant cuts to the public health grant significant cuts to local authorities.
So it's meant that really we've lost a lot of capacity, expertise from public health. It hasn't had the value. It hasn't had the priority perhaps that it needs, which has become evident in the course of it. And there's also now we're facing significant costs. changes ongoing in terms of where public health sits nationally, and it's still unclear in terms of how some of that will pan out.
Michael: In relation to the recent structural changes, it is unclear how it is going to pan out. And I think generally there was consensus amongst most commentators that a restructural organisation of public health services in the middle of a pandemic doesn't really make sense. It may be, maybe it's something that could have been thought about once we got out of the pandemic.
It's very interesting how they decided to announce that PHE would be replaced by a communicable disease organisation, the UK Health Security Agency, and then subsequently, a few months later, then realised there was a gap. to be addressed in terms of non communicable disease who created a separate organization the Office for Health Promotion, which seems to be somewhat of an afterthought.
There are lots of questions that remain unanswered about funding as well. So the there's been real terms decreasing. public health funding over, over the last decade. And in addition, there is a lot of redirection of public health funds in the local authority level that is undocumented because many public health departments seem under pressure to direct their funds to other local authority departments, such as education or social services because they can see the public health benefits in doing so.
but then it leads us in a difficult situation where we don't really understand how much funding is being used for strictly public health services.
Jessamy: Out of interest 50 years since the inverse care law this year, what do you think the sort of, some of the trends of increased privatization or sort of the use of private providers in the NHS means for that sort of conversation about market forces in healthcare and inequality in today's world.
Michael: There's two aspects of the conversation about the private sector and then the implications of inequality. There is obviously NHS funded care in the private sector, which is over the last two decades has increased, but it's stabilised now. So approximately 7 percent of the NHS spend is on, on the private sector.
But that's just secondary care in primary care. It's a bit more complicated because it's very difficult to decide what is a private contractor and. Who is not because the contracts are the same for each and you could argue that independent GPs operate as private providers. I think the most important thing to consider with this debate is it's very contentious on either side.
And it's very passionate debates, but the most important thing to think about is the institutional culture of the organizations that deliver NHS services, irrespective of whether they're, They are a traditional NHS trust or whether they're Nuffield Health, if their organizational priority is maximizing profits at the expense of quality, then that's something that's negative.
But if they are, if their priority is about delivering the best quality of care to patients, then that's the more important distinction irrespective of whether they're an NHS or private provider. But how can you determine that? Because if the private sector. is untransparent, and the private sector is evasive of regulatory visits.
There is no data to observe the quality of care. Then we can't really monitor what's happening in the private sector. So the key is privatization is okay, as long as the private sector is involved in the broader national clinical audits of quality. They have advanced data systems so we can monitor their outcomes, their readmissions, their unplanned patient transfers.
And some work has been done on this. There is an organization, the private health information network that's mandated to do that. And they are working with NHS digital as part of an ADAPT program to try and integrate the healthcare data sets. So with appropriate monitoring, I think it's okay.
The second point you mentioned about in terms of inequalities, we have a system with supplementary private health insurance whereby people can access private health care via privately funded health care via self pay mechanism or through an insurance system. They cannot opt out the public system.
Therefore, the, in the same way that people that access private schools they still contribute towards they still pay their taxes and contribute towards the public system. There are benefits in the respect that if there is a certain proportion of the population that's willing to pay for private health care, they remove themselves from NHS waiting lists.
As long as the redistributive mechanism isn't harmed then that's crucial. But having said that we'd still there is an ethical bait around, how right is it that these people can just jump waiting lists and access care in the private sector.
Jessamy: Unprecedented is a word that's been used a lot during the pandemic and that's the nature of the game when you've got a crisis of this scale.
Future crises are likely to also be unprecedented and not, they're COVID 19. Direct responses to it. might not necessarily work. What have we learned from this pandemic in terms of how the NHS works and what might make the NHS more resilient to future crises? I, we picked up on it earlier but it would be good to just and on hearing your thoughts about that,
Emma: I guess we've talked a lot about the the financing element that's there for it. Other points that come out are around, we have to secure a workforce that's fit for purpose, that's sustainable and that will add to resilience of the system. We've mentioned that we need to have some buffer, so some capacity in the system to allow us to.
Respond or to have some extra capacity when future shocks or futures crises occur. I think it highlights some other points. I think the points around whether it's integration, whether it's coordination and so on, if we can do that better in so called peace time then we can, do that when we're in time of shock as well.
Something that the pandemic has shown, is the gaps in the system. So is the, transition between health and social care and so on. And then if we can really work and sort those out in normal times, then that's going to stand us in better stead in terms of future times.
The COVID 19 has shown us, the health implications, the health shock, but it also shows us the significance of the rest of life, really, in terms of spending on that. And when we think about when the NHS started, it wasn't, with a view just to health. It was also what, in the context of providing a strong welfare state around it, and I think some of the things that are come out in terms of inequalities, in terms of the way people live, the precarious employment that people are in, and so on.
They're much broader conversations than the NHS, but inevitably they help the NHS if we don't only think about the NHS, but think about these wider points. We've said already that. NHS response, has been very strong. We've been able to do some things that we weren't, apparently weren't able to do for a long time before.
And I think we should, think about keeping the positive changes that we've been able to maintain and to take them going forward. To keep the actual learning from the response for. for normal care and for future events.
Michael: I think we've, for quite a long period of time before the pandemic, we were running the NHS with very little excess capacity.
So we have one of, the lowest bed numbers in, out of EU 1527 countries. And we would consistently run at bed capacity of the high 80s. And then every winter, you would hear the repeated calls of winter crises and elective surgeries being cancelled. to accommodate emergency admissions. So I think we, we've realized that's not a sustainable way of running a healthcare system.
And we're just extremely fortunate that we never really needed the Nightingale hospitals. We shouldn't have really been in a position where we needed to build them. So I think in the future, there'll be a renewed focus on capital investment. And we won't do what we, hopefully, we won't make the same mistakes of raiding capital budgets to address revenue pressures.
Gavin: Thank you Michael and Emma. For an overview of the modern NHS, the commission and the general direction of travel, Jessamyn and I also spoke with Jennifer Dixon, Chief Executive of the Health Foundation. We're delighted to be joined by Dr. Jennifer Dixon, Chief Executive of the Health Foundation. We've heard from the commissioners of the NHS Commission on this podcast, Michael and Emma, but we thought it'd be interesting to get a different perspective from someone who didn't work on the Commission, but of course has such a wealth of experience in dealing with health policy.
Jennifer, actually, just as we're doing this interview we've heard that Simon Stevens is due to step down. What do you think that means for the NHS at this kind of critical time? They're grappling with increased demand. There's a pandemic backlog. It's it's quite a big development.
Jennifer: It is a big development, actually, because Simon's been knocking around for some time, only the last seven years as chief executive.
And then Many years before that as a policy advisors and strategists, so his sort of fingerprints are over the shape of the NHS, I would say I think the first thing to say is that what Simon has done with the long term plan in crafting that is he has set out a long term strategy for the NHS. which is unusual and pretty unheard of before 2014 to have a 10 year, five to 10 year long term plan.
And that was actually enabled by the 2012 Act, which separated off the department from the NHS and gave more space to the Chief Executive of the NHS and staff to be able to craft the strategy. So in a sense, that imprint is laid out. Hopefully that will let's see if it's days, but at the moment, that's the imprint that I can't, I don't hear any major voices countering that major strategic direction for the NHS.
But as you say, there's clearly been a massive insult on the NHS recently to do with the pandemic, which has resulted in an enormous backlog. But also, even though the NHS did have its own strategy, there was still cumulative funder funding of the service, despite the big 20. 5 billion pounds birthday present in July 2018 in particularly the backlog in capital spending, but also revenue as well, which has also led to significant under planning of staff.
So staff shortages are rife, as we know, which will aggravate. So going forwards, there's still fish to fry with when it comes to making sure that. given the big fiscal overhang as a result of pandemic and the economy that the NHS is still able to attract the kind of level of investment that it should be having to deal with the backlog that it still is able to craft a workforce strategy that is funded enough to get the supply of staffing to deal with the backlog.
And also that we have maintained capital spending, in fact, enhanced capital spending to be able to fund the new technologies that will enable, hopefully, a step change in productivity that we need to get rid of the backlog, at least deal with it. And the backlog is pretty amazingly big, as you say, and we've calculated that it would take the NHS, you can't do it in one fell swoop because you haven't got the staff, even if you had the money, you also don't have the supply.
It would probably take 10 years of a really big effort. Estimates vary, but sustained development and sustained strategy in that period. So the NHS, as I would say, hasn't got necessarily a. big strategic questions coming up about the shape and size and all the rest of it, but what it does have is it needs constant resourcing and powerful figures to argue for that resourcing as well as powerful figures to bail out what it will take over the next few years.
and also to maintain the strategy's strategic direction and we're not blown off course by some great new idea that comes out in the next three years.
Gavin: So I'm interested to hear where you think this commission fits in. Now of course at the Health Foundation you put out lots and lots of research and reports on the NHS, on health systems, on policy.
What makes this commission stand out do you think?
Jennifer: I think what I really welcomed about this commission was that it was incredibly sensible and it was another group of people saying very sensible things. Real questions for the future are not about fundamental reform of the health system. It's about fundamental long term investment with it.
So it's in a sense, it's a technocratic agenda, not a democratic agenda. It's not a political agenda for the NHS. It's a technocratic one, which requires patient tending over the next few years. To both invest in the way that we need, but also to maintain innovation and actually increase the speed of innovation and spread and technology.
But to enable us to do more with less in futures that will release more with a, within the envelope that's voted in for the NHS resourcing envelope. So I think that's where the pressure is. And this report is very sensibly setting that out. So any politician looking at it will be looking to say where's the big political idea that's the kind of administration defining reform?
And the good answer is that the good news is that there isn't one in here. It's more to do with how the service is funded. I suppose that's the big political question, but secondly, how it's managed and how technology is enabled and frontline staff supported to spread. change rather than a kind of administrative reform of the type we've seen over the last 30 years.
Gavin: One aspect of policy in the UK that seems to have a lot of consensus at the moment, and the Health Foundation's put out a lot of research about this, is the kind of need for A bit of change in long term care, and it seems as well that a lot of political parties, a lot of political stances seem to agree that there needs to be this kind of radical change in long term care, in social care.
What are your thoughts on that? What do you think it will take for this kind of meaningful change to take place?
Jennifer: It's a really good question because today we hear it's announced that social care is going to be kicked kicked down the road again that it won't appear in the Queen's speech on the 11th of May which is worrying because, as the Prime Minister did stand on this.
steps of Downing Street in, what was it, 2019, late and said that we are, we're going to fix social care once and for all and clearly the need to do that is also riven inside the long term plan, that the changes promised by the NHS long term plan were contingent on there being a decent funding settlement for social care and for reform to happen.
Because without that, as many has said, many have said, there's a kind of leaky bucket when it comes to the NHS, you pour money into the NHS and it leaks out because there is just so much need in social care and there are so many patients, people, older people, who could be supported at home who aren't being and therefore revolve into the NHS through want of basic care.
So that is a major stumbling block that needs to be sorted and we'll see whether the spending review in November produces any more cause for hope. It seems to be in the political sides, at least some aspects of social care reform, but it's costing quite a lot. That's the issue at the moment. I suspect it's coming up against the treasury, uh, obstruction certainly in, in this Queen's speech, at least.
And obviously that's linked to the whole cost of the pandemic and having to somehow pay that back or address it somehow.
Jessamy: I wanted to pick up on that point, Jennifer, because it seems emblematic to me of many of the other things that we've seen about the NHS that, it's very good at dealing with emergencies and with acute problems, but has become more and more You know, it's much more difficult to deal with many complex, multi morbid patients and the response to the pandemic has been similar in that we've pivoted everything to make sure that everybody's got a bed, we've dealt with these, very acute problems, but at the expense of then a huge backlog, putting everything else off.
And obviously we're wary of big changes again, because we don't want big changes, but at the same time, what's become so apparent about inequalities, the social determinants of health, all of these other parts of social care that impact directly on health. And although in the short term, it might cost more, but in the long term, it's actually far more dangerous to put these things off.
We don't want big changes, but it almost feels like sometimes there's, there needs to be a big change to deal, to, to change the ethos, to change how we're able to deal with these very much more complex patients and very much sort of different demographics. I just wanted to hear your thoughts on that.
Jennifer: I think from a political point of view, obviously, risk management is a critical thing, and there's no doubt that hospital care is very spiky, the emergency, the life or death, it's very visible as well, obviously people backing up in A& E and a bad winter, so you can see that's where the money goes in order to try to mitigate risks, there isn't the same kind of back up in primary care that's so visible and so obviously newsworthy and similarly in social care too.
So that's a sort of, in a sense, a superficial response to the question. The other one is also dealing with short termism. If you think about it, the NHS is an asset that's been with us now for, what, 72 years, coming up to its 73rd. And still we have you know, year to two year spending settlements.
And if you think about it, this is an asset where a lot of the key parts to make it work should be planned over a longer period than one to two years. Training of staff, building of hospitals, training staff to change their practice in order to soak up new technologies and use them well. For example and so we're not so good at planning for the long term and we're not so good in planning for things that don't produce an immediate risk, which really means, primary care and social care are in that kind of basket, aren't they?
And if you look over there, we did a study about a year ago, which looked back over the last 20 years of NHS spending and we looked at the differential growth in different types of care. And of course, those areas that are more politically hot get the funding. So acute care has really eaten up most of that growth over the last 20 years and primary care has hardly had anything despite the volume and demand growing up.
The one part of the answer is to try to see whether or not there is a way of planning and thinking about a national asset like the NHS a bit in the way that we're doing for the Green Agenda. We are now thinking ahead for more than two years. We're thinking ahead for, clearly, for 30 years in the Green Agenda.
So whether or not we can somehow do that, and of course our ability to do that has been increased as a result of the 2012 reforms, you could argue, because NHS England has been able to set out a ten year, five to ten year plan. That would never have happened had it been directly tucked under the Secretary of State, who's interested in the political time span of three to four years.
So I think it depends how far this reckoning from the pandemic really seeps into. The way we think about the future and resilience and planning for some of our big assets. And I don't know whether that's the case and whether or not, as I say, green is a really good case example.
Jessamy: That's interesting.
And we've spoken already or the word innovation has come up a lot already and it's something that, the NHS has really honed in on over the last 10 years, and I think it's often been a bit of a euphemism for doing, more for less and a sort of focus on efficiency because of.
Funding and everything else. And it seems to me that we need to move that narrative to a conversation about innovation for resilience and capacity after COVID 19, we've seen that a health system can't function on that, on purely being efficient, it must be resilient because otherwise universal health coverage doesn't protect you from a poor response against COVID 19.
I just wondered how you think that narrative can be moved on.
Jennifer: Yes. I think two things on that. One is that I think everybody has seen the fact that if you don't have spare capacity priced into the system, you will come a cropper on risk at some point. And those countries that had higher hospital capacity did better with respect to managing, as you can see clearly.
So in a sense, we've got a lesson right in in front, but resilience and spare capacity costs money. And that resilience includes thinking, people who think about strategy and who can imagine the future and the future risks, as well as those people who are the beds, spare capacity of beds and other equipment, and also spare capacity of staff.
I think there is a moment now to price that in. in the way that we haven't done before. But the other thing is I wouldn't want to lose the importance of productivity. And I know, my background is in medicine and I know my medical pals would not get out of bed to work to, with an efficiency mantra at all.
That's antithetical to their kind of practice. However, if we are going to be able to afford all the things we want to afford, including whether it's the new CAR T or gene therapies, we have to create headroom for that through. somehow being able to do all that we do and more with fewer costs.
So it's also, there is a moral case as well, I think, for efficiency, as well as the mitigating risk argument for to price in. resilience, if with increasing demand, where is the hope for more productivity going to lie? One aspect is, somehow we're going to supremely improve management so that we can get rid of a whole load of bureaucracy and we can speed up change at the front line, give people more cover to take risks and try things and test them out.
That's certainly possible. And the other is, of course, new technology and whether that can somehow substitute for staff, which is the biggest budget line in the NHS. So I think those are the two sources. And at the moment, there's more emphasis on technology, particularly at the bioscience end. And there isn't enough emphasis on technology for productivity, which there should be in my view.
And secondly, there really is no emphasis at all on good management and the active ingredient that is to improve productivity. And until we get those, both of those in our sites, that we're going to become a cropper. So that I think is the next phase of the NHS, not another 10 year long term plan.
That's particularly different. I think it's on these elements that will help us speed up the change. And as you say, pricing.
Gavin: There's of course been a lot of reform of structures around public health recently. I'd be interested to know your opinion on these public health reforms.
Jennifer: At the centre is an argument about whether or not you should separate out health improvement of the health stock of the population, that's population health, from the management of threats, which is infectious disease and hazards and chemicals and all the rest of it.
And, public health England brought them together and now they're being pushed apart. So I don't know what the right thing is. I don't necessarily think there's a strong case. So that's point number one. Point number two is that, of course, everyone's got the pandemic front of mind and managing health threat.
But actually, the bigger injury to health is not these threats or sudden insults that come across, we come across now and again. It's the grumbling long run inequalities in health, which is caused by the wider determinants of health that are weathering all of our health stock. And so the big thing for me is to make sure that what is the, what is that part of the national agenda is not lost.
And actually it's beefed up. And I don't mean by that health promotion and I don't mean by that taxes on, necessarily sort of risk factor taxes like Tobacco and all the rest of it, although those, and sugar although those I think are a good idea, need to be thought through. I'm thinking of tackling the wider determinants of health, and I really think it's very important now to link that to the levelling up agenda.
Otherwise we'll miss the boat, because those are the things that are withering our health, and will actually be a break on future prosperity. It's in part Michael Marmot, but it's also in part what other things beyond public sector spending. or lack of it, is injuring health. And there are big questions there about the long run shape of the economy, for example that has led to a dual labor force and rank exploitation and, workers rights eroding, which have resulted in poor quality work, which injures health and poverty.
So there's a lot there, I think. And the last point on that is, whether this, whether the government as it is, recognizes and acknowledges those wider determinants that impact on health as opposed to personal responsibility is a moot point. So that's one of the things we'll be pushing for.
Jessamy: I just wondered whether we might finish on, we read your the Health Foundation book on, window breakers and glaziers last year.
And we had Jeremy Hunt on here actually earlier on this year about, the different health secretaries and their experience. And it's a great, it's a great, it's a great metaphor actually. And I just wondered what you think we need now. For the NHS, do we need a glazier or a window breaker?
Jennifer: For the NHS, I think most definitely a glazier. So that's more of the same, but better because of the pandemic. But for her health side the public health side, I think we need a window breaker. I think we need somebody who really just takes government and says, these are the things that are injuring our health and we have to now work on them.
And that means working on a wider cross government strategy. It means working on local government. It means putting more money into local government and it means acting on the commercial determinants. So that's where a window breaker and really strong public health leadership is where I think it's at.
Just as we've got climate leadership, we need the same kind of window breaking activity.
Gavin: So just maybe we spoke to Michael, we spoke to Emma, we spoke to Jennifer. We've heard a lot about the NHS, where it's been and where it's going. Now you've spent a lot of your career working in the NHS. So I'm interested in your perspective. What are some of the things that you've taken away from these conversations and from the commission?
Jessamy: The sort of conversation about funding is. is a very difficult one and one where because there's been so many changes over the last 10 15 years from various successive governments and those changes are quite polarizing I mean I think we heard Jennifer Dixon there being quite supportive of the Health and Social Care Act of 2013 sort of 2012 2013, but lots of people are not supportive of that and so there's this sort of feeling that we don't want to change things too much we don't want to make any big changes because actually it takes focus away from some of the other goals that actually just focus on health.
But at the same time, I think what's clear is that for social and for welfare, there does need to be a real change. There needs to be a radical rethink of how we're going to provide that. And now that we know the extreme impact that has, and not that we didn't know before, but we've seen it in such clear light from COVID 19 that has on our health, it's an absolute priority.
And that's why it is disappointing to hear again that's been kicked down the line from a sort of political point of view in the UK. And why I think you and I are going to focus on doing a welfare kind of state type episode in the coming future.
Gavin: Yeah, definitely. It does feel like something that comes up a lot so much across all of our conversations and across all of our podcasts.
I'm completely with you on the social care front. It does feel like one of those rare things that both sides completely agree on by this point, both sides of the debate. It's obviously there are a lot of overriding concerns at that moment, as we spoke about with with our commissioners, we're still in the middle of a pandemic, but social care is not going away.
And actually the long term morbidity caused by COVID 19. is going to be a problem going forward. And that's going to impact on social care as well. More people will need care as a result of COVID 19.
Jessamy: What really comes across clearly from the commission is there's a clear argument for why we can't go back to a kind of austerity type thinking post the pandemic because of whatever sort of economic factors that are in play.
And that just. cannot be allowed to happen. And so that's an important message also to hit home. But it's not even austerity, it's more money. We need more money for the NHS, we need more money for social care and welfare, but we also need to rethink how those two things are being delivered. And I think another thing that really struck for me, particularly from the conversations, was this sort of division between the NHS's performance and the political performance.
And, we often marred those a little bit by asking how the NHS performed. And actually the NHS for the most part performed well. It was more the political decisions and the interaction between, governing bodies and the health system that made things more difficult or resulted in a poorer response.
And I think going forward, that division more broadly outside of the UK as well, on how the political system impacts on health systems and what that relationship should be, In the future needs to be really carefully explored and perhaps redefined a bit
Gavin: covered as with so many things brings a perfect example, doesn't it?
The political decision in the UK of keeping everything open until the hospitals are on the verge of being overwhelmed, which has been our kind of overriding decision making aspect of when we should bring in a lockdown. If you compare that as we have in a paper in the Lancet this week with other countries that actually acted it.
Very hard, but very quickly and very early on. There was no element in their thinking of healthcare systems being overwhelmed because they were never even remotely close to being overwhelmed. Actually, there's a very interesting article in The Economist out this week as well, looking at excess death rates.
And in all those countries that lockdown and have had protections in place the excess death rates. are actually far below the five year projections. There's lives saved on top of the lives saved from COVID. Now, of course, that's not the only measure of anything, but it is a very interesting outcome.
And I think it really illustrates, as you say, how political will impacts on the performance of a health system. And that's why we say, isn't it, that health is politics.
Jessamy: Absolutely. And, I think going forward, that question about, outside of COVID 19, public health intervention, sugar taxes, alcohol, all of those types of things, we have to have a much more honest and clear understanding of who's influencing who and how they're influencing and why they're influencing and whether the health system is able to, What that, what that means for the health system.
Is it reasonable for us to have a government that wants to, step back a little bit, not, do sugar taxes or not be involved in people's lives, but expect the health system to cover the burden of that sort of slightly irresponsible view. Do you know what I mean? And I think that's it.
That's it's quite an interesting space. And I don't know where it's going or what that relationship might look like in the future.
Gavin: I know exactly what you mean. I think this exact conversation is going to be repeated very strongly when it comes to tackling climate change over the next few years.
To what extent is intervention in an individual's life, the right thing to do? To ensure we tackle climate change
Jessamy: and therefore how, how can we expect public institutions to, to try and overcome or to make up for some of those deficits?
Gavin: Yeah, it's an open question. It's not what we're going to solve here.
It is going to be the, when we move past COVID 19, I think there are signs that, especially with the Biden administration, that the world is starting to take climate change more seriously than it was before. We, of course, have seen the announcement this week as well from the German government that they are committing to net zero carbon emissions a lot earlier than they were planning on before.
There's a direction of travel there. But yeah, the conversation about to what extent that direction of travel impinges on personal freedoms will be ongoing and interesting.
Jessamy: It will be, and I finished reading that book Radical Help by Hilary Cotton, and at the end, she Brings up this great kind of analogy of how we used to look at sort of population health and starvation and this sort of moral thing that we have that even though there's enough food that some people just starve and that's because of how it is now that seems completely terrible 300 years ago that was That was what people assumed was how things were.
And I think, thinking now about, the welfare state and about health, how we let people slide through the holes, how we let health be poor because of a sort of ideological underpinning. How are we going to view that in a hundred years time? Is that going to seem completely almost archaic or will we have moved to a different space?
I don't know. Thank you for listening to this episode of The Lancet Voice. Remember you can subscribe to The Lancet Voice wherever you usually get your podcasts and we'll see you next time.