It’s rare for the NHS to be out of the headlines. From immediate winter pressures to the longer term challenges of promoting wellness and preventing illness, there is a continuous national conversation about the NHS. Like the weather, everyone has a strong opinion on our prized national institution.
The NHS is, as Professor Don Berwick astutely described, a “world leading example of commitment to health and healthcare as a human right.” People are as protective of it as they are critical. They want the best from the public service they turn to when they are in pain, vulnerable, and worried—they want to trust it and they want it to give them hope.
The NHS creates unparalleled social and economic value. It is a constant presence in everyday life, in sickness and in health—not least as it employs over a million people, and has a major role in local and national business through procurement, capital investment, and research and development.
Politicians understand the resonance of the NHS and the impact it has on their electorate’s voting intentions. Working with the NHS’s leadership and statutory bodies—most visibly NHS England, Monitor, the Care Quality Commission, the NHS Trust Development Authority, and Public Health England—politicians have helped build up a strong narrative around the NHS of the future.
There is, once the hyperbole is removed, a surprising degree of consensus across all political parties. They advocate the integration of health and social care; a greater focus on prevention; better access to primary care; seven day services; and, at last, true parity of esteem for mental and physical health.
These are imperatives for new ways of delivering care that build on local strategies and implementation. But this is where there is a disconnect between the overall narrative and the reality.
While nationally there is a shared ambition for radical change, at a local level politicians frequently insist that their services stay the same as they’ve always been, denying their constituents health and care services that are suitable to deliver 21st century care in favour of the status quo—irrespective of evidence.
Local services meeting national standards doesn’t mean that the NHS works the same way in every town and village. It doesn’t mean that local services will never change or that we should accept today’s standards as the best they can be.
The problem: ensuring we have a NHS and social care system that matches 21st century healthcare needs.
There are more people, living longer, with more numerous, complex, and serious health conditions. A one size fits all NHS doesn’t do justice to these needs. A NHS stuck in the formaldehyde of the 20th century will eat money, never quite managing to help people enough.
The solution: money, time, and space.
Everyone knows that the right people need to be in the right place at the right time to provide the right care for patients and service users.
Everyone in the NHS—from board to ward—knows what they would do to make things better if they could. That’s why they joined the NHS: to make things better. But today’s pressure leaves little room for anything save keeping heads above water.
How do we move forward, both changing and preserving this key public service?
Unavoidably, a large part of the answer does come down to funding. Political acceptance of this is dawning. There is a quiet acknowledgement that without adequate funding, care standards or the current range of services cannot be maintained. But we are some way away from a full realisation of the scale of the increase needed, and from a candid debate about what it would mean to make such a level available.
Realistically, that will only happen after the general election. So NHS Providers—representing over 94% of NHS acute, mental health, community, and ambulance services—are setting out our plan to take us from day one of the next parliament.
By then, the NHS will be under even greater pressure: it is then that we must fight hardest to be true to the NHS’s founding principles, and change the way we deliver health and care.
The NHS needs substantially more money from the government, and the NHS need to do better with it. Local health systems—with providers and commissioners working in partnership—need to invest in improvement and in working towards shared objectives.
How funding flows through the NHS can be improved too. The NHS funding cycle currently asks those on the frontline to say what they’re going to do before they’ve been asked to do anything, and before they know what resources they’ll have to do it. This must stop. We need an adequate multi-year NHS funding deal, to invest efficiently and effectively in current and future care.
The board of directors of an NHS foundation trust or trust is responsible for the care provided. An engaged workforce that feels valued is essential for successful, consistent, and compassionate high quality care, and boards must be able to create the necessary conditions.
A board must set the tone, empowering staff to fulfil a shared vision, while ensuring the right staff are available and have their pay matched with their performance.
Regulation alone cannot prevent poor care, or impose good care. Regulators can only look at what has happened: they do not pretend to hold the clinical expertise of those on the frontline. Yet the centrality of the NHS to everyday life and to the political narrative drives a level of risk aversion, which incentivises regulatory over-reach and performance management. The rate, cost, and burden of regulatory intervention and reporting are growing at pace, without clear patient benefit.
The right role for regulation is making sure that the systems and standards are in place for good care to happen—ensuring good governance, and removing barriers to quality and performance.
NHS providers need freedom to innovate, design, and deliver the care that patients need. If they are given the money, time, and space to achieve, they—and their commissioner partners—can be held accountable for the results. Through that balance of autonomy and accountability the NHS becomes truly high performing.
NHS providers have the clinical and operational expertise we need to transform the NHS into the 21st century service we need. Professionals and policymakers visit to learn how we can do so much with the money we have, which is lower proportionately than that invested by the largest, comparable countries. Our comparative performance and leadership is downplayed by politicians and the media. As citizens we trust the NHS every day with our lives. We forget that over seven decades it has changed radically, and must continue doing so.
Our “Programme for the next Parliament” sets out the path for changes in these four areas. As we move to new models of care, there are barriers and distractions to remove, and capabilities and capacities to enable.
As we do so, we need to renew our confidence in the NHS, a world class investment that cares for one million people every 36 hours. More than just money, it is a truly inspirational social construct. The vision of giants.
A lot of rhetoric is used about our beloved service. It’s time to make it real. We all want the NHS to be fit for purpose, to be here today, tomorrow, for you, for me, and for our children. Let’s make it so.
Gill Morgan DBE is chair of NHS Providers.
I have read and understood BMJ policy on declaration of interests and declare the following interests:
· Chair NHS Providers (paid)
· Chair Alzheimer’s Society (unpaid)
· Adviser De Poel (paid)