The NHS at 75 needs to be rebalanced

To coincide with the 75^th anniversary of the founding of the NHS, the NHS Workforce Plan has now been published promising 300,000 new healthcare workers. This is clearly welcome but the current ills of the health service will require action on a broader front and it remains to be seen whether such a number could be recruited or retained without other significant changes being implemented. Our view is that the NHS needs a reset, not just a recruitment drive, in order to deliver systemic change for its long-term future.

The need for a rebalancing of the NHS was the conclusion reached by the Henley Centre For Leadership 2023 Symposium on the NHS – a diverse group of executives from the health, education, technology, energy, community inclusion and charity sectors who met in June at Henley Business School.

Whenever new or additional funds are announced for the NHS, hospitals tend to receive the lion’s share. They are vital and also popular with MPs and voters alike. Hospitals will always need additional funds and we are clear that they continue to need significant investment but new funds are needed now for primary and community care, at one end of the system, and social care at the other. Primary care provides patient education, prevention and early diagnosis and treatment. It can reduce and even obviate the need for hospital care in a great many cases. Social care and care in the community create more opportunities for patients to be discharged from hospitals without delay. This shift in spending priorities will rebalance the entire healthcare system. By creating better services at the beginning and end of the process, pressure on secondary care can be eased, and the health of nation will improve. These changes must include recruitment and retention of professional staff to deliver services.

What we are proposing will require brave leadership to create a short, intensive programme of investment that is funded with additional money for a limited time period. Our belief is that this could deliver the long-term dream of flattening the ever-rising line of NHS expenditure by reducing demand for hospital treatment and retaining those who provide it. This was always Bevan’s dream but it has proven to be elusive.

The prime minister, speaking in support of the NHS Workforce Plan, described a once in a generation opportunity to bring in more talent to the NHS. However, if we do not reboot the system, the new doctors and nurses will be parachuted into services that are still lurching from one crisis to another, because the core issues have not been dealt with – too much demand and too few resources.

Focus on primary and social care

Our view is relatively straightforward although it will require strong leadership to see through a period of change.

Since the NHS was founded 75 years ago, most governments have invested in a sickness service in hospitals but at a lower level of investment than our wealthy nation peers. The consequences of this underinvestment have been woeful:

• fewer doctors, nurses, hospital beds and scanners per 1000 population
• an exodus of skilled professionals to the private sector or to other countries offering better pay and/or conditions
• huge increases in waiting lists (we are now up to around 7.5 million people waiting for treatment)
• a higher mortality rate in the UK than our nation should expect

Clearly, the NHS can be set up to improve people’s health and take a great deal of the strain away from hospitals. A reconfigured and properly resourced primary care sector is essential to meet the demands of modern Britain.

Since the NHS was originally set up in 1948, health requirements have changed but they are not adequately reflected in our funding priorities. The infectious diseases of the 1940s and 50s have largely disappeared. Today, we have a population that is suffering from chronic conditions, such as obesity, diabetes, high blood pressure, arthritis, and poor mental health among others. These are best treated in community settings before they get to a point where hospital treatment is required.

At the same time, we have an ageing population increasingly in need of better social care so people who are in hospital can be discharged far quicker. The problem for many people is they get admitted to hospital, receive their treatment and then, like Hotel California, cannot leave.

However, let us be clear: we are not calling for a reduction in spending on hospitals. That will continue to be vital. Robbing Peter to pay Paul is self-defeating. But by reducing the number of patients needing hospital treatment and by freeing up beds sooner, there is some chance that we can make serious inroads into the numbers waiting for treatment.

Retaining our professionals

The NHS Workforce Plan made no mention of pay levels. Our cross-industry group were wary of constant pleas for more money for the NHS. Yet two points of view drew unanimous support. First, healthcare professionals are seriously underpaid. Doctors and nurses, for example, are leaving the service in significant numbers causing significant distress to the staff themselves and rendering their expensive training wasted. Second, a new vision for healthcare in the UK is unlikely to be realised without refocused investment.

Recruiting 300,000 new healthcare professionals is one thing but retaining them is quite another. Rebalancing the NHS so that these new recruits can enter a stabilised organisation is one crucial step. Without adequate pay and a constructive culture, many will leave for better pay and working conditions in Tesco or in Australia.

An additional step towards making their work more rewarding and productive, is going to come through technology. The headlines will concentrate on how this will aid early diagnoses but, just as importantly, it will take away the hours of paperwork a healthcare professional has to wade through every day. This is time that could be far better spent on direct patient care. And this benefit can be realised relatively swiftly.

Budget

It has become increasingly clear that rebalancing requires investment. Professor Sir Chris Ham’s report for the King’s Fund The Rise and Decline of the NHS in England 2000-2020 found that between 2000 and 2010 improved investment in the NHS led to better outcomes. Unfortunately, these gains were short-lived. The global financial crisis in 2008 led to serious under-investment in healthcare and the reversal of earlier gains. The pandemic came when the healthcare system was already impoverished and it nearly crashed the entire system.

Sir Chris's report pointed out that UK health spending would have been £40bn higher every year between 2010 and 2019 if it had matched the average among the wealthier nations in Europe. It is likely that a similar sum may be required each year over the next four to five years to reset the NHS, but this is an investment rather than merely a cost.

We are calling for a temporary investment of new money to rebalance the system around primary and social care and facilitated by an imaginative deployment of new technology to improve the working lives of health and social care professionals, in order to liberate more time for patient care.

To avoid the customary heartsink caused by any mention of restructuring the NHS, the purpose of this reboot is not to restructure but to ensure that a rebalanced system fits the public’s needs better, saving hospital capacity by primary, community and social care playing an enhanced role.

This article was co-authored by Sir David Haslam (co-chair), Former Chair of NICE, Past President of BMA, Past President and Chair RCGP Professor David Pendleton (co-chair), Professor in Leadership, Henley Business School.