Fewer than one in four people are satisfied with the NHS, and it’s not hard to see why. Millions are languishing on waiting lists, and millions more are frustrated in their attempts to see a GP. The stories about NHS failings, avoidable deaths and A&Es in crisis are so frequent they no longer generate shock; just disappointment.
Cue calls for more staff and more money. Yet, while there are undeniably workforce shortages in some locations and some areas of staffing – namely outside of hospitals – there’s a much more fundamental issue undermining our healthcare system: over-centralisation.
Aneurin Bevan’s infamous words at the inception of the NHS have long been seen as fundamental to its functioning: “If a bedpan is dropped in a hospital corridor in Tredegar, its reverberation should echo around Whitehall.” But what if the “national” in National Health Service is actually the problem?
Few are aware that, 75 years ago, there was in fact considerable debate about whether a national or local model was best. Obviously a national system won out, and the belief that this prevents a “postcode lottery” has reigned ever since.
Yet wide variations in both access to healthcare and health outcomes are stark. In Derby, one in ten GP appointments take place more than a month after they are booked. This number drops to one in 50 in Liverpool and North Central London. People aged under 75 in Blackpool are three times more likely to die of preventable causes than those living in Cheshire East.
It is a myth that a nationally consistent model means nationally consistent care. That is because standardisation actually undermines the pursuit of equal outcomes rather than helps it. Different demographic profiles, types of morbidity and health behaviours lead to highly divergent requirements for health services. There is a reason few other countries have chosen to run their health services from the centre.
Our high degree of centralisation is also undermining the move to a more preventative model of care, despite a now broad consensus that, if we are to have a more clinically effective and fiscally sustainable health service, this is essential. Early intervention is most effective, most efficient, and indeed most deliverable at a local – or even a hyper-local – level.
Instead, the priorities and much of the activity is dictated centrally by NHS England, an arms-length body set up in 2014. Despite good intentions, people sitting in central government simply do not have the local understanding needed to tailor services to diverse local populations, and top-down diktats rob local areas of the flexibility to act differently.
That’s why we’re calling for a radically different approach. In “Close enough to care”, the latest report from the public services think tank Reform, we argue that, as regional devolution matures across England, the lion’s share of the £168bn NHS budget should be devolved to locally elected regional leaders. This should take the form of a block grant of at least five years in duration, and mayors should be free to spend it how they see fit – including on non-NHS services if they would boost health.
The Greater Manchester Combined Authority shows how such an opportunity could work. While in no way full devolution, it has taken on more health commissioning powers since 2016 and we are seeing improvements in healthy life expectancy, as well as a decrease in alcohol-related hospital admissions. Local people know their local populations and what they need.
To make this work, that also means a fundamentally different and much more streamlined role for the centre, including abolishing NHS England. And it means genuinely empowering local areas by scrapping national contracts and tariffs and devolving workforce planning. A coastal town with an ageing population will need a different workforce balance to an inner city with a young one.
That is not to say that the centre should not retain a key oversight role – it should set core-service entitlements and monitor overall system performance. But this would mean a centre that intervenes if necessary, rather than interfering at will.
The NHS is buckling under current demand, without serious reform it certainly won’t be able to keep up with rising future demand. We are already seeing that more investment does not automatically translate into better access or outcomes. That’s what happens when you pour more money into an outdated system.
The public may be committed to principles of the NHS, but it need not be centrally organised and planned. It will always be a National Health Service in name, but its survival depends on it looking more like a local health service.
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