A Royal Commission on the NHS

Lord Saatchi and Dominic Nutt last week published a remit for a Royal Commission on the NHS. The NHS staggers from crisis to crisis. The demand for a non-political party strategic review, first proposed by Norman Lamb, then shadow Health Minister for the LibDems, is growing. About 100 MPs agree.  We supported the idea some months back. The government does not (yet) agree.

The Saatchi paper was cited by Dr Andrew Murrison who also pushed for a Royal Commission in a PMQ on 10th January.  The Prime Minister briefly dismissed the proposal with disdain:  any problems the NHS may have need immediate attention, rather than awaiting a Royal Commission.  The party line is that everything is fine because the Department of Health now has a Plan.  The PM’s response is flawed: a strategic review would not inhibit any improvements that can now be made.

The only previous NHS Royal Commission was set up by Harold Wilson in 1975.  Little has changed.  Waiting times at A&E were one concern, excessive bureaucracy and layers of management were two others. Some of the reports’ conclusions are familiar: “The development of nursing homes could make a major contribution to the care of the elderly.” (22.32) Mental health needs to “be integrated fully into a unified psychiatric service, and to receive a proper share of capital monies.” (22.34)  “22.35 Finally, we concluded that communications between the hospital and the community services were not all that they should be, and that the arrangements for community workers to work in hospitals, and hospital workers in the community needed to be improved. Strong links were particularly important in the rehabilitation services.” Many of the 58 recommendations, such as compulsory seat belts, were successfully implemented but many others still, 39 years on, need to be.

That report focused on effectiveness, i.e. NHS value for money, but even so, it took four years to produce.  In contrast, the Saatchi remit covers almost everything conceivable: “The aim should be to produce a fully costed blueprint that delivers the best possible outcomes over the coming decades at the lowest cost.”  Actually: “a series of options for implementing its central ideas, each of them fully costed”. Identifying and measuring “the best possible outcomes” would be ambitious, never mind quantifying all the alternative cost implications.  Health inequalities between different parts of the country and of society would be corrected along the way. “The Royal Commission would also be tasked with investigating a range of other issues, including the gap in health outcomes between rich and poor, and between Britain and other countries; the ageing population; the pace and cost of medical innovation; the need to integrate social and long-term care with health care; the case for and against greater private sector involvement in the delivery of health care; the tensions between privacy and better use of health data; and potential additional sources of revenue for the NHS to complement general taxation.”  And “Mental health provision must also be considered, including as a chronic, public health issue which causes, and can be caused by, poverty.”

This brief, to cure the NHS, adult social care, mental problems and poverty, would, if it were feasible at all, require many more years than the four of the 1979 report.  Can the NHS afford to wait that long?

Norman Lamb’s proposal that a non-political party “convention” be tasked to report back within a year is realistic and practical.  Like the 1979 report, it should focus on value for money, i.e. minimising waste, and leave the issue of the quantum, i.e. the total amount of the departmental budget, the nation can afford to the Chancellor.  This would make the convention far more acceptable to a government tired of being lectured about increasing NHS spending.

There is plenty to go for.  The 2016/7 Department of Health accounts (p.119) shows that, of the total Department of Health £139bn. expenditure, £106.9bn. (77%) went to NHS England, £2bn of which was passed on to Local Authorities for social care (unblocking beds).  The vast majority of adult social care is funded by the Department for Communities and Local Government (as it was until January 2018).  Only about £100bn. (72%) reached the front line, i.e. treating medical and dentistry patients, medicines and devices.  5% of the departmental total (£7.2bn) went on quangos – some necessary, some not.

Comprehensive as the Saatchi remit is, a few areas seem to be been overlooked such as:

Restraining demand through co-payments, as already apply to dentistry and prescriptions, and redrawing the boundary of what the NHS should provide.

How to push treatment back from higher cost (acute hospitals) to lower cost provision (towards cottage hospitals or home).

The impact on management hierarchies of closer integration of the (vertical) NHS and (local/lateral) adult social services.  The latter is less top heavy and may be the better model.  For example, the widely discredited CCGs could be eliminated at a saving of £1bn. p.a. of managerial costs.

We are short of GPs, geriatricians and nurses essentially because people don’t want those careers.  Paying them more would help up to a point but the problem has more to do with job satisfaction. Less bureaucracy, interference, record keeping and more trust would help.

A Royal Commission is attractive but, sadly, not feasible.  The Saatchi remit would take too long, cost too much and arrive on the desk of a new government which is unlikely to share the perspective of the current team.  We need decisions before the next election.  On the other hand, the Lamb proposal of a non-political party, year-long convention is something the government should rush to accept.  If it does not, the House of Commons Health Committee should commission it as it is perfectly entitled to do.