Wes Streeting wants you know that he really, definitely isn’t plotting against Keir Starmer. Honest. In fairness, with NHS productivity flatlining since the pandemic, resident (formerly known as ‘junior’) doctors striking again after getting more than 20% extra pay last year and a raft of much-needed NHS reforms being announced this week as well, there’s plenty to keep the precocious Health Secretary busy in his current job without worrying too much about the next one.
Of all the items in his overflowing in-tray, those NHS reforms are probably most important over the long term. Because, and it’s sad to say, the NHS is no longer the envy of the world.
Our life expectancy is worse than countries like Sweden, Switzerland, Australia or Japan, which all spend similar percentages of their GDP on health. Health inequalities are bad and haven’t improved for decades, which means that people in poorer families still live years less than people in rich ones. And staff morale is getting worse, too.
The long list of previous failed reforms ought to give the Health Secretary food for thought. Lots of his Labour and Conservative predecessors tried to solve problems by moving decision-making into and then back out of different parts of the NHS organisation chart. But none of them addressed the underlying systems, processes and culture which dictate how NHS decisions are taken, and whether they drive year-in, year-out performance improvements or not, no matter where in the organisation they happen.
The levers that really control whether those systems and processes are delivering good outcomes or bad ones are things like the professionalism and training of NHS staff, and whether the people leading each shift or department or trust have the talent and freedom to keep raising their team’s game every year.
Wherever they do, the NHS delivers world-class healthcare. But where they don’t, the rest of the healthcare system isn’t strong enough to make sure problems get fixed on their own. The result is drift, inertia, stagnant productivity and frustrated staff.
How can we improve consistency? By giving patients the right to take their health problems elsewhere, as they already can in most other walks of life, so they can switch to an alternative publicly-funded health provider if they aren’t happy with the service they are getting at present.
Installing this new performance-improving engine would mean creating four rival, publicly-owned and funded, non-profit National Foundation Trusts (NFTs).
To start with, each one would be responsible for organising healthcare for a quarter of patient households in each part of the country, with funding to match. But after that, each patient would have the right to switch to any of the other trusts each year if they thought they were offering a better service, and each National Foundation Trust would have to accept any patient who wanted to switch to them. The four trusts would agree a funding formula between themselves, depending on each patient’s circumstances (like their age or existing health conditions) so money would follow each patient when they moved.
Each new NFT would have the same set of outcome-based health objectives, set by government and approved by parliament, to deliver for their patients. The existing Care Quality Commission would publish an independent annual report for each NFT, including an Ofsted-style one-word summary judgement of their performance, so patients will be able to see how well they are doing compared to the other three in case they wanted to switch. Any NFT that got a below-par evaluation would have to publish a performance improvement plan within three months to fix the problem, approved by the Department of Health.
The effects of this single, simple change would be electric, because patients wouldn’t have to accept whatever healthcare they were offered anymore, even when it wasn’t very good. Instead, all four NFTs would be running in parallel, often responsible for different patients in the same building, making performance comparisons and patient switching straightforward.
That may sound an administrative challenge, but in fact it’s already happening. Many NHS hospitals are already serving multiple masters, because they treat insurance-funded patients in private wards alongside their NHS work. It’s an already-established, successful practice, rather than something new.
With real choice available to patients, if their existing NFT had worse waiting times than the others for a particular treatment they needed, or didn’t offer online appointments while they were at work when other NFTs did, or couldn’t provide an NHS dentist nearby when another NFT would, then they would be able to choose a better service instead. Patients will get better services and be healthier; high-performing NFTs will grow and prosper; and poorly performing NFTs will have to improve or shrink.
Equally profoundly, each new NFT would initially inherit all the existing NHS agreements with GPs, hospitals, Integrated Care Boards and other providers, but would then have complete operational freedom to renegotiate them however it needed to improve performance in future. This would smooth the initial transition away from a single monopoly NHS, but give patients a steadily increasing range of options on everything from GP appointment waiting times to the quality of post-op home care packages, as each NFT delivers incremental performance improvements by adjusting which suppliers it works with and how.
Last but not least, Britain should train significantly more staff than the NHS will need in all disciplines and specialisms, to become a net exporter of health and care professionals rather than a net importer at present. This would reduce the number of expensive agency staff, saving money which could then be redeployed to improve other parts of the service. It would strengthen UK’s soft power abroad and give generations of domestically trained people great opportunities for a fulfilling career.
The NHS can become a national treasure again, but – as Streeting has rightly said before – it is a service, not a shrine. If he introduces these reforms to fix it successfully, he might even deserve to be Starmer’s successor. One day……….
If you like this idea, you’ll find more details, soundbites and rebuttals about it under A Better NHS in the Policy Thumbnail section of our website
This article is the latest in a fortnightly series of policy proposals published in CapX from John Penrose and the Centre for Small State Conservatives.
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