A reformed NHS should be accountable to the public

The writer, a former head of the Downing Street policy unit, is a Harvard senior fellow

Only the British, an Italian friend points out, could accept “Protect the NHS” as a slogan in a pandemic. Surely, he says, you should expect your health service to protect you? The NHS is a national religion. But with heroic doctors and nurses now trudging exhausted towards the light, it is time to ask what changes we need if they are to protect us in the future.

Before Covid, the system was already creaking at the seams. Survival rates for many cancers were below the EU average. Nurse vacancies were at a record high. Friends who work at my local hospital have delighted in showing me where cockroaches fall through the ceiling. Those buildings haven’t changed much since my children were born there, and even since I was born there. Worse, the system architecture — a landscape of siloed hospitals, GPs, mental health trusts and social care — hasn’t changed much since 1948.

In postwar Britain, you went to hospital to have a baby, or to recover from an injury. Then you went home. Now, an ageing population pings between hospitals, clinics, care at home and care homes. The bulk of the NHS budget is spent on people suffering from chronic diseases such as heart disease and type 2 diabetes, who use the service many times a year and need it to be joined up.

The pandemic showed how fatal silos can be. When hospitals decanted people into distant care homes without testing them for Covid-19, they left the UK with one of the highest death rates in the world. The crisis has also exposed longstanding health inequalities, with poorer people especially vulnerable to coronavirus after years of failure to prevent chronic disease and tackle obesity. But in addition, it has shown how much red tape in the NHS is unnecessary. Paperwork was shelved, the Nightingale hospitals were put up in days and staff retrained into new roles in weeks — despite the grumbles of regulators, professional bodies and quangos, some of which look increasingly redundant.

Bureaucracy has been expanding for years under reforms that tried to promote efficiency by imposing market discipline. New Labour’s top-down targets and private sector operations initially did bring waiting lists down. The Conservatives in 2012 gave GPs control over budgets to make them the “gateway of choice”. Yet the result has generally been increased focus on compliance, complex procurement processes and less staff time spent with patients.

Today, the reality of life on the NHS frontline is repeatedly being asked for duplicative data without knowing why, spending hours reporting incidents and receiving tick-box appraisals. A recent review found that community-based doctors now spend a third of their time on administration and patient co-ordination. Unsurprisingly, rising numbers of British doctors end up in New Zealand and Australia.

The UK government is proposing to end compulsory competitive tendering and to promote collaboration between services. This marks the end of 30 years of attempts to create an internal market and is a categoric admission that the Cameron government’s 2012 reorganisation of the NHS — which I opposed at the time — has been a failure.

They don’t have all the answers yet, however. The history of wholesale reforms suggests that it will be important to tread carefully. Social care, a vital part of the picture, is still under discussion. And while the new, local integrated structures may take prevention more seriously, there is a risk they will turn out to be cosy and complacent. The big question is how to drive improvement in patient care, in the absence of a market, and hold providers to account.

One way could be to maintain a plurality of provision, as in France and Germany, and to retain competition in some areas, such as elective surgery. Part of the answer must be transparency. In France, every citizen owns their electronic health record. In England, although we are near the point where intelligent predictive data could shape personalised care, patients are asked for the same information over and over.

Moreover, we remain largely ignorant of what can be alarmingly wide variations in outcomes. A review of maternity care noted that it was of poorer quality than in much of Europe and detailed some shocking tragedies. No system is perfect. But last year, in a society whose citizens are not terribly litigious, the NHS faced a £4.3bn bill for clinical negligence.

We citizens probably need to act less like grateful patients, sitting dumbly for hours while a grumpy administrator searches for our lost test results, and become more demanding consumers. I don’t mean being bolshie: when my father was in hospital for two months, I watched aghast at how some relatives bullied staff. But I do mean carrying our own health records, taking more responsibility for our health and asking more questions.

Who, though, is accountable to the public? The core expenditure of NHS England, excluding emergency Covid costs, is about £150bn a year. Making this quango operationally independent of government in 2012 removed some of the political pressures on it, and has provided more consistency of purpose. But it must answer to parliament. In the pandemic, the NHS chief executive made decisions with little challenge from parliament or the media, but the secretary of state took the heat. Some rebalancing is needed.

My admiration for many NHS staff knows no bounds. But I don’t feel the same about many quangos, regulators and agencies which litter the system. If we want to truly “protect the NHS”, we all need to hold it to account.