NHS England chief executive Simon Stevens has been remarkably successful in prising more money for the health service out of the government, but short-term ministerial thinking about the service and its resources has resulted in an unedifying, dysfunctional scramble for cash in austerity Britain. Finally, though, ideas are emerging that could change all that.
Trying to meet rising expectations without the money to do it has driven the NHS to run every part of the system hot. As fissures open up in budgets and services, the army of healthcare special interest groups such as the BMA trade union, NHS Confederation and the medical royal colleges – which collectively far outgun the rest of the public sector for political influence – powerful, persuasive healthcare special interest groupportray every difficulty as a lethal crisis. When Treasury resistance is finally overcome, unrealistic promises have to be made to provide political cover for the capitulation. Then the dance begins again as the NHS pursues another set of unrealistic goals with too little money and too few staff.
Crucially, this political battle is largely disconnected from any debate around wider social policy goals, save for the fact that everyone is scrapping over taxpayers’ money.
Now Stevens is beginning to stimulate discussion around a different approach. In recent speeches to the Health Foundation and Royal Society of Medicine, he has argued that wider social policy decisions should be used to predict future demand for healthcare.
This is a powerful lens. For example, as demonstrated in London, we can easily determine how many thousands of children are being exposed to illegal levels of pollution each day as they go to school, and there are numerous studies demonstrating the link between pollution and illness. Pollution is not some unfortunate accident but a consequence of a range of policies – from the provision of bus services to the price of petrol – that influence how we behave.
Similarly, as United Nations rapporteur Philip Alston has forcibly pointed out, poverty is a policy decision, and we know poverty drives mental illness and obesity. If the policy is to have children living in poverty, we can estimate how that will drive demand for health services.
If this way of thinking started to get traction it could be transformative. It would certainly focus ministerial minds if they had to explain to parliament and the public how they were going to address the consequences of failures, such as planning for a large increase in respiratory specialists over the next two decades, or predicting how many children below the poverty line would need mental health services before they were 25.
This might sound ambitious, but support for just such an approach may well emerge from the five-year study just announced by the Institute for Fiscal Studies into the forces that shape inequality and what we can do about it.
The £2.5m programme, funded by the Nuffield Foundation, is being led by Professor Sir Angus Deaton, who was awarded the Nobel prize for his analysis of poverty, welfare and consumption. This is a big, politically high-risk undertaking for the IFS, and with so much money and intellectual firepower behind it there is every reason to hope it will have a significant impact.
There are other ways in which thinking about the wider role of the NHS is becoming more sophisticated. There is growing interest in how hospitals can use their muscle as major local employers and contractors – so-called anchor institutions to benefit their local economy. Many hospitals, notably in deprived areas, are among the biggest local employers. To take just one example, Sheffield Teaching Hospitals NHS Foundation Trust has 17,000 staff. And healthcare organisations spend roughly £20bn a year on goods and services. There are also signs that the relationship between health service and climate change is finally getting some attention after years of talk but little action.
Taken together, these are significant developments. They present a rare opportunity to join the dots between the NHS and the other parts of public policy which determine how we live and when we die. In the long run they could encourage far greater debate and understanding around the connections between political decisions, inequalities and the scale, shape and role of our care system.
