NHS: Long-term Sustainability

Lord Warner Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Warner (CB)]

My Lords, I congratulate the noble Baroness, Lady Ramsey, on her excellent initial contribution to our debates. Unlike the noble Lord, Lord Patel, my experience is that too many interests are still worshipping at a 75 year-old NHS shrine that only 25% of the population is satisfied with. The NHS is trapped in an over-centralised management and service delivery model that cannot improve efficiency fast enough to cope with the tighter funding it faces.

As others have said, too many services are delivered to what I would describe as overcrowded, expensive and overprotected acute hospitals. We have neglected investment in primary care, community health services, social care and public health. We should ignore pleas to pour more money into this dysfunctional 75 year-old and focus on fundamental reform, led by people capable of delivering change at pace. My sketch of a five to 10-year operational plan to do this has five main strands.

First, we need fundamental change of a failing top management at the Department of Health and Social Care and its replacement with a new health and care management board, chaired by the Health Secretary, a CEO with high-level management experience outside the NHS, supported by a chief people officer for all workforce issues, and a chief finance and efficiency officer. I will not go into more detail, but I think this would lead to the abolition of NHS England—which would get quite a few cheers in the NHS, I suspect— and some other health quangos, which would get a further lot of cheers.

Secondly, we should consider emulating Singapore, which has similar health outcomes to the UK while spending less than 5% of its GDP on health. This low figure is accomplished because it delivers so many services outside acute hospitals, using up-to-date technology. It is very difficult to get into an acute hospital in Singapore. To achieve this change, we need to restrict the proportion of NHS funding going to acute hospitals over a five to 10-year period and invest much more in community-based services. We would need a clinically led national team, perhaps using the Academy of Medical Royal Colleges, to concentrate more specialist services in fewer sites, but with an enhanced capital investment programme for selected hospitals. Those hospitals with fewer services should become local community hospitals, and this should be the end of the district general hospital, a 1960s model. To make these changes stick, they should be underpinned by secondary legislation.

Thirdly, in consultation with the Royal College of Surgeons, all elective surgery should be undertaken in its own units, either provided by the NHS or contracted for with the private sector at NHS prices, which we managed to achieve in the noughties. Again, that would be a capped five-year budget which would not be used for other purposes.

Fourthly, we should be devolving responsibility for the management of all GP contracts, primary care, community health, social care and public health to new regional bodies, with elected mayors heading up as many bodies as possible, using devolution deals such as that done in Manchester. There should be a protected budget for this sector, growing faster than acute hospital budgets, with any real-terms cuts reported to the Public Accounts Committee.

Fifthly, a statutory proportion of the NHS budget should be devoted to public health, administered under the guidance of a new independent office of public health, set up on the lines of the Office for Budget Responsibility. It would be able to take the kind of difficult decisions on public health that the experience of recent years suggests elected politicians find very difficult. I would call this the “tough love approach”, and it is the direction of travel the NHS needs to consider taking. If the Front Benches want to find out more, they can go to the Social Market Foundation website and read my pamphlet on the NHS at 75.