For any incoming government, improving health, health care, and social care will be top of the in-tray. Health is the largest single area of government spending – almost £1 in every £5 spent and growing. The NHS is consistently number one on the list of voter concerns, not least with a record 7.6m people on waiting lists for elective care. Life expectancy and healthy life expectancy are stalling, and a record near 2.6m people of working age are economically inactive due to ill health. And in the face of rising numbers of older people (and relative to workers) with increasing health needs, publicly funded social care is already scandalously threadbare to non-existent for many.
All three areas are huge, needing an intelligent strategic programme and investment over the long term. The main solutions are well known and supported by wider consensus and evidence. The most important are unglamorous and basic with no immediate appeal to voters. For example, more and better targeted investment, better management and planning of key resources, more effective implementation and coordination across agencies, and coherent clear short-, medium- and longer-term strategy and action. For these, it is hardly an absence of research evidence on what works that blocks progress.
Within this wider picture, picking out specific evidence-based recommendations for a new government will inevitably be very partial and subjective. A new government will want deliverable short-term objectives with impacts visible to voters, as well as working on long-term priorities. The focus should be on what not to do as well as what to prioritise. So, here’s three.
On the NHS, getting waiting lists down and improving access to primary care are the hottest issues. Both will mean boosting staff numbers, already on the cards through the NHS Workforce Plan (shaped by independent analysis). On waiting lists, lessons from the 2000’s showed the positive impact of investment, focused targets and performance management, design of financial incentives and use of non-NHS suppliers of clinical care. Design for today’s context will take time but no less is needed for a serious attempt to make progress. On access to primary care, apart from boosting GP numbers and other supporting staff, and tackling the ‘inverse care law’ in access across England though better targeted investment into underserved areas. Priority should also be to boost capital investment in digital and communications technology so patient interactions with services are as convenient and slick as possible (e.g. no waiting in a queue to make an appointment) in part through steady development of the NHS app. For GPs, ample surveys report the level of admin is far too high, and can be significantly reduced through using technology existing today.
On improving population health – where to start? We could wait for the economy to improve and, with it, health – which could take a long time. But a new government is likely to find the stark picture of declining life expectancy in some areas, large inequalities in health, and ill health forcing over 2 million people of working age out of the workforce (and making many more economically underactive) unacceptable. There are many evidence-based solutions for example acting on the wider determinants of health, on reducing more specific known risk factors. But for starters a new government should develop a robust cross-government strategy to improve health (acting on the wider determinants) and a related strategy to reduce inequalities akin to that developed in the 2000’s. This multi-year and multi-faceted strategy aimed to reduce geographical inequalities in life expectancy by at least 10% between the fifth of local authorities with the worst health and deprivation indicators (so-called Spearhead areas) and the population as a whole. It had positive impact. Recent analysis sets out a useful framework for practical action on inequalities by national and local government. A new government could also strongly target the biggest specific risk factors to health for the population as a whole, in particular smoking, poor diet, physical inactivity, and harmful alcohol use. It would help if the Khan Review’s evidence-based recommendations were acted on, and tougher action to adopt price-based policies, taxes and regulations already proposed in previous government documents. Examples include minimum unit pricing for alcohol (already introduced in Scotland and Wales); bolder reformulation of food and drink to reduce sugar, salt and calories; further restrictions on advertising of junk food especially to children; and raising the age of sale for tobacco from 18 to 21. These actions require government action and don’t heavily rely on individual choice and behaviour to have impact.
On social care, the main priority here should be to invest more so there is better publicly funded support for older people, and to shore up the supplier market which is currently very fragile (or ‘at tipping point’ as the CQC stated 7 years ago). Current efforts are not nearly enough, and action to improve staff pay and conditions (there are shockingly high rates of poverty among care workers) need immediate remedy. Insuring people against catastrophic costs could be done by implementing existing policy on the statue book – the core principle behind the Dilnot Commission’s recommendations previously accepted by government but not yet implemented. In the longer term, mandating saving for support in old age must be on the policy cards, given demographic shifts. But this will all need careful handling, learning from international approaches such as that taken in Germany, building more public and cross party consensus (as far as possible) on sources of funding, and doing this well clear of a general election period.
About the author
Dr Jennifer Dixon is Chief Executive of The Health Foundation. Prior to this, Jennifer was Chief Executive of the Nuffield Trust from 2008 to 2013, and before then she was Director of Policy at The King’s Fund and was the policy advisor to the Chief Executive of the National Health Service between 1998 and 2000. Jennifer has undertaken research and written widely on health care reform both in the UK and internationally.
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