Chapter 7: Towards a lasting political consensus
321.The time has come to change the way we approach the provision of health and adult social care. This chapter will highlight the clear lack of long-term planning across the board, including by politicians, and will conclude that further independent oversight and scrutiny is needed, and that a new independent body should be charged with this task.
A culture of short-termism
322.Our inquiry uncovered endemic short-termism in almost every area of policy making. Those charged with planning and making decisions which affect the whole NHS seemed to be plagued by short-term pressures and, as a consequence, lacked the ability to look beyond the ‘here and now’ to the longer term. Long-term planning for NHS and adult social care services is clearly insufficient. This short-termism represents a major threat, and seems to have been a longstanding problem; even when resources were more plentiful, little thought was given to the longer-term problems the NHS faced.
323.As we mentioned in earlier chapters, the most notable exception to this was the Five Year Forward View pioneered by Simon Stevens, Chief Executive of NHS England, but the timescale covered by this document (2015–20) is nearly over. He told us in December 2016 about a forthcoming extension to the document which will look beyond this Parliament:
“In three months’ time, I intend to publish the delivery plan for what the National Health Service will look like for the rest of the Parliament. Probably going into 2018, given that it is important that the strategic questions that this Committee is addressing are out there for public debate, I intend that NHS England will publish a set of proposals, a manifesto if you like, for what going into the next Parliament should look like over the medium term: the kind of timeframe that this Committee is debating.”291
This development is encouraging, and although the delivery plan had not been published at the time of writing this report, we await its publication in the near future.
324.Despite this, we were not presented with any of the details of the planning for the NHS (including for funding, social care and the workforce) that goes beyond 2020–21, despite a wealth of evidence on the likely changes in demography, burden of disease and emerging technologies. There appeared to be a prevailing culture of complacency within the Department of Health, including amongst its ministers and officials who did not see the benefit of planning for the long term. This was clearly demonstrated when we took evidence from Chris Wormald, the Permanent Secretary at the Department of Health. Although we questioned him at length on the work taking place in his department on the long-term future of the NHS, revealingly, we were not provided with any concrete examples. Moreover, he questioned whether this was work that should even be taking place in his department explaining that: “Personally, I am not a fan of trying to answer every question from a desk in Whitehall.”292 When we questioned him on what work the department was undertaking to plan a system that was more likely to distribute the resources available in line with the service delivery needs of health and social care in the future, he went on to explain that this planning for the future was taking place within the Sustainability and Transformation Plan process. We were unconvinced by the answers he provided and we are left with no choice but to conclude that the Department of Health is failing to plan for the future.
325.We look forward to the publication in the near future of NHS England’s delivery plan for what the NHS will look like for the rest of the Parliament. This will be a positive development in the short term. We are extremely concerned, however, that the Department of Health is failing to plan for the long-term.
Building political consensus and engaging the public
326.A lasting political settlement for the NHS and social care was highlighted by a number of witnesses as the main solution to many of the current problems. When we put the prospect of such a settlement to Chris Wormald, however, he expressed scepticism:
“Turning to your question of whether there should be a long-term settlement of that issue, obviously there is a lot of politics in that. There are few more debated topics. My personal view is that there should probably not be. I do not see that you can deal with health spending either economically or in policy terms in isolation from the rest of government. That question of whether you want to invest a greater proportion of GDP as the economy expands is a question of how you prioritise health spending against other forms of public spending and wider economic activity. I am not sure that is a question you can have a long-term answer to.”293
We are of the clear view that a political consensus on the future of the NHS and social care is not only desirable, it is achievable.
327.Toward the end of the inquiry, we invited the health spokespeople for the three main opposition political parties in Westminster to appear before us; we are grateful for the time they took to speak to us. Norman Lamb MP, the Liberal Democrat Health spokesperson, told us about the failures of the past: “The brutal truth is that none of the political parties at the last election had a solution for the long-term funding challenge of the health and care system. No party proposed any mechanism to increase funding for social care.”294 He went on to argue that a lack of political consensus was doing real harm and inhibiting the ability of those in positions of responsibility to plan for the longer term: “There is a sense of complete inertia. We are sleepwalking towards the edge of the precipice. There is an urgency, therefore, about this.”295
328.Looking to the future, he told us about a piece of work he had commissioned:
“… I have set up an expert panel to advise my party, which will report within six months. It includes the former head of NHS England, the former head of the RCN and many other eminent people, together with two health economists, looking specifically at the case for a hypothecated health and care tax and the level of that tax that is needed to properly fund the system. We will come out with a policy next year, as soon as the panel has reported, to contribute to this debate.”296
329.Despite this specific example, from the evidence we received we were far from convinced that the political parties have truly bought into a longer-term approach that would inevitably curtail their room for manoeuvre at election times. Dr Philippa Whitford MP, the SNP Shadow Westminster Group Leader (Health) told us:
“When we move towards an election time, people are doing soundbites around the NHS because it is so important to the public and we are not moving forward … “297
330.We received a number of calls for a commission to be established to help bring about a new political consensus. Mindful of the fact that there have been numerous commissions and reports on different aspects of health and social care provision in the past, we feel that this is not the most effective way to proceed at this time. The public expect political consensus to be delivered as a result of cross-party talks and it is the responsibility of the main political parties finally to come together to make progress on all of the issues examined in this report.
331.Meaningful public consultation will be critical for any political consensus to be accepted by those who work in and use the health and care systems. The Patients Association told us that such an exercise would need to be tailored and multifaceted:
“By its very nature, public engagement cannot be a ‘one size fits all’ model and engagement should be embedded in everyday practice. The public must see the value in engaging in what they want from a health service, which will require real change developed from their contributions.”298
332.There is, of course, a difference between consultation which doesn’t have any tangible influence on the future direction of health and care, and consultation which is actively listened to and has a discernible effect on the formation of policy. Applied Psychology Ltd explained that this would require: “closing what might be described as the ‘credibility gap’ between the public and the planners, by listening to views that are already expressed publicly, and by demonstrating an authentic desire to learn from formal consultations.”299
333.Many called for a ‘national conversation’ on the future of health and care, an aspiration we share. The Academy of Medical Royal Colleges presented the need for a national conversation in the light of the exceptional pressures being faced by the health and care system at present:
“In light of the extreme financial pressures the health and care system in the UK are under and the fundamental changes required to create a sustainable system, there should be a ‘national conversation’ to determine how the shortfall should be funded and what reconfigured services should look like.”300
Such a conversation should be truly national and involve people throughout the country, including those involved at all levels of decision-making, as well as those who make up the NHS workforce and, importantly, those who use the health and care system.
334.The historic political failure to take a long-term approach to the provision of health and adult social care has been a major stumbling block to longer-term sustainability. Efforts should be made to encourage cross-party consensus. If this consensus is to be accepted by the public it should emerge as a result of committed cross-party talks and a robust national conversation. The Government should seek to initiate these immediately.
The case for a new body
335.Securing a much awaited political consensus on the way forward for health and social care is important but this is only part of the solution to long-term sustainability. Given the amount of public money spent on health and adult social care, accountability is important. Such accountability, however, should not simply refer to what the money is used to pay for. It should also cover the standard of planning, the way in which money is allocated and the over-arching long-term strategy for the future of health and adult social care provision. Apart from periodic reviews, commissions and parliamentary inquires, there is currently no individual or body charged with performing this task.
336.When questioned on the merits of creating a new body similar to the Office for Budget Responsibility (OBR) to oversee longer-term health and social care funding and planning, Labour’s Shadow Secretary of State for Health, Jon Ashworth MP, was enthusiastic:
“I am very much attracted to the idea of an OBR-type body which gives periodic reports on the financial pressures on the NHS, what is needed and what are the workforce pressures, and offers a degree of objectivity in the planning which is slightly separate from the political knockabout that inevitably happens in the House of Commons. It is a very sensible idea and is something I would support.”301
Following the evidence session, he echoed his call in the press for an OBR-style body for the NHS which would help ensure that the NHS received adequate funding and was not the subject of political rows.302
337.Simon Stevens, Chief Executive of NHS England, was similarly enthusiastic and pointed out that such an approach might reduce adverse annual variations in funding:
“It is an idea that in some respects has its attractions. With other countries’ systems, which are financed with universal coverage, you get less lumpiness as a by-product of the funding mechanism in its own right. Beveridge303 systems are more prone to lumpiness, so the question arises: can you overlay the sort of mechanism that you describe?”304
338.We were encouraged to hear the Secretary of State for Health also express interest in the idea. When we questioned him on whether the Government needed more help to plan over the longer term and overcome the ‘five-year groove’, he said “I think there is merit in the direction of travel.”305
339.Dr Philippa Whitford MP told us that such a body should not only be advisory but should be part of the decision-making processes:
“I totally support the idea of an arm’s-length body but you have to remember that the OBR only reports in, it just says, ‘This is what it will cost, you are on track, et cetera’. We get reports on performance from the National Audit Office whereas really what you require is an arm’s-length body that is part of the decision-making so that it does not become nailed down into the five-year cycles. You can never let go of it completely politically, but you can look at setting down what are the aims of an NHS … on an occasional cycle.”306
340.Robert Chote, Chair of the OBR, explained that there were a number of existing bodies which could provide inspiration:
“If you were setting up a body in health in this area, again, you have that choice between saying, ‘Do you want them to go away and work out what we need?’ or do you want to say, ‘Health can have 9% of GDP to spend in 20 years’ time. What can you deliver for that?’ It could be approached in either or, indeed, both of those ways, if you wanted to. I would have thought models such as the Low Pay Commission or the National Infrastructure Commission would be possible ways of going at this.”307
We were grateful for Mr Chote’s willingness to speak to us about his experiences as Chair of the OBR and were encouraged by his ability to entertain the prospect of a body which may fulfil a similar function for health and care.
An Office for Health and Care Sustainability
341.The NHS is such an iconic part of Britain’s social fabric. If its sustainability is to be assured, a new independent mechanism needs to be created to counter the endemic NHS disease of ‘short-termism’. It is possible to retain overall political control and accountability for the NHS and yet introduce some level of independent scrutiny of the key longer-term issues facing the health and care system. This happened with the advent of the OBR and the National Infrastructure Commission (NIC). The provision of advice on low pay has also been handed to an independent commission. Such a body for health and care may be charged with advising future governments in the light of robust demographic data and changing levels of demand. The time has now come to move in this direction to secure the long-term sustainable health and care system that the public clearly want.
342.We were grateful for the work completed by Emma Norris, one of our Specialist Advisers and Programme Director at the Institute for Government who, on our behalf, carried out an audit of 16 independent and semi-independent public bodies, details of which can be found in Appendix 5. Based on her work we are convinced that there is a strong case for a new, independent standing body enshrined in statute to safeguard the long-term sustainability of the NHS and social care. This body should be named the Office for Health and Care Sustainability.
343.As explained above, the body will need to have a clearly defined and well-understood remit and its work should always be grounded in what are often termed ‘the knowns’, such as the available demographic and disease profile data, for example. It is not our intention to articulate all the specific details of the new body, which need not be very large. Instead, the Government should examine the audit set out in Appendix 5 of the report to determine the remit, governance and composition of the new body before introducing a Bill.
344.We recommend the establishment, before the end of this Parliament, of an independent standing body named the Office for Health and Care Sustainability to assist the Government in safeguarding the long-term sustainability of an integrated health and adult social care system for England. It should play no part in the operation of the system, or make decisions, but should be given the independence to speak freely about issues relating to its remit. It should report directly to Parliament.
345.The new body should be given a clear remit to advise on all matters relating to the long-term sustainability of health and social care. Initially it should focus on three key issues: (1) the monitoring of and publication of authoritative data relating to changing demographic trends, disease profiles and the expected pace of change relating to future service demand; (2) the workforce and skills mix implications of these changes; and (3) the stability of health and adult social care funding allocations relative to that demand, including the alignment between health and adult social care funding. It should continually look 15–20 years ahead.
293 Ibid.
295 Ibid.
296 Ibid.
302 Jon Ashworth MP, ‘Labour calls for OBR-style watchdog to assess NHS finances’, The Guardian (27 December 2016): https://www.theguardian.com/politics/2016/dec/27/labour-calls-for-obr-style-watchdog-to-assess-nhs-finances [accessed 28 March 2017]
303 The Beveridge model is named after William Beveridge, whose 1942 report contained the proposals that provided the basis of the modern welfare state, and describes a system where health is provided and financed by the government through taxation.