Health reformers should paint an inspiring vision of what progress could mean for patients and for health professionals rather than focus on the negatives that have necessitated it, says Simon Stevens.

If you’re prone to pessimism, there’s much to depress you as you survey the coming decade and beyond. A throbbing economic hangover from the worst global recession in a century. The seven billionth human contribution to climate change. And for those with an apocalyptic streak, Astronomer-Royal Martin Rees’s prediction of a one-in-two chance that our species will be extinct by 2100.

But for those of a more cheerful disposition, consider Steven Pinker’s recent observation that violence has declined such that we are now living in the most peaceful epoch in human history. Or reflect on the perhaps somewhat tongue-in-cheek claim I heard from one of the world’s leading Nobel-winning geneticists at Davos last year that breakthroughs in cell biology could mean human life expectancies of 500 years. And that within two decades we may be able to pinpoint advanced life forms elsewhere in the universe.

Set against such profound possibilities – that surely rival the invention of agriculture, the Copernican revolution or Gutenberg’s printing press – rehashed debates about British public sector reform seem thin gruel. But controversial these reforms always are, and nowhere more so than in the NHS.

Why is that? And how should we reconcile the facts of steadily improving patient care and population health with the periodically-recurring narrative of an NHS in crisis?

Partly, it’s because of the NHS’s tax-funding mechanism, which means that whenever the post-war British economy sneezes, the NHS catches a cold. In 1951, 1968, 1976, 1987-88 and 1999, the infection nearly proved fatal. So, despite its effectiveness as a reasonably equitable, if somewhat crude cost control mechanism, the inevitable lumpiness of NHS tax-funding has also meant long periods of relative underfunding, followed by acute but avoidable crises, and then bursts of compensatory but inflationary “catch-up” spending. And, since Britain has not in fact eliminated economic boom and bust (just as “history” did not in fact “end” with the collapse of the Berlin Wall), the NHS now faces its deepest and most sustained budget crunch since 1948.

Partly, too, it’s because – as Canadian academic Bob Evans has noted – while typically the private sector succeeds by showing how well it is doing, the public sector often declaims its own failure in the hope of extracting more government spending.

And, partly, it’s because publicly-funded healthcare means collective decisions about who will get what – the very essence of politics, and ethics. So, like the proxy wars fought by Cold War superpowers in far-off places, what are putatively local conflicts – in this case “health policy debates” – often turn out to be manifestations of far deeper ideological clashes. About state versus market. Freedom versus solidarity. Autonomy versus paternalism. No wonder these zombie “NHS” controversies keep reappearing, continually inverting discussion of “ends” with debates about “means”.

Such then is the terrain on which all NHS reform plays out. But the new government is also confronted by two further paradoxes.

NHS reform is most urgent when funding is tight. But, historically, NHS reform has needed substantial budgetary lubrication (the Clarke reforms of the early 1990s and the Blair reforms of the 2000s being just the most recent examples). In constrained circumstances, policymakers often, therefore, resort to short term expedients. Of the needed NHS efficiency gains over the next several years, the Department of Health says that at least four fifths will come from a top-down staff pay freeze and a hospital pricing squeeze. So the first paradox is that, despite the Sturm und Drang over the new Government’s decentralising health legislation, in practice the NHS is once again in a highly centralising moment. In time, the attempt to run the NHS as if it were one big hospital will inevitably again be superseded. Managing that transition – against the backdrop of continuing austerity – is going to require exceptional sophistication in policy design, political stewardship, managerial execution, clinical engagement, and public communication, if a crash landing is to be avoided.

In designing that transition, policymakers are faced with a second paradox. Improving population health, care quality and service efficiency mostly requires changes in how clinical care is delivered and how patients are engaged. Yet most NHS reforms focus instead on rearranging the administrative deck chairs, particularly the layer of management that sits between Whitehall and the GP surgery or the hospital. In part, this is a genuine – if ultimately unsuccessful – attempt to try and upgrade the effectiveness of these “intermediate tier” organisations.62 But, in part, this is also displacement activity. It avoids asking – and having to answer – the far tougher questions about what the NHS and its staff are actually doing for patients.

For example, how is it that only half of NHS diabetes patients get theevidence-based care they need – with a five-fold variation across the country?63How can there be a 40 per cent difference in local rates of age-standardised NHS hip replacements, cataract surgeries and gall bladder operations?64How can a quarter of NHS trusts get away with having their “value for money” accounts qualified by their auditors?65How can a fifth of hospitals treat their older patients without dignity or compassion?66Why is it that nearly a third of health care organisations say they still lack a system for monitoring the performance of medical practitioners?67And how is it that a single hospital in mid-Staffordshire could have been responsible for killing its patients at a level equivalent to two or more Lockerbie air crashes, yet apparently no one noticed or did anything?68

These are the inconvenient truths that any fundamental reform programme would tackle. Genuine reform would also help “future proof” the health service against major environmental trends headed its way, such as the ageing population, the rise of chronic diseases, and a decline in paternalism. It would do so in part by taking full advantage of some important opportunities.

On the demand side, at a time when six out of ten British adults are overweight or obese, the new science of consumer behavioural change has clear implications for prevention and health, which the wider debate on food policy, urban design and the like should not obscure.69 As important will be the future of informal voluntary care. Valued at £119 billion a year, and functioning as a hidden “heat sink” (the Big Society in action?), its rise or fall will have profound implications for the sustainability of formal tax-funded health and social services.

On the supply side, as biology becomes an information science, as the cost of personal gene sequencing falls from up to $3 billion to perhaps $1000, and as digitisation opens the way for profound changes in how medicine and healthcare is delivered, will the NHS embrace or resist the new possibilities presented by personalised medicine, nano-robots, vaccinations against virus-inducing cancers, tissue engineering, and neuro-assisted devices – to name but a few of the technologies that are headed our way? Doing so holds out the prospects of important advances in health and well-being, but will mean weaning the NHS off anachronistic models of care delivery.70

What is the regulatory and policy regime best placed to help the NHS do so? Some of the active ingredients are: actively empower patients so their needs and preferences continually reshape care delivery; align incentives, information and decision rights with the frontline health professionals who can best effect improvement; remove barriers that block job redesign and new ways of working; look sceptically at organisational monopolies created in the name of integration; prefer rapid experimentation, adaptive feedback loops, and emergent organisational configurations over one-size-fits all solutions from Whitehall; stimulate pluralism by ensuring level playing fields for new entrants; strengthen scrutiny of clinical care, and introduce full public transparency on performance variation; and ensure the overarching structure of health system regulation is fit-for-purpose.

If “to will the end is to will the means”, these are some of the agenda items that NHS reformers will have to pursue over the coming few years.71 But, as the King James Bible puts it: “where there is no vision, the people perish”.72 So, rather than framing the debate on the future of the NHS in narrowly technocratic terms, or as an unpalatable but unavoidable response to austerity, reformers should also paint an optimistic and inspiring vision of what progress could mean for patients and for health professionals as the 21st-century unfolds.

This essay appears in The next ten years published by Reform.


62: These periodically reincarnated entities exhibit a limited set of naming permutations down the years: health authorities, area health authorities, district health authorities, strategic health authorities, regional health authorities, regional offices, primary care groups, clinical commissioning groups, primary care trusts, and so on.

63: Department of Health (2010), NHS Atlas of Variation.

64: Appleby, J. et al. (2011), Variations in health care – the good, the bad and the inexplicable, King’s Fund. Rates are standardised for age and gender differences between geographies.

65: Dowler, C. (18 August 2011), “Quarter of trusts fail on value for money”, Health Service Journal.

66: Care Quality Commission (2011):

67: Santry, C. (20 October 2011) “Fitness to Practice”, Health Service Journal.

68: British Medical Journal (2011);342:bmj.d2900 (6 May 2011).

69: Cabinet Office (2010).

70: Imagine for example a new medicine that could reduce the risk of diabetes by 58 per cent: doubtless the pharmaceutical industry would have quickly mobilized to ensure widespread worldwide adoption. But what if an equally dramatic impact was found to be obtainable by a carefully-tailored lifestyle intervention? In the decade since a landmark randomized control trial of a support intervention for weight and diet showed precisely that, the NHS has done nothing to implement it at scale. See: Diabetes Prevention Program Research Group (2002), “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin”, New England Journal of Medicine (2002; 346:393 – 403 at

71: Source: Nobel Laureate David Baltimore.

72: Proverbs 29:18.