Using the patient to smash the NHS begging bowl

The health and social care secretary has made much play of two changes which are necessary to fix a “broken” NHS. The first is to reconfigure the service’s “care model” by means of the “three shifts”; the second is to renew its “operating model” by reversing the trend of centralisation and giving greater autonomy to local organisations.

In arguing for the need for these changes, the government has made much of the rise of Reform and falling public support for the service. This, it claims, has created a substantial and existential threat much greater than in 1997 when Tony Blair declared there were “24 hours to save the NHS”.

However, there is a third “model” central to the NHS which the government is just as determined to change but speaks a lot less about: the service’s “business model”.

This government believes it should not prioritise increasing health spending, a distinct departure from all previous Labour administrations – and many Conservative ones too.

It argues that other competing demands, such as increased defence spending, are now inescapable; while others such as education, social care, and housing are more deserving and will have a greater impact on the nation’s wellbeing in the longer term. It is an argument with some force.

The New Labour government felt it – and not its right-wing competitors – had the credibility and mandate to reform the NHS of the noughties by introducing competition and an enhanced role for the private sector. Now this administration is convinced only it has the competence and public support to dash the “begging bowl” from the service’s hands and say, “no more”.

Within this broad mission is a sincere belief that NHS finances have become inherently unsustainable as a result of an approach which has relied on continual bailouts, constant use of accounting “tricks” and the stealing of funds intended to drive transformation to shore up the broken care model. It is another argument with considerable weight.

The government’s approach to the challenge facing the service is summed up in a phrase increasingly heard in policy circles: “Tomorrow must come to the aid of today.”

Labour policymakers have become very excited about genomics, artificial intelligence and personalised medicine without feeling the need to learn much about the reality of their real-world potential. But even they admit any real impact will not be felt until the start of the next decade.

What they do expect to have a more immediate impact on the nature and cost of NHS care is a step change in individual “patient control”.

Power to the patient

The “business model” the government wants the service to adopt is one in which patients are enabled to take greater responsibility for their own care, and one where patient choice drives poor quality services to extinction.

This is, of course, the playbook followed by banking, retail, insurance and a host of other sectors which have transformed their cost base and delivery models in the last quarter of a century.

Once again, this is an area where Labour feel they have permission to be radical in a way that the Conservative Party does not.

The vanguard of this push will be the NHS App, which has already become the most effective way to engage with 111 services. The App’s role as the service’s “front door” will be accelerated through integration with hospital electronic patient records and GP equivalents, and the expansion of proxy controls which will allow everyone from parents and carers to manage the care of the very young and the very old.

But there are bigger and more controversial changes in development.

One of the big NHS reforms that Labour ran out of time to embed when it was last in power was the use of “personal budgets” – under which those with long-term conditions are given money to directly spend in a way which they believe directly meets their needs.

Personal budgets have gained substantial traction in social care in recent decades but – despite a push during Simon Stevens’ time at NHS England – their use remains limited in healthcare. Now policymakers are keen to resurrect the idea.

Elsewhere, the “patient power payments” floated in the 10-Year Health Plan, while frankly outlandish in terms of delivery, are a clear symbol of the intent.

Whatever the vehicle(s) finally decided on, giving patients the ability to wield financial influence is seen as a key incentive to get them to accept more responsibility for their own care (and its costs).

The new market entrants

Aligned to these new paymasters will be some interesting market entrants very different from the ones the New Labour administration introduced. The 2025 Labour policymakers see the country’s leading pharmaceutical and technology companies as the key disrupters rather than private healthcare providers.

The government is determined to both boost the economy and reduce the cost of NHS services by tapping the expertise of these sectors. Indeed Alan Milburn, the most influential voice in Labour health policy circles, sees them as valuable providers of healthcare within an expanded NHS ecosystem.

The role of the Department of Health and Social Care will be to “make the market” by setting standards, opening the system up to new entrants, increasing transparency so patients can choose well and, critically, ensuring that whatever money is available is rewarding services which boost patient control and responsibility.

Central to this drive is removing the default starting point that even the frailest patients must be treated as “dependent” on the NHS and care – instead they, too, must become more autonomous.

Any senior government policy figure reading this piece will argue that HSJ has presented an overly simplistic picture of their plan, which they would rightly say in fact relies on yanking a whole range of levers.

Our counter-argument runs thus: the NHS is unlikely to ever again receive paradigm-shifting funding growth; and scientific and technological advances will not be able to deliver significant change during this parliament. Therefore, another major intervention must accompany the tweaking of existing policies if the NHS is not to become, in Wes Streeting’s words, “a poor service for poor people”.

Only one idea put forward by this government stands an (admittedly slim) chance of reconfiguring the service’s cost base without having to reduce the scope and/or quality of the NHS offer. This would be a transformation in the role of patient equal to that which bank customers underwent during the past decade.

Editor’s note: Henry Anderson and I discuss Labour’s health policy plans in (even) more depth on this week’s HSJ Health Check podcast, out tomorrow.