Breakfast Seminar

“Whatever people say about devolving power to local services, the truth of the matter is that the apex of the NHS is still the Health Secretary,” Lord Warner told Care Conversation delegates. “The Health Secretary still has the capacity to try to control events. The myth of ministerial control is still very potent.”

What this meant was a ‘dysfunctional’ culture in the NHS, he said – a belief that “somehow the Health Secretary has to be able to stand up in Parliament to account for every little misdemeanour”. As the NHS was one of the largest employers in the world, things were “going to go wrong on a fairly regular basis”, he said.

In terms of future outlook, the NHS was on a trajectory of decline and increasingly unable to cope with the demands put upon it, he stressed. Part of the reason was that it still had “the wrong business model”, he said. “It’s very hospital based. Men used to die about three or four years after retirement, which is very convenient for a healthcare system. Now people are living much longer, often with multiple, chronic conditions.” The current business model was bound to fail without the “annual handout the NHS has got used to”, he pointed out, and while there were good examples of local innovation the necessary ‘grand plan’ for the next five to ten years had yet to materialise.

“So what will happen? To begin with, I think the tide has finally turned in terms of the integration of health and social care. People are now at least talking about this.” The necessary integration of means-tested and non means-tested systems, along with budgets and commissioning, would inevitably be “very tricky”, however, while payment by results would also “need to be scrapped”, with a shift back to block contracts for hospitals the most likely scenario.

“The issue around how money flows is going to be very big. What you need to tackle is population health, not population healthcare.” However while there would be no “bravery before May”, it was likely that some radical measures would be adopted in the first two years of a new Parliament. “Will there be an alternative to straightforward taxation, or a move away from Whitehall trying to define models of care? We’ve now reached a situation where no one is quarrelling with the £30bn deficit by 2020 if things go on as they are – that’s taken as a given.”

It was likely that people would start “reaching for solutions that take the pressure off the centre”, he explained. “We have four NHSs, not one, and in per capita terms NHS England is the most under-funded. There are going to be some very tough sorts of political debates about the money and the money flows.”

In terms of communicating the case for change to the general population, however, he was a “sceptic about our ability to do that before bankruptcy is imminent”, he said, although there had been some encouraging examples when doctors had been fully onside.

“If you take the reduction of stroke units in London from 32 to eight, for example – that actually started with the ambulance service, then the doctors got behind it. They were able to communicate the simple message that ‘you’re more likely to stay alive if you go to one of these eight specialist stroke units than your local A&E’. But it took two years, and the debate in the media is still exclusively about money.

“The default setting for the NHS is as a public monopoly, and the stark political reality is that the money just doesn’t add up,” he stated. “And the sooner you get that message across after May, the better.”