Breakfast Seminar

“When I first told my friends I was thinking of joining the board of NHS England, half of them told me that I must be mad – that it would be frustrating, riddled with politics and hard to get anything done,” David Roberts told Care Conversation delegates. “The other half said, ‘You must do it – it would be so rewarding’. It turns out both were right.”

The NHS was a national asset, he said. “Those of you who’ve experienced healthcare systems overseas will know that. But I think we’re involved in a fight for the sustainability of the system, for care free at the point of delivery.”

That system had remained largely unchanged since it was designed in 1948, and the stresses and strains were becoming more acute, he said. There was fragmentation between primary and secondary care, mental and physical health, providers and commissioners, and elsewhere. “If you were designing it now you wouldn’t have any of that fragmentation, and I’m also blown away by the complexity we’ve designed into the system.”

The biggest challenge, however, was one of sheer scale – in terms of both budget and staff. “The scale is truly awesome, and people have been trying to run it as a national system. But we do need to put more power into local hands.”

While it was true that the NHS was underfunded, it was not ‘hugely’ so as a percentage of GDP, he pointed out. “But, as we all know, it’s heading into a perfect storm – one of demographics.” This would mean huge increases in dependency, strain on resources and the need for social care, he said. “And we can’t just think about it purely as a healthcare system – we have to think about the broader needs of the population. We’ve almost eradicated infectious diseases, but these have been replaced by long-term conditions, which are very expensive to manage.”

This meant that investment in prevention and primary care was vital, he stressed. “But people’s expectations are also increasing all the time. Why are there such variations across the country – in things like the cost of hip replacements, how long it takes people to become fully mobile afterwards, incidence of cancer, treatment pathways? Why do we tolerate this? It’s shocking.”

But it was also an opportunity, he stated. “We need to address this inequality, these variations in outcomes.” The NHS Five Year Forward View was the first time a strategy had looked at “what the system needs, rather than how to win a few votes”, he said, with its emphasis on prevention, increasing efficiency and putting the patient in control. “And the way most industries have been able to transform themselves has been through giving consumers more power, control and transparency.” There needed to be a focus on pathways, as well as on new models of care, he said, particularly in terms of populations and technology, with a “huge challenge” around the latter.

Also fundamental to long-term sustainability was “bending the demand curve”, he said. This, however, was where “policy meets politics”, with ideas such as alcohol minimum pricing or a sugar tax. “But we do need people to take responsibility for their own health, and it needs to start in schools. Otherwise, we’re building up huge problems for the future.” In one Clinical Commissioning Group area, just 4% of patients accounted for 50% of costs, he explained – “so we need to find ways to get in there earlier with that 4%.”

There would inevitably be some difficult choices, he warned. “We might have to create some harder incentives, or at the very least start that debate. We also need to demonstrate to industry the benefits of investing in the health of their workforce.”

A key question, he acknowledged, was how to bring all of this about in a system that “operates in little fiefdoms, that can struggle with leadership, and with a culture that’s becoming more about inspection than helping people. The only way we can do it is if providers and commissioners, social care and healthcare, mental and physical health, and all the others, start pulling together. And that’s not just a structural thing, it’s also about a willingness to work together, to share and take on best practice.

“I see a system that’s crying out for leadership,” he said. “The NHS is a national asset, one that we can be genuinely proud of. There is a battle for sustainability, but the answers are all in front of us.”