The NHS has much to celebrate as it enters its 'golden years'. But it also faces formidable fiscal, demographic and public health challenges as austerity bites
The NHS has just has reached its 65th birthday. Until a few years ago, we might have expected our well-worn and well-loved regime of GPs, A&Es and PCTS to be settling down in its golden years into a period of lowest ever waiting lists, historically high satisfaction rates, and fairly decent performance on a range of measures.
But the economic downturn, a new government determined to bring the deficit down as rapidly as possible and a backdrop of demographic change accelerating from the mid-2000s has torn up the NHS’s retirement plan. It has brought to the fore uncomfortable truths: that our beloved health system was becoming more and more costly, while productivity was stubbornly low.
NHS spending had doubled in real terms since 1999, just to keep things on an even keel by the time the economy faltered in 2008. Suddenly, throwing resources at our health system to keep it afloat was no longer an option, and the systemic and procedural weaknesses were exposed.
As former health minister Lord Darzi has recently explained: 'What happened in the last ten years is that the injection of cash did a lot of good. There was a huge amount of progress, fantastic outputs, fantastic outcomes. But we missed the best opportunity in the history of the NHS to actually reform it. We just threw money at it, rather than reforming it.'
The new government’s response to this was a radical shake up of the NHS, in the form of the Health and Social Care Act 2012 – bringing in a whole range of new local structures, shifting commissioning responsibilities and creating opportunities for a wider range of providers. This was aimed at changing the make-up of the NHS from the ground up, to make it more sustainable in a time of thrift just as in a time of plenty.
But was this a solution looking for a problem? Could improved financial sustainability be achieved through a less disruptive and more effective route?
While this debate remains a live one, and while financial pressures may seem insurmountable to those on the front line, these concerns actually mark a short period of difficulty in the life of the NHS. The fact remains that it is a longer term trend – that of demographic change – which will prove to be the NHS’s biggest challenge. And it will be inescapable, even if our economy renders massive injections of cash once again a viable health policy.
Our society is changing around the NHS. We are living longer, and more of us are over 60. Many more are living with long term conditions and disabilities, thanks to our increasingly unhealthy lives offset by breakthroughs in medical science.
The result is that ‘treat and cure’ is a dwindling portion of the NHS’s work. Its bread and butter is now supporting people living in poor health, perhaps with multiple lifestyle-related conditions, for many years. Forget influenza - the only epidemic that will test the NHS now is obesity.
And this means only one thing. The NHS is becoming a health and behaviour management system, and the lines between it and questions of public health are becoming blurred. The NHS can no longer start at the door of the A&E, but must get into communities – into people’s homes, schools and workplaces – and work in partnership with the people it is trying to help.
With this in mind, Demos has just published a collection of essays with the Wolfson Institute at Durham University that considers both the question of the NHS and of public health - not simply for thoroughness, but to reflect the increased link between the two.
The public health impact of economic decline – higher unemployment, job insecurity, fuel poverty, homelessness and other social ills – have a direct effect on the NHS. Moreover, the government’s response in cutting the national deficit – unprecedented cuts to disability, unemployment and housing benefits, social care budgets and funding for third sector support organisations – means our capacity to deal with these social problems are greatly undermined.
As many of the assembled experts in this collection conclude, the result can only be poorer public health, increasing health inequalities, and disrupted local health structures with fewer resources to cope. Health policy makers (and indeed, local MPs and campaigners) are often focused on visible change within the NHS, such as hospital closures. But they should instead be looking beyond the hospital walls – to unemployment levels, child poverty and housing costs.
These factors now have an ever greater impact on the sustainability of the NHS as it battles conditions more closely linked to the quality of life than contagion of diseases, and they are getting worse as austerity bites. If our public health inequalities were not resolved in a time of plenty, what chance do we have now?
The question is, will our health policy makers grasp this nettle? Beyond immediate and controversial reorganisations, there does not seem to be a long term response to the inexorable demographic change which is redefining our understanding of health and healthcare. Policy makers have yet to look beyond the hospital walls.
Claudia Wood is deputy director of Demos. Health in Austerity was launched this week at the Labour Party conference
