I’ve been thinking about the next stage of the NHS. What it will look like, how it should be funded, what it should be doing, and even if it has a future at all.

If that last one sounds dramatic, blame Chris Ham of the King’s Fund; his excellent paper Rise and Decline of the NHS 2000-2023, was a stark reminder that what NHS commentators write about these days in terms of a huge crisis was not always the case.

Between 2000-2010, the NHS improved in many ways. Funding increases went way above the tracking norm. Capital budgets increased allowing the service to invest in new premises and equipment, while staff became better paid and motivated.

Meanwhile, NICE allowed investment in new medicines and tech where it was most needed, waiting times came right down, and patient satisfaction reached an all-time high.

After the 2008 global crash, a sense that the good times couldn’t go on set in. David Nicholson set his QIPP challenge to save some £20billion, a challenge largely met in the end by freezing staff pay and paying hospitals less for activity.

Tough, but when then compounded by the sudden shock of several years of no real-terms funding growth, a chaotic reorganisation of the NHS to make it more ‘competitive’ and huge cuts to local authority budgets we suddenly found ourselves with failures, stresses, strikes and permacrises.

This has gone on to the present day, with COVID-19 massively exacerbating what was already a desperate situation.

You can debate whether this was inevitable, and if different choices could have been made after that crash and in the decade following it (hint – they could!). Whatever the case, I’m increasingly hearing questions from my clients in industry about whether this level of dysfunctionality is sustainable.

Chris Ham’s solution, for what it’s worth, centres around managing demand; by investing in primary, community and especially social care; providing alternatives to hospital care; and making patients and communities engaged in their own care. Above all, it’s about the political will to ensure the NHS can go on in its current format.

It’s all good, if not new; whisper it, but my clients are also asking if we may not just wait for the next Labour government to fix these things.

This brings me on to the second paper I’ve been considering this month – the Hewitt review – published in April, which focuses on the future of integration.

Led by former new Labour Health Secretary Patricia Hewitt, you can read between the lines an acknowledgment that things were better in her day. Could she sprinkle some 2000s stardust on the current malaise?

She reasons ICSs are here to stay, so let’s get them to work as best they can. It’s all about flexibility, and local empowerment.

The Hewitt Review has some sensible suggestions. While the government isn’t bound to following any of them, it’s safe to say some of them will make it into the policy mix.

However, she has to work with what she’s got. None of the things Ham points out as essential for improvement are really dealt with – she assumes a similar, grotty picture of funding, staffing and capacity.

Is this the future? It might be the best short-term view we have. So let’s look at these and ask the burning questions: so what? And what does it mean for industry?

The first point: these super ICSs, together with their freedom to set their own payment systems and a general move towards localism. If I were working in market access right now, I would be discerning where these super ICSs were, what were their priorities and attempting to establish if there were new potential for collaboration – patient discovery, pathway change and service redesign.

Manage expectations though. We’ve always had an NHS in which some bits worked better than others – greater political cohesion, better at balancing their books, more visionary in achieving superior outcomes.

The places that have really made progress tend to be small, manageable locales, such as Torbay in Devon, where patient engagement, anticipatory care for older people and joined-up health and social care services really made a difference.

At scale, these kinds of improvements have been highly challenging. It remains to be seen whether these Super ICSs, with greater ‘freedom and control’, will really be able to change much.

The second point: fewer top-down targets, more set locally. Interesting for pharma. Again, a close look at what these are, and which areas are prioritising certain patient groups and therapy areas, will be beneficial.

The third point, for those selling to primary care, there’s likely to be further shake-up of incentive funding for their outcomes, including a redevelopment of the QOF. I’d keep a close eye on what the new indicators will be, as it’s likely to include much more on outcomes, which pharma can definitely leverage – as opposed to a glorified disease registry.

The rest of it? well, it’s hardly revolutionary. ‘AHSNs to lead on innovation.’ This is what they are supposed to be doing anyway. Some of our clients have had success working with them, and they can provide the kind of scalable best practice that can make a difference – they’ve done some good work on AF, for example. But there’s some wheel reinvention going on here.

Will comms be kept under review? Well, we’ve already had notice that some 65 services will be delegated to ICSs, so smart companies are already gearing up to deal with their new customers. Some will be kept national, such as certain rare diseases. We knew this already.

Finally, investment in health improvement and prevention. Systems, whether CCGs or ICSs, have been told to do this for at least ten years, and it’s not really happened. Where it has, and had success, it’s been mainly done by local authorities and involves enlightened population health policies, granular patient stratification and integrated social care.

The NHS is at its operational limits dealing with existing disease, without the bandwidth to deal with the future. This is surely an area where pharma can add value, using its data management and patient modelling, and its stories about what ideal looks like. Wilmington Healthcare is currently helping scores of clients do this, by helping them set out achievable change to NHS decision-makers.

So, if this is the future of the NHS, it’s a short-term future. What we can discern is, localism will be important; outcomes will be more important; and the whole thing won’t really be fixed until there is a massive injection of investment in prevention, out-of-hospital services and social care, with genuinely transformed pathways.
I’ll leave it to you to determine whether that will require a new government, with that political will. In the meantime, get your ideas for improvement ready and in a workable, scaleable, NHS-friendly form.

Oli Hudson is Content Director at Wilmington Healthcare.
Go to wilmingtonhealthcare.com