Behind the Curve – how a focus on cost reduction and competition has left the NHS unable to protect the population’s health.
David McCoy, David Rowland & Vivek Kotecha CHPI March 18, 2020
The UK’s National Health Service was born out of the biggest public health emergency of the 20th century. When, in 1938, the threat of war became an almost certainty, government planners began to put in place a system of public health protection designed to cope with an unprecedented threat to the civilian population, co-ordinating hospital facilities and building public health surveillance laboratories to protect the population from infectious disease. The success of the Emergency Medical Service during the war provided a blue-print for the post-war NHS structure.
Unlike the war planners of the 1930s, who had little advance warning of the coming conflict, policy makers have known about the likelihood and impact of a virus like Covid-19 for many years. Since as long ago as 2008 a disease outbreak of this nature has featured as the number one risk on the UK civilian risk register as the event most likely to occur, and also as the most catastrophic, with predictions that half the population would be infected, as indeed now appears to be the case.
In addition, in the 21st century major infectious disease outbreaks are now happening more than once every decade – SARS in 2003, the Swine Flu pandemic in 2009 and MERS in 2013.
Despite this, the enormity and prevalence of the risks to population health have barely received any mention in any of the long-term planning documents produced over the last decade for the English NHS. Neither the authors of the 2010 White Paper on Liberating the NHS or the 2019 NHS Long Term Plan saw any need to build the likelihood of a pandemic into the planned structures for the provision of healthcare services.
As a result, the design of the healthcare service in England has been undertaken almost completely without reference to the lessons learned during the second world war, namely that the health system plays a critical function in protecting the population.
For it to be able to protect health and deliver health care services on a routine basis, a number of key ingredients are required.
The first ingredient is resilience and reserve capacity. This is what allows a health system to accommodate acute disturbances, external shocks and sudden surges in demand for healthcare. Ideally, capacity would be fairly and evenly distributed across the country. If a health system’s capacity becomes over-run, it also needs systems of triage and rationing that are both cost-effective and fair, as well as options for expanding the health system into other community-based assets.
The second ingredient is cooperation and coherence. To deal effectively with an acute pandemic, different parts of the health system need to work in a coordinated and consistent manner, with each part being willing to fill in gaps and help out as needed. This is about a culture in the health system that is used to working across organisational and professional boundaries in support of an effective, coherent and systemic response to a health crisis.
The third ingredient is scientific and policy expertise and research capacity. As well as public health, clinical and basic science expertise being critical, a social science understanding of the social, political and economic dimension of any pandemic is vital. Crucially, while there is a basic rule book for the management of a disease outbreak, every epidemic is different in multiple ways, requiring on-hand expertise as well as reliable data and analysis to guide policy and plans. This requires scientists, technocrats and politicians to work together harmoniously and through an appropriate division of labour and responsibility.
The fourth ingredient is socially responsible and trusted authority. Those setting policy need to be socially responsible by being respectful of science and evidence, and sensitive to the particular needs of different communities and their different levels of susceptibility and vulnerability. Disease control measures that involve curtailments of freedom and civil liberty are more likely to succeed when there is trust in the health system and government. Trust in scientific and policy expertise is also vital to prevent panic, especially in the context of misinformation campaigns on social media and attacks on science and rational public discourse. Earning and maintaining trust requires openness about all the evidence being relied on, and how it is being interpreted. And since social divisions within society are weak points in any defence against an epidemic, trust in the NHS as a universal and national public service is all the more important.
The final ingredient is a global outlook. Covid-19 has shown, with great clarity, that international cooperation, agreement on shared approaches to disease control and the sharing of data, is required to contain pandemic threats. Those working in the grossly under-resourced health systems of poor and fragile countries need support from richer countries in the event of a global pandemic.
However, many of these ingredients are now lacking from the 21st century version of the NHS. The reasons for this are two-fold – the prioritisation of efficiency, competition and cost reduction over all other objectives and the downgrading of public health and health protection as important facets of the nation’s health policy.
Over the past decade, the nation’s public health capacity has been significantly reduced and moved outside of the NHS structure –the Health Protection Agency was replaced with Public Health England which became a Whitehall department, and other public health functions were moved into local authorities. At both the central and local levels, public health budgets have been cut back to the bone.
This lack of focus on health protection over the last decade is now being seen in the government’s current response to COVID-19 – there is a growing sense that the current plans which are being enacted for creating surge capacity, drafting in retired medics, and the provision of thousands of additional ventilators have not been properly planned, never mind tested. Likewise, the lack of clarity and accuracy in the information to the general public suggests a lack of rehearsal with several questions about the scientific basis of the containment strategy remaining unanswered. The shocking lack of the required personal protective equipment (PPE) for frontline medical staff is again an indication that the necessary contingency planning and stock piling of supplies has not taken place.
However, it has been the prioritisation of efficiency, competition and cost reduction over the past decade which has mainly undermined the NHS as a health protection system. In particular, it has left the NHS without the necessary resilience and reserve capacity to respond to a pandemic.
Even with less severe episodic challenges such as winter flu, the NHS has been increasingly struggling, with doctors describing the NHS as now experiencing a year-round capacity crisis instead of just during the busier winter months. The reduction in bed capacity has been occurring for several years with almost 6,500 General & Acute hospital beds closed between December 2010 and December 2019, and with intensive care beds now operating at 80% capacity, meaning that there is no slack left in the system to deal with any unanticipated events.
At the same time, staff shortages combined with growing demand from a growing population have weakened resilience within the system by lowering staff morale and motivation.
This has been produced through the combined effects of years of austerity and the short-term focus on cutting costs and maximising budget surpluses. The fact that funds for capital investment have to be raised from revenue generation has also resulted in an uneven pattern of infrastructure development that is not entirely needs-based. Austerity has also diminished other public assets such as community halls, libraries and youth clubs, all of which could otherwise provide additional resource for dealing with a health emergency; and which create social and cultural capital that may be critical in a crisis.
The focus on efficiency, competition and cost reduction has also been at the expense of coherence and cooperation. This may be hard to quantify, but it is qualitatively clear that marketization and competition within the health system have added transaction costs to cooperation, while also eroding the sense that all parts of the NHS serve a common public interest. Competition and fragmentation have also weakened management and accountability, population-based information systems, and the ability to deploy effective command and control authority when required. The constant reorganisations of the NHS have also led to losses of vital institutional memory and invaluable informal networks.
When compared to many countries, England is lucky to be able to rely on an NHS with a strong public service ethos and many of the best public health and communicable disease experts in the world. We can also be proud that many UK-based scientists and public health professionals are at the heart of the international response to Covid-19 which has been more rapid, cooperative and effective than was the case with the SARS epidemic.
But once we are past this current crisis, it will be important for society to re-evaluate the current model of the NHS, and consider a renewed focus on a universal health protection system that it is more resilient and coordinated, and better able to respond to large and acute threats.