This article was originally published in The Times, 21/01/23: https://www.thetimes.co.uk/article/fe92cb40-98f8-11ed-a130-baced48eb788
One of my earliest memories is visiting the GP with my mum. The surgery was a short distance from our Bristol flat, so we had walked there together. Despite the somewhat shabby exterior, it was one of the best in the area. After sitting in the waiting room, Dr Gandhi welcomed us into his office. I was not the patient that day — I must have been six or seven. I was there to translate for mum.
Even now, friends and family tease me about my questionable Punjabi but, as I always point out, Zubaida Javid remains fighting fit to this day, so it can’t be that bad.
My father, Abdul-Ghani Javid, did not have to rely on my translation skills. However, like so many others, he did rely on the NHS. Soon after I was elected to parliament in 2010, he was diagnosed with colon cancer. By the time he found out, it was too late. It had already spread to his lungs and liver. He received incredible care at the end of his life, something neither I nor my family will forget.
The NHS has played an important part in my personal story, as it will have done for so many others. Since 1948 it has been part of our national story too. That’s why the images playing out on our television screens and printed in the papers over the past few months have hit a nerve with the public. Services are under extreme pressure; waiting lists grow; and it feels as if patient queues are longer than ever before. The impact of the pandemic has been huge. But we know that NHS dysfunction is not an isolated event — it has become an annual ritual.
So when I give evidence to The Times Health Commission next week, I intend to say the 75-year-old model of the NHS is unsustainable. And unless it is radically reformed, the principles on which it was founded cannot survive much longer. This may not be a popular view. But we are at the crossroads, and I feel it needs to be said. So why have I come to such a view? And what should come next?
During the pandemic, an estimated ten million people stayed away from seeking care and treatment. Illnesses and conditions went undetected and untreated, causing a surge in demand, particularly at hospitals. Since the NHS was founded, our demographics have changed. We can expect to live more than a decade longer. In 1948 some half a million people lived past the age of 80. Today, that is more than three million and rising. This increases complex long-term conditions, with the burden of disease changing too — from polio and diphtheria in 1948 to cancer, obesity, cardiovascular disease and degenerative diseases. The resources required are intensive and expensive.
To overcome these challenges, radical reform is required. However, part of the problem, and the reason why the NHS is under so much pressure, is that political debate about the NHS’s future has become so constrained. This self-imposed caution extends to both voters and politicians, and it is letting patients as well as NHS staff down.
In one of my first meetings as health secretary, I remember being told how strongly the public felt about the state of the NHS and its dysfunction — but also how their proud support for the institution meant they were resistant to anyone meddling with it. “Fix it, without touching it” was the message. To a large extent, this is understandable. We know how much people care about the health service because of what it has provided them and their families for generations. We rightly appreciate the incredible work of NHS staff, who labour tirelessly in challenging circumstances, but too often the appreciation for the NHS has become a religious fervour and a barrier to reform.
Politicians have too often leant into this narrative of adulation because it is what people want to hear. I was certainly part of this, though I tried to shy away from tokenistic gestures like wearing the NHS badge.
This has also led to a cross-party conservatism about proposing necessary changes. The shadow of the 2012 Lansley reforms has loomed large for far too long. These reforms in 2012 were wide-ranging and would have introduced top-down reform of the NHS with very little groundwork in articulating the problem they were trying to solve. This experience led many to shy away from further reform, and more than a decade later I remember the cautionary tale often being raised to me in meetings within government.There is a much wider chilling effect too. It seems every time a politician opens their mouth to talk about NHS failings or a new way of providing healthcare, they are pilloried. This happened recently in Scotland, where reports of discussions around asking the wealthy to pay for treatment provoked a furious backlash and were shut down before they’d even begun.
At almost every election since its creation, we’ve seen cynical scaremongering about fictitious conspiracies surrounding the future of the NHS. The outcome is a status quo where we pour ever greater amounts of money into the NHS but become increasingly unsure as to where exactly it ends up. In 2000 the UK health budget accounted for 27 per cent of day-to-day public spending; next year it will hit 44 per cent. On this trajectory it will be more than 50 per cent by the end of the decade.
This level of spending and its rate of increase is unsustainable, particularly with the tax burden already at a 70-year high. As I made clear when health secretary, with so many competing priorities, the long-term answer to increasing demand for healthcare cannot always simply be more and more money. Not only is this unsustainable, but also leads to pressure on other priorities, such as education, policing and defence which must contend with an ever-decreasing share of the pie.
To really address this, we need a change of approach, and the best way to do that is the emergence of a cross-party consensus on the future of healthcare.We can achieve the reforms the NHS needs to survive. It will involve an honest conversation with the British people — even if political parties are not rewarded at the ballot box.
We should start by looking at the supply side. What frustrates people is having to wait for GP appointments; for scans and operations; for ambulances and emergency care; wait for everything in fact. In the past year, according to YouGov and Eurostat, one in six adults has been unable to access a medical appointment they needed. Almost half of those people blamed long waiting lists. This response was the highest out of 36 European countries and almost triple the EU average.
Our relative position compared with other countries is no coincidence. When it comes to the supply of healthcare, they have more tools available to meet the challenges faced. It’s not a question of finance — UK health spending is above the OECD average and countries known for impressive patient outcomes. It’s about how the system operates. For the NHS, when faced with excess demand, the only rationing mechanism is to make people wait. This is not the norm in any other comparable country. Across Europe we see different versions of a contributory principle to complement public financing. This helps providers manage demand, and direct it to more efficient methods of supply.
Take Ireland, where some people are entitled to free healthcare through the public system, based on household income. Others must pay nominal fees. One such is a €75 charge if you attend an injury unit without a referral from a GP. If you have the referral, the service is free. The advantage of this system is people take active steps to assess whether their demand for frontline services is required.
Too often we hear doctors and nurses frustrated at people making unnecessary trips to frontline services, which takes time from other patients. Would the same level of demand exist here if this Irish model were adopted? This extends to GP appointments. In Norway and Sweden a visit to the GP comes with a contribution of about £20. For some people, just like my parents, that is a noticeable part of the weekly budget. But as demonstrated by so many other countries, it is possible to means-test this provision. Even a tiny fraction of patients reconsidering their visit to the GP (and perhaps visiting a community pharmacist instead), would save thousands of clinical hours.
Co-payments are not the only alternative. Germany’s social health insurance model gives the structural benefit of a greater choice of providers, including non-profit community hospitals, and therefore less pressure on the public system. In the UK, more and more people are moving towards private healthcare (including within NHS Trusts). But provision is limited in comparison. Other systems with a contributory principle have seen a range of providers emerge. Patients in the UK are all directed towards the front door of the NHS, which only worsens the queueing.
For patients, this is not cost free. More waiting can mean an increased risk of illness and discomfort. And for NHS staff, it also means a constant tide of pressure (and sometimes abuse). We have already instilled an element of contribution into the NHS: we ask people who can afford it to pay towards the cost of prescriptions, and dental and optical care. Labour and Conservative governments have had a role in this. We should look, on a cross-party basis, at extending the contributory principle. Primarily with the objective of helping with the allocation of what will always be limited resources, not fundraising.
As a country, we rightly have a strong belief in protecting those on low incomes and this is not about privatising the NHS. But the present model is unsustainable, and we therefore need to affirm our values within an alternative system.
Getting these structures and incentives right will be no easy task but is essential in the long term.We must also find ways to reduce the level of demand. For too long the NHS has been viewed as a “National Hospital Service” — treating people when they get sick rather than preventing them from becoming ill. By some estimates 40 per cent of NHS spending goes on treating preventable conditions. We need to get better at taking a long view — and this is where the structures and incentives of politics often fall down.
My attempts to address this led to something of a reputation for announcing ten-year plans. Reviews, investigations and consultations are viewed with scepticism — but these are critical to building consensus. Whether it is cancer, dementia, mental health, or suicide prevention, we need to get ahead of the curve and quickly.To deliver these, we will need our excellent workforce, too.The NHS has never done a long-term plan on what our staffing requirements will be in the next 10 to 15 years. This is a workforce of more than one million people, and it is constantly changing. That’s why the government needs to publish the workforce strategy I started last year.
Adopting a “Pharmacy First” approach would also relieve pressure and help to support patients. It is also clear that the “one size fits all” model of primary care is no longer fit for purpose. We should back leaders on the ground who are developing innovative models. In 1948 Nye Bevin achieved reform with GPs, in his own words, by “stuffing their mouths with gold”. Solving the problem now must involve a more fundamental rethink before the gold runs out.
Digitisation and data are going to be critical. The government should waste no time in implementing the recommendations of the first ever digital health and social care plan published when I was in office. For patients, digital innovation in hospitals is crucial. I remember visiting the impressive Milton Keynes University Hospital in 2021, which had just become the first in Europe to use surgical robots for big operations. Robotics engineers told me how their precision led to a lower risk of infection and faster recovery times. At the moment, there is too much variation in the use of technology, and it needs to be scaled up.
These are just some of the changes that can be implemented, but it will require a continued change in overall approach and attitudes. For decades we have been too focused on firefighting short-term challenges, rather than addressing the cause of the fire itself. These reforms can help address that. Alongside them, it is the introduction of a contributory principle that will be crucial. This conversation will not be easy, but it can help the NHS ration its finite supply more effectively. That will not only help improve performance, but in doing so secures our health service and the principles underpinning it for the future.
We can build a reformed NHS, primarily funded by taxation, that releases the pressure on staff and patients. We need to shake off the constraints of political discourse and start having a grown-up, hard-headed conversation about alternatives. The institution faces nothing short of a 1948-style moment. The NHS was there for my parents, but to be there for my children a new political consensus on serious reform is urgently required. Without it, we cannot keep the dream of 1948 alive.
Sajid Javid is MP for Bromsgrove and was health secretary 2021-22
Photo: STEFAN ROUSSEAU/PA