Andrew Haldenby: Ministers can deliver real improvements to the NHS before the election – but only with a new policy

Andrew Haldenby is Co-Founder of Aiming for Health Success and a former head of the political section at the Conservative Research Department. “A new lease of life: three steps for success for the NHS” is published by the Social Market Foundation.

That the NHS is performing badly, and in some respects unacceptably, bears repeating. The even more interesting question is why – and what that means for Conservative policy.

The Health Service is losing public and professional confidence. It is drifting towards a three-tier system: access for patients in more affluent areas, limited access in deprived areas, and a flight to paying for private care.

Waiting lists have risen by 400,000 since Rishi Sunak’s pledge to reduce them in January 2023. Both the Prime Minister and Victoria Atkins, the new Secretary of State, have said that industrial action is to blame.

But, as the table below shows, waiting lists were rising well before recent strikes; they may be a convenient excuse, but they aren’t the real problem.

The real issue is how the NHS organises itself. It has come to think itself as a hospital-led service: it pulls people into hospitals even when they would be treated quicker, better and more cheaply elsewhere.

We can see this in two further sets of data: contact with A&E departments and delayed discharges. In some cases, people visit A&E because they can’t get help elsewhere.

Rising A&E admissions are a sign that the NHS way of working is out of balance; as the next table shows, both visits to A&E departments and admissions via A&E departments were rising before Covid. They dipped during the pandemic ,but have since been rising again.

On delayed discharges, there have been 14,400 patients in NHS hospital beds with no medical reason to be there (i.e. around 14 per cent of the total bed base). That is higher than a year ago, despite huge efforts by the national NHS agencies and initiatives such as the 100-day challenge.

Kevin Lavery, the chief executive of the Lancashire and South Cumbria NHS region, summed up the situation at his board meeting last month:

“Looking forward at the changing demographic of our population, the nature of predominant illnesses/disease areas are likely to be diabetes, mental health conditions and management of long-term conditions. Our aging population with increased acuity in care needs could see the demand for our hospital bed base increase by some 60 per cent.

“This is both impractical and unaffordable. To respond to this will require a seismic shift in the way we configure the health and care services we commission. There is no other alternative but to turn the dial and move to a more community centric system.”

In a recent paper for the Social Market Foundation, Professor Nick Bosanquet and I set out the three steps that can deliver this better way of working.

The first is to leave behind the district general hospital (DGH) model. The DGH hospital is no longer relevant in the context of modern demand for health services, largely driven by people with long-term conditions.

Instead the NHS should develop Dynamo Centres – acute services concentrated on fewer sites – to take full advantage of the scarce time of highly-trained teams. Funds set aside for the extremely costly New Hospital Programme can be used to invest in new facilities.

The goal is to raise productivity in hospital services by 20 per cent. The surgical hub programme announced by ministers is right in principle, but not at all “hubs” announced so far are large enough to make a difference.

The second is to reduce hospital admissions by 30 per cent through the development of joined-up teams of GPs, physiotherapists, counsellors, and other practitioners in local areas (“integrated neighbourhood teams”). Care provided in this way is much more cost-effective than hospital-based care. It is also the way to restore continuity of care, including the personal link between GP and patient.

We can make progress towards the admissions target in months; Helen Whately, the Health Minister, made an excellent speech on this theme in September last year.

The third is an introduction of a new metric of cost of service as the key driver of change. The NHS has talked about a new care model for several years, but the pace of change is so slow that it amounts to paralysis. Local managers need to drive change, following the evidence that earlier diagnosis, out-of-hospital care, and concentration of acute services will both improve services and keep them financially sustainable.

Such an agenda would require a shift in Conservative policy, which is not easy for any government. But it would be a challenge well worth undertaking.

Much of the Party’s current policy seeks to defend the hospital-led model that is the key cause of the NHS’s problems. The Prime Minister’s standard argument is that the Government has increased the NHS budget (and workforce) to record levels.

That is true – but it is only a positive if the budget and staff are being well-used. If they are being poorly used, then increasing the budget just makes the problem greater.

Some Conservatives may argue that these are complex issues and the Party would do better to have a simple message – “40 new hospitals”, or suchlike – on election day.

Simple messages are clearly good for campaigning. But the trouble with this one is that it is a root cause of poor NHS performance (as the Opposition will point out). Labour’s current health policy is better: it has rightly pledged to review the New Hospital Programme should it enter government.

The NHS does not need another multi-year plan. It needs immediate, practical steps, which can deliver progress within months and build confidence among patients and staff. Integrated neighbourhood teams can be in action, and work on dynamo centres can be agreed and underway, well before the general election.

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