ANALYSIS
was supported by a major programme of “ investment for reform ” and by the Wanless report, which produced a long term financial plan and brought in the Treasury. 27 These actions created buy-in and momentum which carried the NHS through the next few years when controversial policies were introduced about use of the private sector and patient choice. This momentum was maintained by success in achieving targets from 2002 onwards — with waiting lists and waiting times down significantly, 36 substantial improvements in cardiac and cancer care, and public satisfaction doubling over a 10 year period. The private sector, which had gained patients from the NHS in the 1990s began to lose business from 2003 onwards as people came back to the NHS. Despite this, problems arose because of over-focus on numbers and targets rather than quality. Too many reorganisations took place, and there was political infighting over the direction of policy, too great a political involvement in operational issues and, ultimately, a failure to pivot towards health and away from a focus only on health services. This discussion illustrates how important politics are to the NHS. Political will drove its foundation and the NHS Plan, but political engagement in operational policy and planning can be influenced by short term political objectives, and therefore should be subject to independent public scrutiny. The NHS needs long term thinking and stable, consistent policies. We therefore recommend the establishment of an Office for NHS Policy and Budgetary Responsibility for England. This would be based on the role of the Office for Budget Responsibility. 37 It would review national NHS plans and policies and publish its conclusions, thereby helping to ensure that they are well based on evidence and properly costed. It should not, however, duplicate the roles of any existing bodies. The BMJ Commission group on finance will develop this idea further. Given the extreme seriousness of the situation and the lessons learnt, we recommend that the government in post after the election should declare a national health and care emergency calling on all parts of society to help improve health, care, and wellbeing. The government should, in effect, relaunch the NHS with the active participation of communities, employers, businesses, housing providers, local authorities, food producers, schools and the public, as well as patients, health and care workers, carers, and others in preventing disease, providing care, and creating health. This would involve: • Making a clear statement of commitment to the NHS and its founding principles, and engaging all parts of society in a renewed vision and plan for health, care, and wellbeing that will generate the buy-in and momentum to implement the necessary reform. • Creating a cross-government and cross-sector health, care, and wellbeing strategy, of which NHS strategy would be an integral part, to show how the whole population and all sectors can contribute, and supporting this with legislation as necessary. • Developing better ways to connect patients, the public, and community groups with activities and planning for the NHS, particularly at local level. • Giving immediate priority to tackling inequalities in access and outcomes and paying particular attention to the disadvantage and racism suffered by different ethnic groups both as patients and staff of the NHS. • Establishing an Office for NHS Policy and Budgetary Responsibility to provide an independent and expert assessment
of NHS plans and policies, which would help protect the NHS from short term political pressures and policies that have not been sufficiently thought out. • Providing some additional funding to support early improvements and commissioning a review of future sustainability similar to the 2021 Wanless review. This recommendation is summarised in box 2. Box 2: Recommendations The government in post after the election should declare a national health and care emergency, calling on all parts of society to help improve health, care, and wellbeing and, in effect, relaunch the NHS with the active participation of the whole of society. This would involve: • A commitment to the NHS and its founding principles and engaging all parts of society in a renewed vision and plan for health, care, and wellbeing • Creating a cross-government and cross-sector strategy for health, care, and wellbeing • Developing better ways to connect patients, the public, and community groups with the NHS, particularly at local level • Giving immediate priority to tackling inequalities in access and outcomes, with particular attention on the disadvantage and racism suffered by ethnic groups both as patients and staff of the NHS • Establishing an Office for NHS Policy and Budgetary Responsibility to provide an independent and expert assessment of NHS plans and policies • Providing some additional funding to support early improvements and commissioning a review of future sustainability
Competing interests: We have read and understood TheBMJ policy on declaration of interests and declare that we have no competing interests.
Provenance and peer review: commissioned; externally peer reviewed.
The BMA, which owns TheBMJ , grants editorial freedom to the editor in chief of TheBMJ . Theviews expressed in this editorial, and in the papers of the BMJ Commission on the Future of the NHS, are those of the authors and may not necessarily comply with BMA policy. TheBMJ convened this commission, which was chaired independently by Victor Adebowale, Parveen Kumar, and Liam Smeeth. TheBMJ was responsible for the peer review, editing, and publication of the papers of the commission.
All of the articles in this commission are available at https://www.bmj.com/nhs-commission.
1 British Social Attitudes Survey 2022 records a drop of satisfaction with the NHS and Social Care to 29%, the lowest level since 1983. NHS and social care (natcen.ac.uk). https://bsa.nat- cen.ac.uk/media/39485/bsa39_nhs-and-social-care.pdf 2 Stuckler D, Basu H. The Body Economic: Why Austerity Kills. Basic Books, 2013. 3 Morris J, Reed S. How much is covid-19 to blame for growing NHS waiting times? Nuffield Trust. 2022. https://www.nuffieldtrust.org.uk/resource/how-much-is-covid-19-to-blame-for-growing- nhs-waiting-times 4 All-Party Parliamentary Group Global Health. The UK as a global centre for health and health science — a go-to place for all aspects of health globally. 2020. https://globalhealth.inparlia- ment.uk/news/category/reports 5 Government HM. The NHS Act. 1946. 6 HM Government. The NHS Constitution for England. 2013. 7 Raleigh V. What is happening to life expectancy in England? King ’ s Fund. https://www.kings- fund.org.uk/publications/whats-happening-life-expectancy-england 8 Parliament UK. House of Commons Library. NHS key statistics: England. 2023. https://common- slibrary.parliament.uk/research-briefings/cbp-7281/ 9 Campbell D. Record rise in people using private healthcare amid NHS frustration. Guardian 2023 May 24. https://www.theguardian.com/society/2023/may/24/record-rise-in-people-using-private- healthcare-amid-nhs-frustration 10 Anderson S. Europe is struggling to keep its health systems afloat. Health Policy Watch. 2023. https://healthpolicy-watch.news/europe-struggles-to-keep-health-systems-afloat 11 Ministry of Health. Department of Health for Scotland. A National Health Service. Cmnd 6502. HMSO, 1944. 12 Bevan A. In place of Fear. William Heineman Ltd, 1952. 13 RetireGuide. 49+ US medical bankruptcy statistics for 2023. https://www.retireguide.com/retire- ment-planning/risks/medical-bankruptcy-statistics/
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