ANALYSIS
that their priorities are taken into account. 21-24 This process requires time and resources to be done well, and therefore should be focused on key questions for which general public opinion will add most value. Once decided, the process should enable the public to hear from a range of experts with differing perspectives and give them the opportunity to have an open debate. The independent annual report on NHS performance and population health should include routine, consistent measures that allow year-on-year comparisons to be made. The data should be drawn from routinely collected information, without creating a new burden on NHS providers. It would collate information already produced by sources such as the King ’ s Fund and the Nuffield Trust into a consistent format that allows year-on-year comparisons to be drawn. 25 As a minimum, the annual report should reflect the following measures during the period of the report, and be analysed at an integrated care system level to enable comparisons to be drawn in the efficacy of health spending: • Resources allocated to healthcare (input measures), including funding (capital and revenue), levels of staffing, and service and equipment provision in agreed key areas. • Impact on healthcare (output measures), including staff retention and turnover rates, access to healthcare (waiting lists and waiting times in primary care), patient satisfaction, treatment outcomes, and wider measures of population health. • Comparative measures, including how the UK performed against comparable countries in terms of healthcare spending, population health outcomes, measures of health and healthcare equity, and productivity measures. In addition, an independent, future focused report would be produced every five years, timed to be published in advance of a general election. It would similarly be prepared by the OPBR, drawing on reports and input from relevant national and regional healthcare bodies including NHS England, royal medical and nursing colleges, regulatory bodies, integrated care systems, and public opinion. It would also include medium and long term modelled projections of pressures on healthcare spending. Various approaches can be taken to such projections, 10 but commonly any method would include scenarios informed by various demographic, national income, and technological assumptions and projections. The report would be expected to cover where change will be needed over the next 10 years and to anticipate what changes in funding and healthcare services would be needed to tackle these changes. This would therefore include: • Expected demographic changes, including predicted changes in population health outcomes, life expectancy, and birth rates. • Likely significant technological advances that will affect health and healthcare, including new drugs, advanced therapies, medical technologies, and artificial intelligence. • Opportunities for improving productivity and reducing the carbon footprint of healthcare provision. The government would be expected to produce a public response totheOPBR ’ s report within the first six months of taking office. This response would be developed in consultation with those bodies involved in developing the independent report and take into account public opinion through the citizens ’ council. The government ’ s response should explicitly cover the matters raised in the independent OPBR report, identifying areas that will be taken forward over the subsequent five years. If areas have not been
prioritised for future development, a rationale should be given and the response will be scrutinised by the OPBR. The government ’ s response should be framed as a five year strategic plan for health. It should include: • Expected routine delivery of core services over the five year period, so the public, clinicians, and healthcare managers know what to expect and what to prioritise. • New developments, including service improvements such as infrastructure and capital projects, and facilities needed to deliver on anticipated future pressures. • Support for enablers of the system, such as data requirements, artificial intelligence, digital developments, and workforce plans • A detailed financial settlement for a five year period and a provisional settlement for the five to 10 year period. Conclusions and recommendations The past 75 years have seen dramatic improvements in the health of the UK population, partly as a result of living conditions and partly as a consequence of technological advances. When the NHS was established in 1948, healthcare options were minimal compared with the sophisticated treatments now available. As a consequence, healthcare providers around the world have experienced year-on-year increases in expenditure, and all are concerned about how to prioritise spend to get best value in return. In response to the questions that we asked above, we make four recommendations. Funding model — We recommend that the current model of NHS funding, primarily through taxation, is maintained. This mandatory payment system avoids many of the problems associated with voluntary insurance markets. It benefits from economies of scale in terms of administration, risk management, and purchasing power. Continuing with the status quo also avoids the inevitable disruption of moving to a new model such as a compulsory social health insurance system. Performance monitoring — NHS performance should be monitored by a new independent body, the Office for NHS Policy and Budgetary Responsibility for England. Drawing on existing work from other organisations, it would produce an annual report on the performance of the NHS, including population health outcomes, access, and waiting lists, plus patient and public satisfaction and an analysis of expenditure. Every five years, ahead of a general election, it should also produce a report on the future of healthcare in the following 10 years, covering expected demographic change, technological advances, and opportunities for increased productivity. It would also provide a very long term indicative view (over the next 50 years) of spending pressures based on known drivers of such pressures. Strategic planning — Governments should be required to respond to the report within six months of taking office. The response would be developed in consultation with professionals and the public, setting out what new areas will be taken forward and what cannot be prioritised. The output would be a five year strategic plan for the NHS with a detailed five year financial settlement, and a provisional settlement over the five to 10 year horizon. The response would be scrutinised by the OPBR. Cash injection — In the immediate future, the NHS needs an injection of funding to tackle the emergency in current NHS provision. The settlement should include funding for capital projects that have been delayed or deferred during the past five to 10 years (in 2022 the cost of backlog maintenance was estimated to be £10.2bn in
the bmj | BMJ 2024;384:e079341 | doi: 10.1136/bmj-2024-079341
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