Last week, in a speech entitled ‘The fundamental reform of the British state’ the Prime Minister announced the abolition of NHS England. It was generally welcomed. Yes, people said, it will be disruptive in the short term but the previous arrangement was disruptive in the long term.
Now there is an opportunity to lay foundations for something better. The Prime Minister gave us some clues about his approach. He spoke of ‘a strong state.., reforming it so it’s closer to communities, tearing down the walls in Westminster, Inviting the British people in as partners in the business of change’.
Meanwhile Wes Streeting has told us that his three big reform shifts for health are
Hospital to community
Illness to Wellness
Analogue to Digital
Starmer reinforced the third of these, describing the potential of AI to simplify tasks and generate efficiency.
Yet, although he and Wes Streeting both want to get the state closer to the community, and to create a wellness service rather than an illness service, two elements seem astonishingly absent from the government’s approach – and indeed from the whole discussion around it, to judge by the Institute for Government’s podcast discussion of the speech with former Cabinet Secretary Gus O’Donnell.
The two missing elements are connectedness and learning.
A strong state must be a coherent state – joining up all the contributions of different ministries to a common objective. It must also be a learning state which can adapt policy to changing community needs and changing implementation as its impacts – intended and unintended – become clearer.
Take food and housing as examples.
Connectedness
A recent report by a cross party committee of the House of Lords concluded that
The Government needs a plan to fix our broken food system…obesity and diet-related disease are a public health emergency that costs society billions each year in healthcare costs and lost productivity.
The annual societal cost of obesity is at least 1–2% of UK GDP. There has been an utter failure to tackle this crisis. The food industry has strong incentives to produce and sell highly profitable unhealthy products. Between 1992 and 2020, successive governments proposed nearly 700 wide-ranging policies to tackle obesity in England, but obesity rates have continued to rise.
Voluntary efforts to promote healthier food have failed. Mandatory regulation has to be introduced.
In a speech that focused on improving the nation’s health this public health emergency was not mentioned by the Prime Minister. His only reference to regulation was a generic promise to reduce it.
Learning and Localism
In order to be intelligent government must be set up to learn. Jonathan Shepherd was a maxillofacial consultant in Cardiff. From earlier experience in other locations, dealing with the consequences of Saturday night violence, Shepherd realised that hospital emergency departments had access to information about violent assaults and where they occurred which the police force did not have. He then initiated co-operation between hospital, police local authority and other agencies. That co-operation, which evolved into what became known as the Cardiff model for violence prevention, was found to have led to a reduction of around 40% of violent assaults.
Significantly, the learning started locally. And change came when Shepherd persuaded police, the licensed trade, local authorities and others to sit down together to solve the problem.
So why didn’t Keir Starmer make any link with his own government’s commitment to devolution and talk about mobilising all relevant contributors to better health solutions? It is Metro Mayors and local authorities and parish councils and voluntary organisations and churches and mosques and women’s groups and police and head teachers who best know where the problems lie. Having established its national priorities doesn’t a strong state exercise its strength though empowering and listening to them?
There is of course a crucial role for central government to modernise the flow of data and the sharing of knowledge. But there is little point in this unless the insights provided by the data are put at the service of regions and neighbourhoods. And by the same token the state will only be effective in delivery if it is listening and learning about its impacts from the people on the ground.
Health at the Heart of Every Decision
In 2019 the Mayor of Cambridgeshire and Peterborough created a Commission for Public Service Reform chaired by Andy Wood, at the time CEO of Adnams, to help him understand how his devolved authority could best contribute to improvements in the health of his populations. The commission report was called ‘Health at the Heart of Every Decision’ It looked through four lenses:
The Whole Person – Holistic Approach to Wellbeing
The Whole Community – Holistic Approach to Community Resilience
A Whole Region – Health in All Policies
A Whole System - - New Ways of Working and Organising
It outlined intelligent and locally relevant approaches to planning, transport, housing, food, procurement, the activities of young people, jobs, training and so on.
Imagine the difference if the principles outlined in this report had been adopted by the UK Government. Take housing. The speech made by Angela Rayner announcing the government’s plan to build 1.5 million new homes does not mention health once.
The aim is, surely, not simply to meet a numerical housing target, but, in the process, to build more viable communities in which residents will flourish. Otherwise in your rush to build you could be sowing the seeds for social isolation , building soulless, youth-alienating, car-dependent estates without a sense of community, thereby creating extra demand on the physical and mental health services of the future.
Many people are worried that the abolition of NHS England tilts the balance of power too much into the hands of politicians with a short-term focus. Keir Starmer’s response is to say that health needs democratic control. He and Wes Streeting want to invite British people in as partners in the business of change.
A fine ambition, Prime Minister and Secretary of State. To achieve it your health strategy must first be embedded in all your other missions and, in implementation, must ultimately be local to its fingertips.
That’s what a strong state really means.
Mark Goyder is the Founder of Tomorrow’s Company and Senior Advisor to the Board Intelligence Think Tank. He is the co-author, with Ong Boon Hwee, of Entrusted – Stewardship For Responsible Wealth Creation, published by World Scientific. He was Deputy Chair of a Commission on Health and Social Care for the Cambridgeshire and Peterborough Combined Authority.