What needs to happen with the NHS? TONY EVANS takes to his podium and offers the kind of speech he’d like to hear about necessary reforms.
The Secretary of State for Health and Social Care has promised us a “10 Year Health Plan”, to be published in this spring. Wes Streeting has stated that it will “deliver the biggest reimagining of the NHS since its birth”. Meanwhile, in a parallel universe at the far side of the Galaxy, spring has already arrived, and the Health Plan has been unveiled by Streeting’s doppelganger in a speech to the nation. It’s goes something like this….
“I am sure that you will have been waiting impatiently for the details of our 10 Year Health Plan. Let me first address those rumours regarding our consultations with the other political parties, both major and minor, in England, Wales, Scotland and Northern Ireland. They are correct: for some months representatives of all UK parties have been meeting in secret at Butlin’s Holiday Camp in Skegness, and have now approved an historic cross-party agreement to reform fundamentally the delivery of health care in the United Kingdom. The game-changing Camp Butlin Accord means that the radical proposals that I will outline today will not be vulnerable to cynical political points-scoring, and more importantly, will remain in place after the next election, whichever party – or coalition – is in power.
“Previous attempts at fundamental reform have been hampered by the ability of the British public to hold two conflicting beliefs at the same time: a classic case of what Orwell termed ‘doublethink’. Firstly, that the NHS in its current incarnation is deeply dysfunctional – a belief supported by Lord Darzi’s recent report, as well as the experiences of many patients. Secondly, that the basic principles that have guided the NHS since its establishment in 1948 – including services largely free at the point of delivery, and primary care provided by family doctors in local GP practices – are sacred and inviolable, and have made the NHS the envy of the world.
“The historic Camp Butlin Accord recognises that the NHS can only deliver the service that citizens need if these basic principles are challenged, further recognising that the structures established in 1948 are no longer suitable for the 21st century. I will now outline our forthcoming reforms in four key areas: funding; structures; workforce; and managing future demand.
“Firstly, funding. ‘Free at the point of delivery’ has been, to date, a principle that until now no incumbent government that wished to remain in power could challenge. Under our Health Plan, we will retain the principle that all citizens should have access to vital health care, but the method of delivery will change. We will fund the NHS through an insurance scheme of the kind used successfully in most European countries. In our scheme, all adults will be required to pay into a public insurance fund, overseen and guaranteed by central government.
“Compulsory deductions (taken from all state benefits as well as from wages) will be related to income, with higher earners paying more into the fund. Nominal up-front payments will be required to access NHS services: for example, £20 for an in-person appointment with a GP or senior health professional. These charges will be refundable via the health insurance scheme. Dentistry will be fully integrated into NHS services, and the current anomaly of separate charges for NHS dentistry will end.
“Now, I am sure that many of you will be wondering: ‘Why not use income tax to fund the health service, increasing it to a level commensurate with the money that would be raised by the new insurance charges?’. My response is that an insurance scheme provides a very different psychological context. Increases in income tax rates or VAT are regarded by the public as an imposition by government, whatever nominal purpose is announced. Citizens feel ‘they are taking more of my money’ without any obvious benefit, and this depresses economic confidence and enterprise. In contrast, a payment into a public health insurance scheme is more likely to be seen in the same light as a mortgage repayment or a monthly car lease payment i.e. as a necessary outgoing which brings tangible benefits. Of course, in such a scheme, directly funded by citizens, the current level of dysfunction in the service cannot be tolerated. Citizens will expect to get what they pay for – just as they expect their leased car to be reliable.
“The Camp Butlin plan to make a nominal charge for accessing health services may also be questioned – a common objection to this proposal is that the money used to administer this scheme would be wasted, as the charge is refunded. So why bother? Again, the answer lies in the psychology of the patient, and indeed of the healthcare workers with whom the patient interacts. ‘Free’ services tend to be both overused and undervalued. The (refundable) nominal charge of £20 to see a health professional will encourage citizens more readily to identify issues that are self-limiting, and which can be treated with over-the-counter remedies. The ‘free’ nature of the NHS also places the patient in the position of a charity-seeking supplicant when interacting with healthcare workers – a payment scheme will serve to remind everyone that the NHS exists only because patients are paying the wages of the staff.
“Next I will turn to the structure of the health service. The 10 Year Health Plan will introduce a radical departure from the ‘family doctor’ model of primary health care which has – in theory, if not in practice – prevailed since the establishment of the NHS in 1948. An idealised version of this model is embedded in the British psyche: a world where dedicated, full-time GPs have worked for many years in the same surgery; pillars of their community who have built up an intimate knowledge of their patients, who will see urgent cases the same day, and are not averse to turning out at 3.00am to provide treatment, reassurance or an emergency referral to hospital…
“It is not necessary to abolish this model, since it no longer exists – it has been replaced by, typically, a two week wait for an initial telephone appointment. Instead, we will establish Local Health Hubs, staffed by salaried doctors and a range of other health professionals, and open between 8.00am and 6.00pm seven days a week. Appointments will be available in advance, but patients will also be able to get advice on a ‘drop in’ basis. All patients will be seen in the first instance by the equivalent of an Advanced Nurse Practitioner who can prescribe medication if needed, and can refer on to a doctor if necessary. Most patients with mental health concerns or conditions will be directed to counselling services within the hub, rather than doctors. The current Accident and Emergency units attached to hospital will remain. However, people who attend them with a non-urgent condition will be re-directed to a Local Health Hub. The Health Hubs will also be the focus for integrated preventative care, delivered locally.
“For secondary care, the main change in the plan will be the establishment of a network of Senior Care Hospitals (similar to the geriatric hospitals which used to be provided by the NHS). Some elderly people admitted to these hospitals will be awaiting admittance to a suitable residential care home where they can have assistance with day-to-day living; others will have chronic conditions which require long-term medical treatment.
“Management of the NHS will be rationalised and streamlined. The Camp Butlin Accord includes an agreement that strategic management of health services will no longer be a delegated responsibility of the regional Scottish, Welsh and Northern Ireland Assemblies: policy will be set and managed centrally by parliament, in order to ensure equal, best-practice treatment for all citizens of the UK.
“The 10 Year Health Plan will involve also significant changes to the current terms and conditions of the healthcare workforce. The nation’s tax-payers can no longer afford the luxury of training a doctor or dentist who may then choose to leave the service or work part-time. Therefore, from 1st January 2026, entry to medical and dentistry training will be conditional upon applicants contracting to work full-time in the NHS, as salaried employees, for a period of ten years after qualification. Anyone breaking this contract will be required to repay the cost of their training – over £200,000 after tuition fees are taken into account.
“New medical, dental and nursing schools will also be established so that all health workers can be recruited from UK nationals, rather than imported, and a non-graduate apprentice pathway will be restored to nurse training. We will ensure that enough dentists are trained to supply dental services to all who need them. More responsibilities will be given to other skilled staff in the workforce, such as those currently designated as Advanced Nurse Practitioners and Physician Associates. Staff at this level who are licenced to prescribe prescription medicines will be redesignated as Senior Medical Assistants.
“Finally, this new health plan can only work if future demand for health services is controlled. Toleration of ever-increasing demand for NHS services will sabotage any attempts at reform. The Camp Butlin Accord recognises that there are two large elephants in the demand room. The first is social care, where the current inadequate provision traps patients in hospital. I am delighted to say that cross-party consensus is now close to being reached on the establishment of a national scheme (including the devolved UK governments) which will fund residential and at-home social care throughout the country. In conjunction with the establishment of Senior Care Hospitals, outlined above, this will ensure that hospital beds are occupied only by those who need them, allowing for timely admittance of new patients and an end to the scandal of ‘corridor care’.
“The second demand elephant is the rapidly increasing population of the UK, wholly due to migration. Official government statistics state that in 2023 net migration was 782,000 (https://commonslibrary.parliament.uk/research-briefings/sn06077/). No service planning can cope with a continuation of this level of increased demand. The Prime Minister has agreed that I can reveal today that a further series of cross-party talks will soon be underway in Skegness to address the migration issue; all the participants have already approved an objective of reducing net migration to 50,000 per annum, which will provide the stability needed for long term health planning.
“I would like to conclude this outline of the 10 Year Health Plan by summing up what I believe to be its two most important features. Firstly, and most importantly, it has been produced through political consensus. The days when the major parties could use each other’s proposals for cheap electoral advantage are over. Secondly, it should be obvious that the radical changes introduced will need to be implemented over the long-term.
“Of course, when immediate action is needed to tackle an issue it will be taken, but the fundamental reforms I have here today outlined – for example, the changes to the contracts for doctors entering training – will take some years to show their effect. This should not be seen as a disadvantage: the plan is intended to put the health care of the United Kingdom back on a sound and sustainable footing for generations to come, an objective which deserves the time and effort needed to achieve it. But the Camp Butlin Accord will deliver….”
