Does our NHS need radical reform? A discussion with Siva Anandaciva (Chief Analyst, The King's Fund)

In my introductory article I provided context to the question at hand, ‘Does our NHS need radical reform?’. To contribute to this discourse, I have sat with three different healthcare leaders, all of whom I have been personally inspired by, to acquire some of their thoughts based on their extensive professional experience. 

Along with my conversations with Lord Victor Adebowale and Professor Claire Fuller, I recently spoke with Siva Anandaciva, Chief Analyst at the King’s Fund. He is also a member of the Office of Health Economics policy committee and chairs the National Payment Strategy Advisory Group for NHS England and NHS Improvement. His wealth of experience leading projects covering NHS funding, finances, productivity and performance effectively positions him to advise on the strategic direction of our healthcare system. 

I had a great time unpacking numerous themes with Siva, from the challenges of shifting strategic priorities of a healthcare system to solutions to the current workforce crisis. As always, more time would have allowed for a more detailed exploration of his thoughts. But I hope you as the reader will find the issues we discussed to be of interest, despite the brevity.

Hi Siva, really looking forward to our conversation today. I have given you some context for the series at hand. I would like to start by hearing some of your initial thoughts on whether our NHS requires radical reform. 

Really interesting question and topic that you have posed. I have a few initial thoughts.

Firstly I think it is helpful to put where we are at the moment in context. So absolutely yes, you mentioned low staff morale is one of your drivers for exploring this issue, and it is true. You look at staff surveys and they are consistently showing that staff are under real incredible pressure. And then you poll the public, the pressure is manifested in a different way. People still have, what I call, a belief in the foundational principles of the NHS [all seven key principles can be read in the NHS constitution]:

• A universal healthcare system- in that it is broadly open to all (although we have nibbled at that)
• Comprehensive care- in that we do not only provide one form of care (e.g. emergency care) and patients can access a broad range of services 
• Broadly funded through central taxation and free at the point of use. 

The public are incredibly steady when it comes to their devotion to these principles but they are not satisfied with things like waiting times, staffing levels and all of that. So I think the public are navigating two important factors- faith in the model and dissatisfaction with the care they receive. And I think that's one way we can put the pressures in context.

How else would you contextualise current pressures?

My second initial thought is with regard to international comparison. I have looked into international healthcare systems in terms of how they are financed and structured. The most rigorous studies I have seen have broadly come to the same conclusion- that there is no perfect model to finance a health care system. So for example a social health insurance model or charging for GP appointments is not the solution if the problem you are facing is staff levels.

The model we currently have in our country for raising funds to resource our healthcare system is broadly efficient. So we have to ask what problem we are really trying to address? 

If the problem we are trying to address is increased funding for healthcare services or less variation in funding to aid planning, this can be done with the current model. These are political choices. You do not need to restructure the funding model to achieve that. 

If you want to change how the public relates to the health system, you could look at things like charging [at the point of care]. But you'll have to introduce so many exemptions, like we do with prescriptions, so you won't end up changing public behaviour significantly nor raising any significant revenue. 

But I don't think that's the same as saying we do not need radical reform. I think we do need reform. But it's a reform not of how the NHS is funded, but what our priorities are and how it is funded. 

Okay, could we speak a little about the current priorities of the NHS. What are your thoughts on this and how this is related to the ongoing NHS crisis?

I would say we talk a very good game on investing into wellbeing, health promotion and wanting a health service as opposed to a sickness service. But then you look at where we spend our money, it is largely captured by hospitals. This is entirely rational and there is nothing inherently wrong with a hospital-based system. But when I look at what other countries have done, including Scotland, they have set big targets to reduce the proportion of spending on acute care and shift more towards providing care in the community. 

In the short term this may mean accepting that hospitals may perform more poorly in the interim. But what we are doing is providing a long-term investment into the health and wellbeing of communities. Countries like Costa Rica are investing into community-based services, and accepting the adverse consequences this may have in the intermediate term. 

We therefore have a question that is being asked of us whether we really want to reform the overall priorities of our health system.

That’s interesting Siva, a reordering of priorities! I really like that. Do you have any other thoughts on some of the ‘radical’ reform proposals I had mentioned earlier, like a complete restructuring of our finance model?

Final thing I will say on this is that I am interested as to why people are reaching for social health insurance for example and why really sensible people are thinking about charging for GP appointments. My hypothesis is that if you are faced with two choices, one where people are saying that it is going to take 8-10 years for the NHS to become a neutral topic that is reliably delivering, meeting targets, and staying within budget and that's going to require graft and incremental change. Or you have this other thing that can be done which is a political lever that can be pulled to show you are doing something. I can understand why the latter can be attractive. It gives you a sense of achievement even if you think it is ultimately a red herring.

This makes sense. Politicians should prioritise making short term sacrifices for a long-term gain. However, the public typically will hold them accountable to the NHS achieving more short term goals (e.g. reducing waiting times), so how can politicians navigate this?

I don't think there is an easy way to answer this because making the right decisions can often be a form of a political suicide. It is very easy for me as a policy person to say this and I am mindful of that. However, in a way I believe that it is easier to navigate this now than it has been at any other point in the last twenty years. Because in a way you are not really taking anything away from people.

Under new Labour, it is hard to imagine, but there was a time where 98% of accident and emergency users were seen within the 4 hour target. If you were to tell the public then that unfortunately they will have to wait longer, as more resources are invested into the community to promote better health and wellbeing in the long-term, this would not have been welcomed because of loss aversion. 

But at the moment the proposition to the public is different because of how bad access to care is. The proposition is acknowledging to the public how bad things are and the reality that we may never get to where we were before when targets were being met. Proposals to invest in other aspects of the system, such as community and preventive care, may then be better received as loss aversion is reduced to some degree. 

I'd like to briefly pivot to a topic that I am really interested in, health workforce shortages. Could you offer some thoughts on the causes of the current workforce crisis in England and how this could potentially be solved?

Yh, a really interesting topic. So I think alongside the reform of social care, this has been one of the great policy failures over the past 15 years. In which I and others have been complicit. This may sound baffling to you, but in policy circles, the recognition that the workforce is in crisis took pretty slow to materialise.

That being said, there are a few factors of note that have contributed to the ongoing workforce crisis. 

Firstly there was a real political fear of oversupply of the workforce. I can’t tell you how many meetings I sat in where people said if we overtrained nurses they are going to be on the dole queue. So there was real fear of oversupply of the workforce. 

The second thought is about stewardship. There is very little incentive to go beyond stewardship of public services and boost the number of medical and nursing school places due to long training cycles. This is particularly an issue with governments that are not in-situ for the long-term.

The third thing is that complex problems such as workforce shortages require the involvement of different branches of government. So if you need the Home Office, HMRC and the Department of Health and Social care on the same page to do anything like pension tax reform for senior doctors or nurses or international recruitment, everything just becomes more difficult. The other thing is that within health more narrowly, the 2012 act contributed to workforce planning, recruitment and leadership becoming even more fragmented. It all became scattered amongst the different national bodies, so there was no one body that was responsible for all of this.

I think these are some of the pretty poor reasons for the lack of appropriate investment in the workforce. I know of other countries that are baffled as to why we didn’t do more to avert the crisis. However, I think we are now in a better place, at least in terms of workforce planning, as everything comes back into a single national body that oversees staffing. This should mean less finger-pointing at other bodies. 

There’s also going to be the workforce plan that is due to be published, which is good. However, a delivery plan is also required. We know that the workforce plan is going to say we need more GPs for example, but the question is how we go about achieving this. We need a clear plan on how we are actually going to increase the number of individuals in specialities that are struggling because calculating the number of needed health professionals is not the same as outlining how this is going to be achieved.

Thanks Siva, that was a very thorough summary of the current national workforce crisis and associated contributory factors. Is there a way out? What recommendations would you make for us to solve this crisis?

So I will break it down to different bits, firstly how do we get more people into the health system in the near-term and secondly how do we do this in the long-term.

In the near-term, I think international recruitment is inevitable, but we need to make this more sustainable. I understand that there are good ethical reasons for boosting domestic supply, but we need to ensure that we are setting realistic targets in this area, given our over-reliance on international recruitment for at least the past 5-10 years. So what could improvements in international recruitment look like? Anything from ensuring that our language testing rules are fit for purpose, to wider support for spouses and children to also come to the UK, and improving the training offered to international graduates could all improve the effectiveness and sustainability of international recruitment.

In terms of boosting domestic supply in the long-term, increasing the number of medical and nursing school places will prove helpful. Important to also consider the impact of the location of where new training schools are situated and consider placing them in underserved areas for example. (However, it will be important to ensure that trainees in these areas receive appropriate financial support.) Also worth ensuring that efforts to boost domestic supply are more targeted to areas that are in need, for example improving the incentive to become a nurse in the community as compared with an acute trust. 

So that broadly covers how we get people in, but we also have to promote the retention of workers. And these two themes [workforce shortages and workforce retention] are obviously tied as your lived experience of work is heavily influenced by how many people there are around you. But I think there are other things like bullying, harassment and the culture of working in the NHS that has an adverse impact on staff retention. A survey found that over a quarter of NHS staff experienced bullying by a colleague.

The final thing to mention is that we can promote staff retention by improving all of the little things that make a difference to your life in the NHS that never make its way into national policy. The broken computer that never works, limited access to resting facilities, car parking, hot meals. If you are a foundation doctor like yourself having to sleep on the spare ward bed or in a car if you have one, that is not okay. Where is the discretionary funding and budget and sense of adjacency at a local level as that is not the secretary of state’s responsibility, but your CEO’s. Fixing all of  these small problems can make a huge difference to staff morale.

Yep! I completely agree, as a junior doctor you wouldn't believe the places that my colleagues and I have slept whilst working out of office hours…..

Closing remarks (Dr Jacob Oguntimehin)

This conversation marks the end of this three-part series on whether the NHS requires radical reform. It has been incredibly thought-provoking sitting with three healthcare leaders (Lord Victor, Professor Claire and Siva) who have continued to inspire me over the past few years.

We have explored a range of themes from health inequalities, to integration in primary care, to the ongoing workforce crisis. Please read these articles if you have not already had the chance.

A goal of this series was to challenge readers to think beyond tabloid headlines that frequently highlight various elements of the NHS crisis and consider potential solutions to the problem we face. 

Many, including our healthcare leaders in this series, agree that change is required. That the NHS requires system leaders, policy makers and politicians at a local, regional and national level to actively collaborate and coordinate resources in novel ways to solve the many ‘wicked’ problems that befall our NHS. However, there remains little consensus on how exactly these problems should be solved in a manner that is most efficient, effective and sustainable for the long-term.

It is this uncertainty in the best possible solutions for our NHS that has prompted much debate. I hope that this series has contributed to the discourse in a meaningful fashion, highlighting a variety of perspectives from healthcare leaders supporting the health system in different ways.

Rather than concluding with an answer, I sought to further explore the question as to whether our NHS requires radical reform.