Wes Streeting, the new Secretary of State for Health and Social Care, used his first statement in office to say that ‘the NHS is broken'. So, is it? What a question to have to consider.
But it is a question that has been on the minds of clinical and managerial leaders whom The King's Fund has worked with over the past few months. Through those conversations, three other questions emerged that might help us think through the Health and Care Secretary's bold statement.
The first question is: ‘What is the thing that is broken?'
People working in social care and public health (and wider services such as education) would say the pressures in their sectors are just as extreme. They are right. So, if there is a fracture, it is one that runs through the bones of wider public services in this country.
The second question is: ‘What does broken mean?'
I have sat through debates as to whether the NHS is ‘under pressure' or ‘in crisis' (apparently, it's the former if the NHS has a plan to improve and the latter if it doesn't). But things are now so bad that the debate has moved on to new ground.
To me, the signs of a broken system are when the problems are deep and material - for example, waiting times aren't being missed by marginal amounts but by huge distances. The problems are broad - they are not contained in pockets of pressure in parts of the country or in individual services, but spread throughout the system, from maternity to district nursing, from Cumbria to Cornwall. The NHS has had success (nee failure) regimes for parts of the country before, but the new Health and Care Secretary has effectively just put the whole of NHS England into special measures.
“Perhaps more fundamentally, in a broken system, more of the same doesn't always work - if you break your leg you can't walk, no matter how much energy you put through it.”
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Perhaps more fundamentally, in a broken system, more of the same doesn't always work - if you break your leg you can't walk, no matter how much energy you put through it, it's that simple. In NHS terms, this drives some of the debates as to why the Treasury views the NHS as a ‘bottomless pit'; why there are concerns over slow productivity growth in the NHS; and why there are recurrent winter crises. In a broken system, more money and more staff don't solve the problems you can see coming down the track.
The third question is: ‘If the NHS is broken, who's asking (and why)?'
Asking if our health service is broken is not a neutral, innocent musing. The question elicits reactions that run the gamut from ‘No, why are you even giving this issue oxygen?' to ‘Of course it is, why are you in denial?'
In recent months, we have had former Health and Care Secretaries, such as Sajid Javid, ask the same question. It has been debated on popular podcasts like The Rest is Politics. It has been used to craft the argument for alternative funding models. In short, asking if the NHS is broken has become a mechanism to debate whether the founding principles of the NHS need changing so that it is no longer universal (broadly accessible to everyone), comprehensive (offering a broad range of treatments and services), taxpayer-funded and free at the point of use.
Wes Streeting's statement comes from a different place. This government is likely to have zero interest in exploring more user charges, social health insurance, or any of the other remedies politicians have prescribed when they said the NHS is broken. Instead, his statement does two things.
“Wes Streeting has diagnosed that the NHS is broken. He has five years to fix it. ”
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First, it helps buy him time. Wes Streeting's narrative is not about taking a good system and making it even greater. As with the Chancellor's statement on the wider economy, we should expect national audit exercises that show the new government has inherited a set of problems that will take years to turn around.
Second, it creates a platform for reform - but with a lower-case ‘r'. Rather than glitzy promises to change its funding model, the Health and Care Secretary is crafting an argument that more of the same will not work, and the NHS needs to do more to become the prevention-focused, community-centred service that previous national reviews envisioned. In short ‘modernise or die'.
Is the NHS broken? We can debate the semantics, but I do know this - two years ago, the NHS had the worst winter I can remember in my career. As I was walking down the steps at Oxford Circus tube station, I became one of those annoying people who stops on the staircase for no reason. It was because I had suddenly thought, ‘What if I fall down these steps and break my back again? Would an ambulance even be able to make it? Would the NHS be there for me?' The answer was ‘I don't know'. And that's a scary place to be. Wes Streeting has diagnosed that the NHS is broken. He has five years to fix it.