Out of commission: what might a royal commission mean for the NHS?

Jan 9, 2018 | By Mike Birtwistle | Posted in NHS

Speculation about a royal commission on health funding is welcome recognition of the scale of the problem facing the NHS but would do little to solve the service's problems, argues Mike Birtwistle.

If Jeremy Hunt’s continuation at Health came as a surprise to some, the winter ‘crisis’ is no surprise to anyone who follows the NHS. Yet scenes of overcrowded corridors (let alone wards) and ambulances queuing always come as a shock. This year the focus is more acute than ever. The drama around the difficult start to this year has been heightened by tweets from clinicians, managers and the public. This running commentary from the frontline as well as national commentators makes this crisis difficult to ignore or dismiss.

Yet if the crisis is predictable, then the political response does appear to be somewhat different. From Number 10 we have seen public apologies for cancelled operations and praise for staff. Having previously warned that Simon Stevens would be held personally accountable for winter performance, little attempt (so far) has been made to pin the blame on NHS system leaders.

Instead, we have seen a tacit acceptance that something needs to change, even if there has been a lack of answers from politicians about what this change should be or how it should occur.

Calls for a royal commission on health funding are nothing new. There have been previous cross-party demands for a review and the Labour Party’s 2017 manifesto pledged to establish a new independent Office for Budget Responsibility for Health to oversee health funding and scrutinise how it is spent. Yet these calls are intensifying. Jeremy Hunt has argued for a new 10 year plan for the NHS, the NHS Confederation is commissioning work on the issue from the Institute of Fiscal Studies, there is interest in a dedicated NHS tax and Nick Timothy – who until the election was joint chief of staff to the Prime Minister – has backed the idea of a Royal Commission.

This latter intervention is particularly significant. Key figures in Number 10 always let it be known that they were highly sceptical about calls for increased health spending and they were robust in their briefing against NHS leaders when it was felt they had overstepped the mark in calling for new resources. What is more, Timothy is carefully loyal to his former boss and is unlikely to have floated an idea which is not being actively considered.

So what has changed and what does it mean for the NHS? Events make it increasingly politically difficult to deny the funding realities facing the NHS. The time is approaching where the call for funding needs to be heeded or the people delivering that message need to be removed (and there is still time for both to happen). Yet how or when to deliver additional funding is less clear, particularly with fairly dire predictions for public finances. In the absence of a clear idea about how to address the funding issue a royal commission becomes superficially attractive.

While it may be exciting to many that their pleas appear to have been heard, there are five main reasons why a royal commission may not be good news for health and care services. Firstly, royal commissions take a very long time to deliver any recommendations, with most operating for between two and four years before reporting. What is meant to happen to NHS services in the meantime? Four more winters will seem a very long time to those working – or waiting for treatment – in an A&E.

Secondly, the terms of reference would be highly controversial. Is this a commission on funding of the NHS? What about public health? Is it a commission on health and social care? Hunt’s new title may be cosmetic, but it surely makes it harder not to consider both. Excluding social care would risk perpetuating the divide between health and care, yet inclusion would surely render the Social Care Green Paper (supported by its own team of independent experts) irrelevant. If there is to be a commission, should it go wider than funding and entitlements? What about structures? Should it reach into local government? Will it cover workforce requirements? How much of government policy would the Government be willing to outsource?

Thirdly, the composition of a royal commission would become a fierce turf war. If you intend to act upon the recommendations, then they need to be formulated by people who know their way around Whitehall but should this be from a Health or a Treasury perspective (I imagine, for example, that Hugh Taylor and Nick Macpherson may have very different perspectives on the issues at play). Likewise, clinical and patient expertise will be important, but the identity and perspective of these experts will go a long way towards determining the shape of the recommendations. The experience of other independent inquiries or commissions suggests that simply getting the commission up and running would be no simple task.

Fourthly, does the Government have the capacity or capability to support a royal commission? The Whitehall machine is preoccupied with Brexit and already has a series of independent inquiries to support. On health issues alone, there are inquiries planned into the contaminated blood scandal and Ian Paterson. In other policy areas, the Grenfell Tower tragedy and the child abuse inquiry will require significant support.

Finally, it is not a given that whoever is the Government when a royal commission finally reports will decide to implement the recommendations. Those with memory of the Royal Commission on Long Term Care for the Elderly (1998) will recall that politically difficult decisions become no less politically difficult just because a commission has opined on them. Politics will be no less short-termist or unstable the other side of a royal commission.

Health funding is inherently political and politicians cannot outsource it any more than they can absolve themselves of the responsibility for how the NHS performs. Kicking NHS funding into the long grass will certainly not help this winter or next and it is doubtful that would deliver over the longer term either. 

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