Health systems on perilous tracks: NHS England’s story contains painful parallels for Aotearoa

It is hard not to feel sorry for health minister Ayesha Verrall. After all, the current bin fire which is the health system is not her fault.

Failures on this scale are never the result of a single person or their actions. Rather, they are the result of multiple failures over many long years – failures of leadership and policy, failures to listen to warnings, failures to anticipate events and then failure to accept responsibility when they unfold as predicted.

A recent report from The King’s Fund in the UK details precisely and concisely how the National Health Service there began the millennium with clear strategic intent and successful fiscal management, before deteriorating into a state of chaos.

Reading the report – The rise and decline of the NHS in England 2000-20 – I felt a creeping sense of déjà vu.

Most stark was the realisation that, while Aotearoa’s health service has clearly declined at a similar rate as the NHS in a similar period and for many of the same reasons, New Zealand started with the bar set far lower. Where does that leave us now? And, more importantly, can we learn from the failures of others and attempt to rescue the situation?

The major contributors to NHS’ decline are highlighted as decisions on public spending, rising demand for care, and the failure of politicians and the system in which they operate to heed the warning signs accordingly. The report pithily points out that short-term thinking geared around election cycles, disjointed policy-making and an inability to learn from failures do not a successful strategy make.

The King’s Fund report repeatedly states that social determinants of health must be tackled in order to make long-term improvements in population health and reduce inequalities, noting that programmes to address these “either stalled or went into reverse after 2010, and successive governments were reluctant to use their regulatory and fiscal powers to tackle the wider determinants of health”.

Other recommendations are that there should be a sustained commitment to prevention and early intervention, and the public should be engaged in their own health, seen as active agents in their care, with responsibilities as well as rights, in order to prevent illness and promote health. The UK’s audit office in 2020 warned that, without this approach, the NHS would become unsustainable.

Our own system is buckling under the weight – literally – of obesity and chronic disease

Similarly, our own system is buckling under the weight – literally – of obesity and chronic disease. The means to tackle these issues lie at the population health level which, in turn, depends on cross-government support for legislation that protects and promotes health, prioritises primary and community care, and results in a healthy environment and well-resourced and integrated health and social care service.

None of these have so far been evidenced in the “radical overhaul of the health system” we were promised back in the heady days following publication of the Health and Disability System Review Panel’s findings (the Simpson Report) in 2020.

At that time, there was a brief solar flare of optimism: at last, someone was taking notes. Hopes began to fade during the long period of transition and, by the time the curtain was pulled back last July to reveal very little of substance, the workforce was left feeling that not only did the emperor have no clothes, he was actually now hiding in the bathroom too embarrassed to come out. This feeling is reinforced by the staggering lack of engagement or information-sharing relating to the reforms.

Particularly prescient within The King’s Fund report is discussion of the large NHS reorganisation under way at the time, known as “the only change management system that you can actually see from space – it’s that big”, and resulting in the loss of many experienced leaders. Says the report: “Time that could have been spent improving NHS efficiency was directed to restructuring, which was widely perceived as both damaging and distracting.” The outcome was a lack at the “top of the office” of people with a deep knowledge of health and care able to advise ministers on what needed to be done.

It is worth noting that these “damaging and distracting” NHS reforms were not begun at the tail end of a worldwide pandemic, involving an exhausted, traumatised and demoralised workforce.

Reading on, the parallels continue and give the lie to Aotearoa’s tendency to exceptionalism. In the UK, the “needs of people with multimorbidity present challenges to specialist models of care focused on single diseases” and, between 2000 and 2020, spending on hospitals outpaced primary and community services such that primary care was “struggling to meet the demands of a population with an increasing number of long-term complex conditions”. The concept of “failure demand” is introduced: demand arising from failure to meet people’s needs, such as high rates of attendance at emergency departments because patients cannot access a GP. The conclusion is that the NHS is “focused on responding to failures in other areas of policy”.

Other burning platforms of note were a delay in developing a workforce plan, staff pay and conditions, and a reliance on overseas recruitment.

This sounded so familiar, I was about to scroll back to the front page of the document to make sure it had actually originated abroad, but saw that “the absence of financial barriers to people accessing care…remained a strength”. Not New Zealand, then.

In the UK, deteriorating working conditions and lack of listening from political leaders have led to a radicalisation of the workforce, culminating in recent junior doctor strikes. So many of the underlying issues are echoed in our own health service that similar events are likely here unless the lessons pointed out by The King’s Fund are understood and acted upon.

The author concludes that it is incumbent on governments to create the conditions in which people can thrive through regulation, taxation, legislation and other means. This is a manifesto we could all get behind – and perhaps one to use as a political litmus test in this election year.

Orna McGinn is an Auckland-based specialist GP and chair of the New Zealand Women in Medicine Charitable Trust