Leaving the EU will be one of the biggest, most complex decisions the UK has taken in decades. With the clock ticking, perhaps it’s not surprising that government is finding this challenging to say the least. However, Brexit is not the only big decision that government needs to take, nor is it the only example of public bodies struggling to grapple with big, long-term decisions.
There is a long-established critique of UK governments of all complexions that they struggle to focus on the long term, with short-term political expediency always winning out. The failure to invest in our national infrastructure is a textbook case in point. This bias towards the short term and the quick fix was one of the arguments for the privatisation of the railways and utilities in the early 1980s; under state control they had been starved of investment and, if taken out of government control, could plan and invest for the long term.
Beyond privatisation, governments have also tried to discipline themselves where they know that good decision making might be hard in the day to day ebb and flow of politics. The first major move in this direction was the independence of the Bank of England in 1997. Since then the government sets the inflation target, but the Bank determines interest rate policy and Ministers have no day to day role. Following the success of the Bank’s independence, the coalition government created the Office of Budget Responsibility (OBR) in 2010 with the goal of providing independent and authoritative analysis of the UK's economic prospects and public finances. The OBR makes no policy decisions but is widely seen as having been a success, improving the quality of debate about the economic challenges and prospects for public finances. It also makes it harder for both government and opposition to duck the big issues.
There is growing recognition that much of the critique of economic policy – that it is dominated by short-term tactical thinking with too little focus on the long-term strategic challenges, mired in a political context that makes grasping the nettle of hard decisions enormously difficult – also applies to health and social care.
Focusing on longer term system sustainability
At the Heath Foundation, we have argued for several years that this culture of short-termism is the Achilles heel of what is otherwise a very strong health care system. Workforce planning, productivity and changing models of care to meet the needs of an ageing population with multiple morbidities all require a long-term perspective. These issues require sustained focus and constancy of purpose but have suffered from the cycle of boom and bust. For social care, the problem could not be more acute with reform kicked into the long grass time after time by successive governments over at least 20 years.
The problem, we have argued, can’t be fixed by a one-off review, however well executed. It is systemic and therefore needs a system change. In 2017 the House of Lords Select Committee on the sustainability of the NHS took up this challenge and recommended that the government set up an independent body: an OBR for health, to produce authoritative estimates of the future funding and workforce needs. The proposal has garnered a lot of support, including that of leading politicians.
Building a specialist unit
We’ve been thinking hard about how the Health Foundation can help this debate to move beyond words to action.
We have decided to establish a new Health and Social Care Sustainability Research Centre [update: now named REAL Centre] to provide independent projections, research and analysis, strongly rooted in robust quantitative modelling, to help ensure the long-term sustainability of health and social care in the UK. It will aim to bring about more evidence-based policymaking and a shift in focus towards long-term system sustainability.
We are expanding our team in the Health Foundation to build a specialist unit to lead this work. But we don’t want to work alone. We plan to support a network of academic partners, sustainability research units, in all four countries of the UK to improve the research and evidence base on aspects of health and care sustainability. To do this we expect to provide around £10 million of funding over the next five years. We will award this through an open and transparent commissioning process in 2019.
The Centre will seek to improve our understanding of the drivers of demand for care, the workforce consequences and its supply, the potential for productivity improvements, and the impact of innovations in service delivery, including new technology. It will draw on wider Health Foundation work on service innovations, as well as insights and analysis on the future impact of population risk factors and the social determinants of health.
We are keen to think about how we use the output of projections work to understand the implications for policy and practice in systematic ways, for example by using structured approaches to decision making under uncertainty.
The Centre is at conception stage and over the coming year we will engage widely with policymakers, researchers and those involved in strategy roles in the NHS and care system across the UK to continue scoping this work. We believe it can make a real contribution to improving health and social care for people in the UK.
Watch this space.
Anita Charlesworth is the Director of Research and Economics at the Health Foundation.