Many people may have been unaware of the existence of the British Medical Journal’s Commission on the Future of the NHS: but most will welcome its first report, which combines full support for the founding principles of the NHS with the call for the next government after the general election to declare a “national health and care emergency” and begin an “urgent reset for the NHS”.

While there some familiar names are involved, there are a good number of much less familiar ones, and there is no explanation on how the 28 members of the Commission, which is strongly skewed towards academics and medics – and includes no trade union, wider public or campaigning voices – were selected.

Despite this, the initial findings and the direction of travel for the Commission’s sub-groups appear radical and promising. The three co-chairs and the BMJ’s editor in chief Kamran Abbasi headline the findings as “an emphatic recommitment to the founding principles,” and begin with the call for a national emergency.

This is explained in the report, which interestingly reminds us of the BMA’s initial opposition to the establishment of the NHS when the legislation was passed in 1946 and right up to its launch in 1948. Now the BMJ’s Commission argues:

“The NHS’s problems require urgent and speedy action. The NHS was founded through a major act of political will against opposition from the BMA and other powerful interests. The next government should be similarly bold and declare a national health and care emergency, calling on all parts of society to help improve health, care, and well-being. It should, in effect, relaunch the NHS with the active participation of all sectors.”

The report does not say as much, but the value of declaring a ‘national emergency’ would be as a way to give potential leeway for Labour, the most likely next government, to review their leaders’ repeated, unwise promises not to raise taxation on the super-rich or big business, and even claims the NHS could be restored by ‘reforms’ alone, without additional spending.

The call for the reset is linked to the need for a restatement of the basic principles on which the NHS was founded. This raises an awkward point: “Neither the legislation nor health minister Aneurin Bevan’s speeches mention founding principles.”

However the Commission argues they can be deduced from reviewing the extensive discussion at the time: “… it is reasonable to identify five founding principles: the NHS as a comprehensive service, universally available, based on clinical need, free at the point of need, and funded through collective contributions.”

In recent years some campaigners have attempted to add on a sixth ‘principle’, which was not specifically addressed by Bevan at the time, that services should be publicly provided as well as publicly funded.

The Commission makes only a passing reference to this issue. It notes how New Labour launched its historic decade of investment that rescued the NHS from 2000, by getting support from across the NHS and its partners for a 10-year plan, and by the Wanless report, which revealed the historic under-funding of the NHS, produced a long term financial plan … and won over the Treasury.

This, the Commission argues, “carried the NHS through the next few years when controversial policies were introduced about use of the private sector and patient choice.”

It’s likely this evasion of any discussion of the implications of New Labour’s opening up of a ‘market’ in NHS clinical care will antagonise some on the left. It certainly stands in contrast to the Commission’s otherwise thorough discussion of the continued relevance of the NHS principles, especially on the importance of funding through taxation.

But it’s important to remember that Aneurin Bevan, the founder of the NHS, was not only the politician who nationalised the hospitals: he was also the person who made the historic compromise, when he  “stuffed their mouths with gold”, allowing NHS hospital consultants to retain private patients and pay beds, and allowing GPs to work as independent ‘contractors’ rather than becoming NHS employees.

The argument against the use of private providers for NHS clinical and non-clinical services, whether back in the 2000s or now over 20 years later, must not just rest on asserting an abstract principle: it needs to be focused on the real costs – the negative impact of privatisation on standards of care, on diverting vital resources out of the NHS, on the fragmentation of the NHS into a profusion of contracts, and so on.

The Commission lists the additional principles incorporated into the 2013 rewrite of the NHS Constitution, which include the need to provide “best value for taxpayers’ money,” and “accountability.” Outsourcing services to private providers can be shown to conflict with both.

Perhaps more important than sidestepping a major debate over an issue that was not a founding principle is that the Commission not only concludes that all of the original principles remain valid, but proposes additional principles for the NHS to embrace, not least “a new arm’s length body, akin to the Office for Budget Responsibility, to hold government to account for delivery of the NHS plan.”

It also calls for a “reset” that would recommit to the founding principles of the NHS, including its ongoing funding through general taxation, and launch “an urgent review and national conversation to agree a long term vision and plan for the NHS:”

The Commission urges a renewal and strengthening of the popular roots of the NHS:

“The government should, in effect, relaunch the NHS with the active participation of communities, employers, businesses, housing providers, local authorities, food producers, schools and the public, as well as patients, health and care workers, carers, and others in preventing disease, providing care, and creating health.”

And in addition it goes further than Bevan in calling on the next government to give “immediate priority to tackling inequalities in access and outcomes … paying particular attention to the disadvantage and racism suffered by different ethnic groups both as patients and staff of the NHS.”

The Commission, despite containing no patients or lay members of the public, correctly also insists that “Patients and the public can play a greater role in the design and evaluation of NHS services.” It urges the next government to develop “better ways to connect patients, the public, and community groups with the NHS, particularly at local level.”

It suggests a new way to achieve this: “citizens’ assemblies, where patients and the public can better engage in governance and decision making, alongside other stakeholders.”

And, with commissioning of services in England now less local than ever, and decisions in the hands of just 42 Integrated Care Boards, the Commission argues that: “Local services and planners need to think about how patients, the public, and community groups can be connected at the most local level and feel part of the efforts to care for themselves, their fellow citizens, and communities.”

The most disappointing aspect of the first report is that despite highlighting the significance of additional funding from 2000 in driving improvement in NHS performance, and identifying the extent of the problems caused by 14 years of underfunding, the Commission sidelines the call for more funding to an apparent afterthought in its final recommendation:

“Providing some additional funding to support early improvements and commissioning a review of future sustainability.”

This appears to be dropping the ball at the most crucial point. As Health Foundation policy chief Hugh Alderwick argued in a BMJ article responding to Labour’s Mission Statement last summer,

“The elephant in the room is money. Labour’s narrative is that reform will need to do “the heavy lifting” to improve the NHS – and Starmer dodged questions from journalists about how Labour would fund the plans. … Health spending is set to increase by just 0.1% a year in real terms over the next two years – well below the decade before the pandemic (2%) and the long term average in England (3.9%).

“Contrast this with spending growth of 6.7% under Blair and Brown in the 2000s. No amount of reform will avoid the need for substantial investment for Starmer’s Labour to make real progress.”

It would have been useful to see the Commission echo this warning. But they promise more to come on funding and other topics – and perhaps they are trusting that the calling of a “national emergency” would facilitate a welcome change of tack by Labour on funding.











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