Pride, prejudice and policymaking Responding to the public’s concerns about health care

Ipsos MORI’s regular index of what the British public see as the important issues of the day recently found a sudden increase in concerns about the NHS.

Despite wall-to-wall stories about Brexit in recent months, the health service was mentioned by 40% of people surveyed, more than immigration (39%), Europe (35%) and even the economy (just 25%). It’s not hard to imagine why.

When Ipsos MORI were speaking to the public, the dispute between government and the junior doctors was still raging. A lack of public engagement in the Sustainability and Transformation Plans process in England has arguably fuelled concerns about potential service closures. And, of course, media reports highlighting a continued deterioration in NHS performance have now become fairly regular.

Pressures on performance have become increasingly acute over the last few years. The NHS has had to do more within constrained resources, while the financial situation in local government means publicly funded social care has had to do less. And record numbers of delayed transfers of care are just one of the consequences.

Sudden shifts in public concern can refocus the attention of politicians and policymakers alike: I still recall times in government departments where my plans for days, weeks and even months had to be scrapped after seeing the morning news. Policymaking on the fly is far from ideal but it’s a fact of life, so what are some of the key steps to get it right?

First, is to understand the bigger picture. Amidst what often seems like relentless ‘doom and gloom’, you could be forgiven for thinking care quality is suffering everywhere and will only get worse. That’s understandable – bad news may travel fast, but it rarely tells the full story. In a range of areas, the quality of NHS care has been quietly holding up and even improving despite the unfavourable context.

Falling numbers of health care-associated infections; more children and young people receiving NICE-recommended care processes for diabetes; and reductions in hospital mortality are just a few examples.

Some of those improvements may be from a low base, but still represent progress: UK mortality rates following ischaemic stroke are just below the OECD average but have improved substantially since 2008, for example. In some areas the NHS may compare poorly internationally (eg cancer survival), but compares well or is getting better in many others (eg immunisation coverage). We all know the national picture masks unwarranted local variation – but that seems likely to encompass excellence as well as inadequacy.

I’m not trying to downplay that there are important problems that must be solved. Talking about the parlous state of social care recently, our Chief Executive Dr Jennifer Dixon was clear that: ‘This is a high risk situation needing an urgent political solution.’ But in focusing on what doesn’t work, it’s all too easy to overlook what does.

Second, is to identify clear priorities for action. This is relatively easy: the sheer breadth of health as a policy area means it isn’t difficult to find something worthwhile to champion.

I followed the health debates at the recent party conferences, where the lead health spokesperson for each of the three biggest political parties in England described their respective policy agendas. I didn’t agree with all of the priorities that were outlined, or the prescribed means for achieving them, but could at least recognise that most have an arguable case.

Of course, the real challenge in setting priorities is not setting too many and that will almost certainly require difficult decisions about what not to do. So it’s possible to get this wrong, and our work on making the most effective use of targets identified the wide recognition of the problem to be tackled as an important success factor.

Which leads onto my third and final step: to have a coherent and balanced approach to turning policy into practice. But where on earth to start?

A reasonable starting point is to develop a theory of change. Namely, what is intended to be different, what is the causal chain of events that will make it happen, what might get in the way and what blend of national, regional and local action best fits the situation? This isn’t always apparent in policymaking and, even when it is, the different players involved don’t always all sign up to the same theory.

And ignoring history means we’re probably doomed to repeat it. The UK has been internationally acknowledged for a strong commitment to improving the quality of its health care system. We have a fairly astonishing legacy of policy interventions that have tried, and sometimes failed, to improve various aspects of quality that we can learn from to inform what we can do in the future.

NHS England’s current clinical strategies, for example, arguably draw on the successful approaches used in some of the old National Service Frameworks in the early 2000s.  

To maul a line from the classics: it is a truth universally acknowledged that a health system in possession of strong public support, will rarely want for political champions. But championing the NHS isn’t enough, not without a coherent approach to improving quality. Ultimately, the true test of policy and of policymakers has always been ‘the how’, not just ‘the what’.

Tim Gardner (@TimGardnerTHF) is a Senior Policy Fellow at the Health Foundation