admin
- Kamran Abbasi, editor in chief
- The BMJ
- kabbasi{at}bmj.com
In an inauspicious beginning to one of the biggest weeks in the NHS’s history, England’s Department of Health and Social Care press released its NHS 10 year plan without providing an embargoed copy of the plan for scrutiny. This behaviour became standard practice under the previous UK government. Whether intentional or not, the result is a free pass for political spin. However, the truth will out. The last notable example was the government’s long awaited workforce plan, which ended up being heavily criticised (doi:10.1136/bmj-2024-079474).1 When the new NHS plan finally arrived it was missing detail on how the ambitions, many of them noble, would be delivered.
Speaking at a conference earlier this year (doi:10.1136/bmj.r990), Michael Marmot advised, “There’s enough in the world to make one despair. But, to quote Raymond Williams: ‘To be truly radical is to make hope possible, rather than despair convincing.’ We know what needs to be done. Now we just have to do it.”2 Unfortunately, the difference between knowing what to do and doing it—the know-do gap—is something health systems worldwide are consistently poor at bridging. The World Health Organization once wrote a whole report about the know-do gap,3 but the graveyard of implementation is where almost every plan goes to die.
The 10 year plan, other than beginning with the false dichotomy that the NHS must adapt or die, is well grounded in the founding principles of the NHS and the well rehearsed philosophy of the “three shifts” (doi:10.1136/bmj.q2032).4 There’s much to welcome in its vision, such as the emphasis on patients, science, and child health. The notion that the National Institute for Health and Care Excellence, as well as recommending new treatments, might stop low value care has more potential than the space devoted to it would suggest.
But the covert endgame of a healthier society where healthcare staff are fewer in number, but armed with AI, seems currently implausible. In the same vein the plan talks about a shift from hospital to community, but it might be better described as “hospital into community.” Hospital services are perversely incentivised to deliver more care at more cost, encouraging overdiagnosis, overtreatment, and medicalisation. Many prevention strategies are listed, and the evidence suggests that prevention strategies that work are implemented upstream, in the form of legislation and taxation directed at companies whose products cause harm. The government appears unready or unwilling to tackle those corporations or to articulate the politically difficult message that prevention has a long term pay off beyond election cycles.
Above all, the abyss between the plan’s ambitions and our mundane reality is glaring. Gaps exist between the rhetoric of neighbourhood health services—which sound suspiciously like Ara Darzi’s polyclinics (doi:10.1136/bmj.39577.649502.DB)5—and the reality of absent facilities and understaffing. The shift to community isn’t matched by an increase in funding to general practice or even much mention of it. The talk of high tech solutions is far removed from the low tech that many staff experience (doi:10.1136/bmj.q1171).6 And insufficient capacity is meant to be remedied by unpopular private provision and the speculative magic of AI, which is also set to trigger a radical reform of medical education and training.
Eliminating inequity
Even if you get all of that right, navigating every trap, your system fix won’t hold without tackling the underlying problems. Here, the biggest of all is health inequity and its causes, which the plan does highlight as a priority. Marmot coined the term “proportionate universalism”—in other words, universal policies that are proportionate to need. It’s a concept at the heart of Marmot’s world view: about 50 “Marmot places” around the UK have adopted the eight Marmot principles arising from his work on social determinants of health. Interestingly, proportionate universalism isn’t the same as means testing, which is a solution that governments tend to favour when allocating benefits. Marmot warns that many people just above a means testing threshold “still suffer disadvantages.”
A more recent focus of Marmot’s work is on how racism affects health. It’s also a theme—along with sexism—tackled in the latest paper from The BMJ’s Commission on the Future of the NHS. Drawing from Marmot, rekindling the essence of the know-do gap, JS Bamrah and colleagues tell us that the evidence and policy options for eliminating inequity are clear (doi:10.1136/bmj.r1334).7 Racism and sexism, and inequities related to the other protected characteristics, harm staff, patients, and society—yet discrimination is not only rife and persistent but is “normalised.” The cost to the health service is £31bn-£33bn in productivity losses, £20bn-£32bn in lost taxes and increased welfare payments, and more than £5.5bn in direct healthcare costs.
The recommendations from our commissioners are broken down specifically for the UK government, for the NHS, and for leaders. They provide a sobering reality check to the optimistic ambitions of the NHS plan. We know what to do about discrimination, but we’re not doing the basics in leadership and accountability, in data and research, in better working conditions and modelling anti-discriminatory behaviour, or in eliminating bias from the system—whether that bias arises from human, technological, or algorithmic hardwiring. Solve these conundrums and staff will be happier, patient outcomes will improve, and society will prosper.
Reversing inequity is not “woke” nonsense; it’s central to fixing the NHS. We might judge the new NHS plan to be brilliant or bland. It has much to commend it but is notable for what isn’t emphasised—for example, climate and sustainability, general practice, and high value care. They may come, but even the most cunning of plans will be sunk if we allow inequities and the know-do gap to persist and grow.
