Building from the ground up: a Q&A with Nigel Edwards

Ahead of this week’s Nuffield Trust Summit Series, we caught up with Nigel Edwards for his views on the main challenges facing the NHS, two years after the emergence of Covid-19. He also discusses what could help the situation now, what he thinks about current policy-making, and also reveals what keeps him up at night.

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Published: 28/02/2022

To what extent over the next few years will UK citizens have to expect a poorer quality NHS after the pandemic?

It's going to be a big challenge. In common with staff in other countries’ health systems, many NHS staff are burnt out and exhausted after the pandemic, and we’re now going to ask them to work at a much increased pace, especially in diagnostics and surgery – I think the system will creak in doing that.

Some aspects of people's experience, particularly on waiting times, will not be the standard they have come to expect. There's no particular reason to think that the overall quality of care once they are in the system will suffer, but the experience of poor access is likely to colour people’s perception of the whole experience.

Beyond the ones you’ve just mentioned, what are the main challenges facing the NHS?

The problems that existed before Covid are still there, not least the failure to address the staffing issues in the NHS. The failure to really deal with problems in the social care system is also still a huge problem. And despite the exhortations to discharge people from hospital to make space, the system has also really not managed to respond to that.

I'm very concerned about the state of general practice. Not just the level of demand it is under, but also the patient experience of getting appointments and the prevalence of staff burnout, which was bad before the pandemic and seems to be getting worse.

To deal with the workload, and to have the capability to deliver modern multidisciplinary primary care, significant organisational changes are needed. PCNs are still struggling in many areas to create something that has the infrastructure, change management capability and resilience to be able to form the foundations needed to make the rest of the system work. That is a serious missed opportunity. 

It doesn’t help that a lot of the way that integration is framed is about keeping people out of hospital or reducing stays in hospital. These are important but shouldn’t be the primary focus. It may also mean there is too much focus on integration with social care and nowhere near enough on the NHS integrating with itself. We've got examples of it around the country, but we need more.

All health systems across the world have been affected by Covid-19. What are the lessons for recovery for the UK, and should we be looking to any countries in particular for those?

“Don’t start from here” would perhaps be the main lesson. One of the lessons from our international comparisons work is that the countries who went into the pandemic with lower levels of resilience and resources are probably going to take longer to come out of it. And we were down the league table in our starting point. We were not right at the bottom, but we certainly went in with issues around physical resources – diagnostic equipment and staff in particular – and low capacity across a range of services.

There is a need for a workforce strategy, but that is more about the medium term. Given where we are, the emphasis needs to be on ensuring that staff are retained, new joiners get a good experience, and that we look at skill mix to help fill the gaps. Investment in diagnostics, rehabilitation and home care, as well as other ways of making the system flow more easily and for waits to be reduced, will be important. The government is making some of those investments, but so far too much of the approach on patients waiting to be discharged has been based on exhortation, and not on the development of rehabilitation, home care, palliative care and other community-based solutions. We are underinvested in those areas.

We often hear that any changes to improve the situation in the NHS might take a few years to have impact. Do you think there are any decisions now that could be taken to improve the situation now?

Strengthening primary care is something that ought to be given more attention, because it's the part of the system that people use the most. Another focus should be on staffing. The pandemic has shone light on some basic things about how staff are looked after. When people think about these things more generally, there's often a lot of focus on top leaders, as we saw in the Messenger Review. But more attention ought to be given to supporting and developing front-line supervisors and middle managers – an often-neglected group who are very important when it comes to staff experience and retention.

Two years ago we looked back at your lessons from 40 years of health policy, when you said that many of the better policy decisions had happened quite some time ago. We have had a cataclysmic two years since, and also a flurry of policy announcements and plans for the NHS in recent weeks. What is your assessment of the quality of policy-making in the UK and also around the NHS at present?

There's been a huge loss of policy-making capability after repeated cuts to the civil service, with a marked decline in the numbers of people involved who actually have policy-making knowledge about the matter at hand, including on health. It means we run the risk of repeating ideas that have not worked previously, and paying insufficient attention to the history and the evidence that we should be using.

At present there is a slightly confusing mix of policy approaches. We have a place-based approach combined (in some areas) with big provider collaboratives that cut across that. There is a focus on population health, but also substantial vertical programmes for cancer, mental health, emergency care and now elective recovery and messages about evolution. The more programmes and initiatives that are running, the harder it is to ensure that they all align. 

The current integration white paper is not an example of great policy-making. It doesn't appear to have a very clear underlying theory of change, and the statement of the problem it's trying to deal with is also slightly confusing. It does also look like there's been an attempt to take the pen back from NHS England of late, despite a lot of the policy-making expertise sitting in NHSE. Overall though, it matters less who is actually originating the policy as long as it is clear who that is, and that the different policies are properly aligned with each other.

There may also be some uncertainty about the exact change mechanism expected to make such things happen, which was also a problem with the Long Term Plan and the Five Year Forward View. They were good on the ‘what’, but a bit vague on the ‘how’. The centre has not always shown itself to be very good at the ‘how’ bit of the equation, because a lot of that needs to be developed locally, rather than mandated centrally.

Do you feel that the pandemic, and more generally the era in which we’re living, is reshaping the nature of state-led health care? 

From the right of the political spectrum, there does seem to be a narrative that it's time to completely reform the NHS, but they all seem to be quite vague on what they mean. I suspect they’re either vague because they don't have an answer, or they’re vague because they know the answer that they really want will be quite unacceptable to people.

The pandemic has thrown into relief the extent to which the NHS is highly centralised. While that worked quite well in mobilising a fast start on things like the vaccine rollout, the period has shown the challenge of trying to run a health care system for 56 million people in England as a centralised organisation close to government. The NHS can get sucked into the politics of government, and too often looks ‘up’ rather than to its local communities. One of the few things that I agreed with Andrew Lansley about was on the malign effects of this top-down culture.

What keeps you up at night when thinking about health care in the UK?

The risk that people start to lose faith in their GP and start opting out like they have been doing with dentistry and long-term care, and then they do the same with some specialist care and elective surgery. We then get the same people who say “defund the BBC” saying “defund the NHS”, and the system goes into a death cycle of cuts, staff departures, poor quality and more people seeking treatment outside the NHS.

A more immediate worry is the urge to be radical that politicians in a hurry are prone to. Most successful health care reform takes a long time, has a consistency of purpose, and brings people along with it. But history tells us that none of those feature too highly in the UK’s approach to health policy.

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