Dr Tony Hockley is a Visiting Senior Fellow at the Department of Social Policy of the London School of Economics & Political Science. He is Director of Policy Analysis Centre Ltd and the co-author of Working Systems: Towards Safer NHS Nursing, published by Politeia in 2014.
Britain is changing fast. The coronavirus pandemic has thrown a spotlight on its diversity. Visible cultural, social and economic differences have served to highlight the severe limitations of policies designed on the basis of averages. The simple response to the failure of this approach is to set policy for one extreme or the other, according to the policy-maker’s ideology or constituency. The injustice of either of these approaches will set off a policy pendulum as policy becomes an ideological battleground.
At some point policy-makers must accept the harm of instability itself and adapt to the diversity of modern Britain. A centralised NHS, one of the world’s largest employers, may have been well-suited to the situation of post-war Britain, but it is woefully ill-equipped to tackle the health challenges of the 21st century. Julian Le Grand describes the transformation over this period as a shift from facing ‘five giants of want’ to ‘five giants of excess’. Our centralised health system has been wonderful at handing out treatments, but pitifully poor at helping us avoid ill health.
The pandemic has highlighted these flaws, as well as the strengths of our health system. When the Secretary of State set a target for daily testing, the whole system responded to the logistical challenge. Britain is now a world leader in the number of tests conducted each day (albeit beyond the capacity of the system to handle the results). When it is given a focal point, it will pursue it. But as with every target system, everything not targeted is dropped. This is borne out in the general approach to Covid-19. I have yet to see a health system that has dropped so much else. Only time will tell the consequences of this extreme example of our silo approach to health.
The scale of testing now, however, brings our health system to a decision point. Unlike the situation of the first wave, there is now a much better understanding of when and where infection is increasing – as well as more knowledge of the virus and its treatment. A more nuanced, targeted, and inevitably more complex approach should be deliverable, with renewed central government focus on the core ‘hands – face – space’ message applicable everywhere. Rising unemployment is an important barometer of the harm being done in tackling the virus; the link between unemployment and ill health is a strong one. More attention is also warranted to the deeply worrying data on excess deaths at home and on huge falls in GP appointments and cancer diagnoses.
The current debate over national versus local lockdowns may bring a turning point in public policy. The lion of localism has finally roared when the stakes are high. This is quite a turnaround from those early days when Hartlepool elected a monkey mascot as its mayor. The question now is fundamentally one of funding. Conceding to financial demands is probably a price worth paying, to embed local responsibility and a diversity of approach. Progress is made when people, regions or countries do things differently, not when one approach is taken by all.
The age of diversity may have arrived. If it is embraced then it could open the way to much greater change. The next big challenge, for example, is to resolve the crisis in social care. An approach that embraces diversity would not see this as an opportunity to extend the NHS model of a tax-funded, rationed system which is averse to innovation. Nor would it be little more than a financial problem linked to selling a home to pay for care. Our social care problem is one of dignity, choice, and capacity for care; at all ages and in many different circumstances. The political problem of home equity is much more than matched by the problem of millions leaving work or missing education to become unpaid carers. We could learn much from other systems – and lessons from our own past.
Out of this crisis could come great change. It is time to cast off the blinkers that allow us to see only one issue at a time, each with a singular solution.