Wes Streeting — the NHS’s fifth health secretary in two years — wasted no time in setting out his mission for the health service. Within hours of his appointment, Streeting said what those working in the NHS have known for years, but few politicians have articulated.
“From today, the policy of this department is that the NHS is broken,” he said.
“This government has received a mandate from millions of voters for change and reform of the NHS, so it can be there for us when we need it once again.”
While the sentiment is reassuring, the prospect of another NHS reform will induce a sense of déjà vu and scepticism among anyone with an eye on health policy.
After Labour’s previous landslide victory in 1997, ministers abolished GP Fundholding, which gave GPs some budget to purchase hospital services for their patients, in favour of ‘practice-based commissioning’; primary care trusts replaced health authorities; and NHS foundation trusts were introduced as an alternative to hospital trusts. In 2010, an editorial by health economist Alan Maynard published in the Journal of the Royal Society of Medicine described the high “costs of these upheavals in terms of redundancy payments, pension hand-outs and human misery among NHS staff”.
“Healthcare reform is based on ‘faith’ or the often ideological and evidence-free ideas of passing secretaries of state,” Maynard said, adding that the incoming Conservative ministers at the time were also “focused on further radical reforms for which there is no evidence base”.
The financial incentive for pharmacists in primary care networks to switch patients to DOAC edoxaban is one example of where the evidence base came second to government strategy
The past 14 years of Conservative government have seen two major legislative reforms for the NHS. Among other changes, the Health and Social Care Act 2012 established GP-led clinical commissioning groups, while the Health and Care Act 2022 later abolished them for integrated care boards. Frontline staff have also been subject to changing targets in response to a rapid cascade of strategic plans: the ‘Five-year forward view‘ at first in 2014 and then a follow-up plan in 2017, regional sustainability and transformation plans in 2016, the ‘NHS long-term plan‘ in 2019, and the ‘Long-term workforce plan‘ in 2023.
While the frequent strategic planning changes are often linked to annual government spending reviews and changes to the Cabinet, former Nuffield Trust chief executive Nigel Edwards notes that they cause “disengagement at the NHS front line, cost money and staff time, and make it hard to tell what has worked”.
The financial incentive for pharmacists in primary care networks to switch patients to the direct oral anticoagulant (DOAC) edoxaban is one example of where the evidence base came second to government strategy in recent years. While borne out of 2019’s NHS plan to increase treatment of cardiovascular disease, the incentive was motivated by a commercial deal between manufacturer Daiichi Sankyo and the NHS. The manufacturer offered better prices, investment and support than was offered by other DOAC suppliers.
The incentive meant pharmacists invested significant time and effort into consulting with patients about the switch. Some pharmacists raised safety concerns about switching stable patients to a new medicine, while others noted that the switch had caused confusion. “One patient had even taken both anticoagulants together as they thought edoxaban was a new addition,” Melissa Dadgar, a pharmacist at a central London PCN, told The Pharmaceutical Journal in August 2022.
Then, just two years later, the NHS’s guidance was reversed. Generic apixaban was now the “best value DOAC” available and therefore recommended over edoxaban. Pharmacists approached the updated recommendations with understandable cynicism.
“The time and effort spent could be invested somewhere else where patients need more support and better management,” said Rani Khatib, consultant pharmacist in cardiology and cardiovascular research, on X.
Where that could be invested should be easy to pinpoint for a system that has a massive dataset worth £10bn. For community pharmacy in particular, that dataset is only growing. Community Pharmacy England (CPE) has spent years surveying community pharmacy teams through its annual ‘Pharmacy Advice Audit’ to grasp how pharmacy staff spend their time and where patients need them most. These data are collected for the primary purpose of informing contract negotiations, which are currently underway.
Similarly, NHS England is also in the throes of carrying out its own independent economic analysis of community pharmacy to “inform the negotiation of the future contractual framework” for the sector. Consultancy firms IQVIA and Frontier began contacting pharmacies on 1 July 2024 to start the data collection process and are expected to report back in October 2024.
With all this data — and clinical expertise — to hand, Streeting has an opportunity to tread a different path to his predecessors, steering the inevitable NHS reform away from “ideological and evidence-free ideas” and towards an evidence-based future. Any other approach would simply be lazy; the proof is out there. PJ
