The price of success: UK health chief Chris Wormald on what the NHS can’t do

By on 06/08/2019
Wormald says the DHSC has achieved its original mission and now has to adapt to a range of new challenges.

Marking the Department of Health and Social Care’s 100th birthday, its permanent secretary Chris Wormald both lauded its achievements, and highlighted its limitations. For while health services have radically extended life expectancy, the next steps will demand a return to the broader vision set out by its founders

“What are the consequences of your policy working?” asked Chris Wormald. “We always ask ourselves the consequences of it not working, but what if it works?”

Wormald was musing on the peculiar fate of the UK’s Department of Health and Social Care (DHSC), where he is permanent secretary. Looking back over the department’s history at an event organised to mark its centenary by King’s College London’s Strand Group, he noted that DHSC has now “basically achieved our original purpose”; but this very success, he explained, has now thrown up a new set of problems. “All our financial challenges, all our challenges around social care, hospital care, community care, are driven by the underlying fact that what we did worked,” he said.

The then-Ministry of Health was established in 1919, after World War I – which had revealed the poor health of urban, working class recruits, and been followed by the devastating Spanish Flu outbreak. Recognising that many of these health problems had deep roots in social and environmental factors, the Lloyd George government handed the ministry responsibility for town planning, housing, water, sewers and other key fields – enabling it to address the causes, as well as the consequences, of poor health, disability and infections.

In this, Lloyd George was simply following recognised best practice: it had been understood since the mid-19th century that poor health should be addressed holistically, and in 1871 prime minister Gladstone had combined responsibilities such as drainage and sanitation, highways and public health within a Local Government Board. “We sometimes think of ‘how do we join up?’ as a modern question,” commented Wormald. “Actually, people were thinking about that 100 years ago and before.”

Narrowing the focus

But in 1948, with the foundation of the National Health Service, the Ministry of Health narrowed its focus to health service delivery. Rapid progress was made on reducing infections and curing diseases, and life expectancy climbed. But splitting health from other fields of service delivery weakened coordination and collaboration on the drivers of public health. As Wormald noted, the division created between NHS-provided health services and local authority-run social care created tensions that “the nation has been wrestling with, one way or another, pretty much from that point to the current day.”

And as the department became ever more successful in its core task of providing health services, it opened up new challenges that demand a revival of cross-departmental collaboration. For while NHS services have been highly effective at curing the diseases that used to kill people from childhood through to their 60s and 70s, many among our growing population of elderly people live inharmoniously with disabilities and multiple morbidities – reducing their quality of life. “The really alarming thing for us – and this will be a challenge for policymakers for years to come – is healthy life expectancy,” said Wormald.

This brings the department back to the much broader range of topics which preoccupied its interwar leaders. Close partnership working between social care, housing and health care services, for example, is essential to maintaining people’s quality of life in old age. And while yesterday’s public health professionals addressed environmental problems such as cholera-infested water supplies, issues such as obesity, pollution and international migration provide a new set of challenges. “For quite a long time, we’ve largely debated the supply of health, as opposed to what is creating the demand for health services,” said Wormald. “I think it’s a more balanced debate now.”

“So essentially, if you look at the [department’s] original mission, we’ve basically solved the problem it was originally aimed at,” he continued. “And now we have a whole range of different challenges which are more about what happens when you achieve your original mission, and how you adapt.”

The major health reforms undertaken by the 2010-15 Coalition government gave the DHSC the space to focus on wider policy issues and cross-government connections, Wormald says.

Back to the bigger picture

In part, adapting means rebuilding the cross-government connections that were hard-wired into the department at its foundation. “When you look at who the DHSC has to work with now, in the pursuit of public health, it’s the people with exactly that set of responsibilities,” commented Wormald: with the environment and transport departments on air quality, for example, and with the communities department on housing.

And the major health reforms undertaken by the 2010-15 Coalition government, he added, have left the department better able to respond – for by passing responsibility for service delivery to a set of national NHS bodies and regulators, they’ve given DHSC the space to focus on wider policy issues and cross-government connections.

So the department has “come full circle” and “gone back to being much more like it was in 1919,” he explained. “It’s a strategy house that’s setting direction and spends quite a lot of its time on how we join up with other services, while those questions around how we commission services, provide primary and secondary care, are dealt with by the [NHS bodies] in a separate operation.”

In response to a question from Global Government Forum, Wormald noted that while medical professionals are adept at sharing best practice with peers around the world, the public sector “have to broaden the conversation internationally”.

A shared challenge

Adapting also means learning from health officials overseas, said Wormald. In response to a question from Global Government Forum, he noted that while clinical practices and medical technologies spread rapidly around the world through professional and commercial networks, the public sector does “much less on how we tackle some of the bigger challenges and organisational questions. We don’t have an organisational debate among countries anything like as well as our clinical colleagues talk about the clinical side.” Yet “most advanced countries are basically facing the same set of challenges; we have to broaden the conversation internationally.”

Finally – and most sensitively – Wormald suggested that adapting to today’s challenges will involve answering “a really fundamental question: what is a health system and health policy for?”

Looking ahead

The DHSC has become expert at delivering acute interventions that keep people alive for longer. But many patients suffer multiple conditions and disabilities that much reduce quality of life, while other key services for elderly people – such as social care and housing – receive a tiny fraction of the funds poured into the NHS. 

So there’s a system-wide question here about the nation’s priorities. “Should more of our policy be about how long we live healthily, rather than the question we’ve normally asked ourselves about how long people live?” asked Wormald. He could not, of course, give his opinion: “That’s not a question for administrators to answer,” he concluded. “But there’s a moral question there for society to debate.”

Founded in 1919 with a broad remit to work across health and the causes of ill health, the department has spent the last 70 years concentrating on the narrower agenda of delivering health services. But success in this field can only take it so far. To make further progress, it will have to rebuild the broad-based policy platform created a century ago – and that will depend as much on recreating the vision of the Victorians as on deploying the technology of the 21st century.

About Matt Ross

Matt is a journalist and editor specialising in public services, policymaking, government and management. He was the editor of trade title Civil Service World from 2008 to 2014, serving an audience of senior UK officials; and the features editor of weekly news magazine Regeneration & Renewal between 2002 and 2008, covering urban regeneration, economic growth and community development. He has also been a motoring and travel journalist, and now combines his role as editorial director of Global Government Forum with writing for other publications including The Guardian and Planning magazine.

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