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How NHS decline was allowed to happen 

Chris Ham
By Prof Sir Chris Ham Former chief executive, The King's Fund
24 April 2023

Multi-year funding increases above the long-term average and a series of reforms resulted in major improvements in NHS performance between 2000 and 2010. However, now the NHS is in decline. Its performance has deteriorated due to much lower funding increases, limited funds for capital investment, and neglect of workforce planning. In addition, constraints on social care funding and cuts in the public health grant to local authorities have accentuated the impact of changes within the NHS.

The root causes of NHS decline can be found in the failure of successive governments to act on the insights of the 2002 Wanless Review and its argument that the NHS would become unsustainable unless the population was ‘fully engaged’ in preventing illness and improving health. The 2010s were a lost decade in public health policy with governments reluctant to be seen to be acting as a ‘nanny state’. Improvements in population health either stalled or went into reverse as risk factors such as obesity had an increasing impact.

The population’s poor health contributed to the UK having high rates of excess deaths from Covid-19 and other causes. The effects were particularly stark in the most deprived communities and the Black and Asian populations. Increased mortality from Covid-19 and other major causes contributed to reductions in life expectancy in 2020 of 1.3 years for males and 0.9 years for females, resulting in the lowest life expectancy since 2011. Growing numbers of people who are economically inactive as a result of ill health are another cause of concern.

Addressing NHS decline

Establishing integrated care systems (ICSs) as statutory bodies in July 2022 offers an opportunity to address these issues and reverse the NHS decline. The core purposes of ICSs include improving population health outcomes and tackling inequalities in outcomes. The health strategies being developed by integrated care partnerships within ICSs focus on how these purposes should be delivered. However, their work needs to be matched by articulating a cross-government health strategy, as argued by the National Audit Office and The Hewitt Review.

If the strategy is to be effective, the government must be willing to use legislation, taxation and regulation, building on the example of the soft drinks levy, which came into effect in 2018. Recent data show that five million people in the UK are living with diabetes, underlining the urgency of government action. Big government should go hand in hand with big society by fully engaging patients and the public in improving health and wellbeing.

This means enhancing people’s capabilities to make informed decisions and supporting them to be active agents with responsibilities as well as rights. Care providers, as well as patients, must be willing to work differently to ensure that patients’ preferences are taken into account with support tailored to the needs of different individuals and communities. Improving health is a shared responsibility in which everyone has a part to play.


The most advanced ICSs are acting on these insights as NHS organisations work in partnership with local authorities, voluntary and community sector organisations, universities, businesses and other agencies to improve population health. The challenge they face is how to make progress when three-quarters of ICSs inherited financial deficits from their predecessors, and the NHS across England is working to address backlogs of care that built up during and after the pandemic. Sustained financial pressures on local government also continue to affect population health.

For all of these reasons, progress will not be made through business as usual. The focus now must be on doing things differently, learning from the work of Hilary Cottam OBE, at the Institute for Innovation and Public Purpose, University College London, and others who argue that public services must work with people and not do things to them to improve outcomes.

A new approach

Work on the Wigan Deal illustrates how this thinking has delivered benefits by drawing on the assets and strengths of all partners in the community. Wigan Council took the lead in developing the Deal and, in doing so, showed the benefits of local government leadership. Asset-based approaches in other areas have arisen from the work of general practices and the voluntary and community sectors.

I saw an impressive example recently on a visit to the Frome Medical Practice in Somerset where the practice works with a local community development service to identify and support patients who are vulnerable and in need of support.

It does so by employing ‘health connectors’ to help patients with goal setting, care planning and self-management support. The practice also draws on almost 2,000 volunteers known as ‘community connectors’ who signpost local services using a directory listing over 400 groups. Analysis has shown reductions in emergency hospital admissions among patients in Frome compared with other areas, achieved by tackling loneliness and social isolation and building a model of community-oriented primary care.

This article is based on Sir Chris Ham’s report, which was published by The King’s Fund.

Professor Sir Chris Ham is co-chair of the NHS Assembly, Emeritus Prof at the University of Birmingham and former chief executive of The King’s Fund.

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