This week: Centre for Policy Studies chief executive Robert Colvile
Why he matters: Mr Colvile is a former BuzzFeed and Daily Telegraph journalist, and the author of an acclaimed book on the tech-driven pace of modern life The Great Acceleration. In 2017, he became the CEO of the CPS — a think tank founded by Margaret Thatcher among others “to make the case of free markets and a free society”. Mr Colvile was an important member of the team which wrote the 2019 Conservative Party manifesto.
“It’s obvious there’s a definite shift towards [more] public spending,” says Robert Colvile of the new government’s modus operandi.
“In public services in general, this government is much more focused on outputs. So, the manifesto did not promise big ideological reforms, but 50 million more GP appointments, 50,000 more nurses, increasing school funding [etc].
“From talking to people in the NHS, I’d say that these new targets are in the right areas. They’re attractive pledges, to address areas of pressing concern.”
On a more immediate front, Mr Colvile says Boris Johnson’s administration recognises the urgent need to tackle the “huge issue” created by the 2015 pensions reforms and the financial penalties they can impose on high-earning clinicians.
“Most doctors”, he observes, are “bright middle-class people who’ve been to a good university and seen all their contemporaries go off to earn stratospherically more money than them and buy nicer houses. They may reasonably think ’why am I punished for helping to serve my fellow man?’”
However, he sees fixing pensions as just one of the challenges of keeping doctors committed to the NHS.
“Of course, people want to earn more, but fundamentally [the NHS is staffed by] lots of people doing really tough jobs for not that much money. Clearly there’s an esprit de corps, and a fundamental NHS ethos/faith. But the pressure on those people is ramping up, worsened by workforce shortages.
“It’s [also] very hard for [NHS employers] in certain specialties or areas to raise [medical] salaries [high enough] to recruit.
“If you’re recruiting people to work at Barts or the Royal Free in a popular specialty, you’ve got the pick of the very best — if you’re in a small [district general hospital] somewhere less fashionable or more remote, you’re going to find it much harder.”
Mr Colvile observes this fact also increases health inequalities, and he believes tackling it will be part of the government’s wider political conversation about “levelling up” society and addressing the brain drain away from left-behind towns.
Between market and monopoly
Mr Colvile wrote one of the best long-form pieces in the national media about the NHS’ problems, which was published over several successive days in 2015.
“The reaction to that piece was amazing,” he says. “It was probably read by more than all the rest of what I wrote over those three to four years put together. David Cameron was saying to people in Downing Street ‘read this if you want to understand what’s happening in the NHS’.”
One of the issues Mr Colvile tackled was, in his words, how the NHS is “perched uneasily between market and monopoly”.
The government-backed NHS England requests for legislative changes to the Health and Social Care Act 2012 clearly represent a significant move away from the use of market mechanisms. Mr Colvile recognises that “the internal market had got to the point of payment by transaction [which] risks…incentivising more treatments per patient than are necessary.
“As [former University Hospitals of Birmingham Foundation Trust chief executive Dame] Julie Moore showed me in 2015 when I was researching my piece, an NHS provider can’t differentiate itself and choose its clients: it’s nothing like a supermarket, and accordingly there’s no financial reward for being a Waitrose.
“UHB can’t open another branch: its reward for success is just to get more patients coming there. That means they either get a big deficit if the costs of treating patients aren’t right, or they get long waiting lists. Neither is a just reward for success.”
Despite the problems with the NHS’ quasi-market system, Mr Colvile found it “extraordinary” Labour chose to focus on “Trump and NHS privatisation rather than going on the details like that Mirror story of the sick kid lying on coats on the Leeds General [Infirmary] floor”.
He points to polling that showed it was ineffective and to the belief the Conservatives would form “a sensible centrist government that can be trusted with public services.
“The thing about privatising the NHS is that, even if current Conservative MPs were that ideological, they’re just not that stupid as to say ‘let’s take the NHS — the public service that the public consistently say they love the most, and which is the spending priority for 80 per cent of them — and spit in the public’s faces by privatising it, and then ask to be re-elected in five years’ time’.
However, Mr Colvile does believe “there is and must be scope for market mechanisms within the NHS, not least in providing patients with information on acute providers’ performance, and in patients’ ability to choose.
He also believes it is perfectly legitimate to ask whether out or insourcing a service “gets a patient the best service possible for the lowest cost [and therefore] enables us to help more patients?”
“I find Labour’s position immoral. [They] are saying effectively that nothing can change, and that the only thing our precious NHS needs is more money and to abolish privatisation. But market mechanisms were brought in because things were not working properly. If you love the NHS, shouldn’t you be trying to work out how to make it work better?
“This is not about saying ‘I don’t want to pay as much in tax’; this is about demography, demand and technology. Last year, demand for NHS services was up by about 6 per cent. If that rise happens again and again and again, no government in the world can afford that.
“So, we need to think how to ensure every penny spent wisely. And try to fix this vast and complex system — make it more preventative and improve the health and social care interface. Which is hard while it’s running under the current extreme pressure.”
Councils should not run social care
Mr Colvile acknowledges cuts to local government funding since 2010 created the crisis in social care, which has partly driven the collapse in performance in the NHS.
While claiming “we needed austerity, given the country’s fiscal position”, he adds: “Clearly, social care was an area where the burden of protecting the NHS budget but not the social care budget via the central grant to local government had a negative impact on both systems.
“The CPS does not generally like saying ‘hey, let’s spend more taxpayers’ money’, but in social care, it’s simply dishonest to pretend that there is any real alternative. Unless you privatised the entire system, and no-one would let you do that.”
Mr Colvile claims the government knows “they have to fix” social care.
He feels the issue is “not an area needing someone to come along with a brilliant new scheme that squares every circle and gives all who need it first-class care while costing the country and its people nothing.
“There are a spectrum of well-researched options from people like the King’s Fund. There’s [also] our ‘Fixing The Care Crisis’ work with Damian Green MP — whose vision is to treat social care as a pension style system, where the state guarantees all in need a certain level of decent care, but encourages them to make their own self-funded provisions for extras and improvements on top.”
“We proposed a rise in national insurance for the over-50s which went down very badly. That was an interesting pointer about fairness. People don’t like taxes which hit only one segment of the population. There is a sense that we are all in it together.
“But the more interesting part of Damian’s proposals, which I think got much less coverage than it should, which was his suggestion that we should take the overall responsibility for social care away from councils and return to its administrating it nationally. Social care was moved from national level to local councils in the 1990s, partly as an effort to control and localise what were seen as out-of-control costs.
“But then, councils stopped building and approving new care home construction. Because they started to see the oldest bit of the population who need care as a potentially open-ended cost. Councils may have feared encouraging people to come into their area and be drains on their budgets. This is one reason the UK has such abominably low [levels of] retirement housing, and why the care home estate is so dilapidated. Councils run a mile when people tell them ‘we want to come into your area and build new old peoples’ housing’, because they just see a tide of deficit-red ink.
“So, moving funding for social care — if not delivery — back to a national basis could help. And of course, we also need to focus on adult social care, which people always forget about, but which makes up a huge proportion of spending.”
Mr Colvile wonders if the government’s social care reforms will allow “scope for mechanisms so people can borrow against their homes and leverage assets and the bill comes to their estate.
“The older generation in this country have accumulated an extraordinary amount of housing wealth, comfortably enough to fund social care” when combined with “a decent level” of state provision.
He explains: “If we were to view housing equity as something amenable to a form of insurance, then according to informal discussion with the Association of British Insurers, the level or sum you would need to insure against losing your home would represent a very respectable fraction of the value of a home.”
One last possible and intriguing area of reform which could come more easily to this government than others, is that of the citizen’s responsibilities to the NHS.
Don’t be a dick
Sometimes, says Mr Colvile patients “can be a bit of a dick”.
He remembers one very long-staying patient sitting occupying a UHB bed unnecessarily. “I saw the staff celebrating finally getting him out, and then he’s back, with a broken crutch and claiming to have had a fall.”
Mr Colvile observes a clear frustration with a minority of NHS users’ sense of entitlement, “and I think Matt Hancock is alive to this. The idea needs to be that NHS patients should have responsibilities as well as rights. They’re told them they have right and choices — and they should have those things — but the corollary is that in a system with limited resources, they won’t always get everything they want at the exact moment they want it.”
If there is any political or influential figure you would like HSJ to interview, please email alastair.mclellan@wilmingtonhealthcare.com.
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