Aftermath and legacy

The immediate aftermath: ‘Take the money and run’

The immediate aftermath of the Wanless report might be best summed up by the phrase ‘take the money and run’. That is not precisely what the Department of Health did. But it is pretty close. Before looking at what happened to Wanless’s three scenarios of ‘fully engaged’, ‘solid state’ and ‘slow progress’ (see Box 3) it is, however, worth examining what happened to three specific recommendations that the report highlighted.

Three specific recommendations

The three recommendations were that:

  1. NICE should not just assess newer treatments and technologies in order to decide whether they were sufficiently cost-effective for the NHS to adopt. It should examine older ones to see if they remained cost-effective.
  2. A major IT programme was needed to provide electronic patient records and much better data.
  3. There should be much better workforce planning.

The first of these proved not to be very fruitful. As two senior figures from NICE were to explain in a British Medical Journal paper many years later, no country has found running a programme to disinvest in older and possibly ineffective treatments easy. There are questions around cost-benefit – how much might be saved in reality given the cost of reviewing many hundreds, if not thousands, of treatments? Furthermore some, including Professor Andrew Stevens, one of the longest-serving members of NICE’s appraisal committees, argues that the ‘easy’ hits, such as unnecessary tonsillectomies and overuse of grommets for glue ear, had already been largely killed off by the evidence-based medicine movement from the 1980s on. Sir Michael Rawlins, the former chair of NICE, was to argue that there is little now in the British National Formulary – the clinician’s guide to pharmaceuticals – that is actually ineffective. ‘There aren’t, now, a lot of useless drugs,’ he says, ‘and very little is spent on the few that you could argue are pretty useless. So there are no big savings there.’

A national programme for IT was launched at an eventual cost, depending on whose figures you choose to believe, of £6bn, £12bn or £20bn. It was not a success. Even now, its holy grail of an electronic patient record, fully interchangeable and accessible in all health care settings and ideally in social care, has not been achieved. It was not quite the total disaster that is often painted. It did successfully produce a unique and accessible individual patient number, hugely reducing the large dangers of one Mr Patel or Mrs Smith being muddled up with another of the same name. It did replace costly and inaccessible X-ray film with cheaper and accessible digital imaging. It provided a valuable internal messaging system for the NHS – the so-called ‘spine’ – which among other things gives access to a summary care record, electronic prescribing and electronic referrals. And it did renew some creaking hospital administration systems. But it was most definitely not value for money.

On the third of these recommendations – better workforce planning – there was some impact. Hugh Taylor, who went on to be permanent secretary in the department but who, at the time of Wanless was director general for workforce, says that when he took on the role in 1988, ‘It could not have been much worse. I inherited a complete absence of a workforce plan.’ Workforce planning had been part of the task of the regional health authorities, which had been abolished in 1996, ‘and that had never been properly replaced’.

The job was nominally devolved to NHS trusts but they, inevitably, took a very short term and very local view. The NHS Plan in 2000 had committed the government to a big expansion in medical student numbers and nurse training, ‘And there were successive attempts to set up quasi-regional planning groups under Labour,’ Taylor notes. ‘But it is genuinely difficult to do at a national level and it always tends to concentrate on the hospital sector at the expense of primary care and the social care sector, where it has always been pretty woeful. Wanless did lead to a greater emphasis on workforce planning. There was a huge planned and carefully monitored increase in workforce numbers as the extra investment came through, alongside improvements to recruitment and retention. But I wouldn’t like to say that it was ever done particularly well.’

Richard Murray, now chief executive of The King’s Fund, and who rejoined the department not long after the review to work in Clive Smee’s section says, ‘There was an impact on workforce that was probably more visible internally than externally. I am not saying this was all due to Wanless, but there were huge nurse recruitment drives with jumbo jets flying off to Manila. And you could not put up any submission for change for quite a long time without a workforce analysis. ‘How are we going to staff this?’’ The tragedy, Murray says, ‘… is that all fell away and we now have another workforce crisis’ – with, at the time of writing, the NHS waiting for another, and long overdue, workforce plan.

Dust on the shelf

Beyond those three items, however, the Wanless report was to quite rapidly gather dust on the department’s shelves. One reason, a view of Alan Milburn’s shared by a good proportion of our other interviewees, is that the Wanless report was the Treasury’s – not the health department’s.

Milburn says: ‘It was a good piece of work and the analysis was important in identifying the need for increased investment and a more engaged public. It helped make the case for the tax increase. That was all good stuff.’ But ‘… it was very much a Treasury play, and the subterranean politics were all about Gordon’s power grab over the future of the NHS – and in the end that all failed.’ While the exercise was under way, Milburn points out, ‘It didn’t cause me any sleepless nights. I was clear that whatever happened, Wanless or no Wanless, I was going to secure large increases in funding for the NHS and for social care, because Tony had made his promise – and Tony and I were aligned.

‘The internal politics massively devalued the report’s purchase. That was not Derek’s fault. He was an innocent bystander. But it was a Treasury exercise. The Treasury can muscle as much as it likes, but unless the ownership is jointly and separately shared with the relevant delivery department then it is going to go nowhere. It inevitably turned to dust.’

Richard Murray says, ‘There was no constituency for it within the department. The only people who really spoke about it were my fellow analysts – who had done a lot of work on it. But the fully engaged, not engaged scenarios – they fell away pretty quickly.

‘I do remember a conversation with Michael Barber, the head of the Prime Minister’s Delivery Unit, asking, how do I get from one scenario to another? What would the target be? And our answer was well… we can’t really tell you that. We had the Wanless model, and people were asking shall we maintain it – keep it up to date? – which would have been a lot of work. But there were no requests, and there was no interest from policy leads and politicians in that. So it just stopped. The interest was all about waiting times and foundation trusts and the tariff, and all that delivery agenda.

‘I would not want to damn the report with faint praise. The money made an enormous difference. There was the IT programme. And there was that impact on workforce.’

Hugh Taylor says it was a missed opportunity that the public health aspects implicit in the fully engaged scenario were not pursued more vigorously in the way that the National Service Frameworks were, for example. But Taylor also says there was scepticism in the department about the scenarios. The report described broadly what they would look like, but with no real detail about how they might be achieved. ‘Furthermore I thought they looked rather naïve,’ he adds. ‘This sort of thinking is still alive and kicking, but I have never seen any convincing evidence that improving people’s health in an economically active and successful country, and integrating services much better, reduces the demand for health care and reduces its cost – or indeed that it significantly slows the rate of growth. It can certainly improve quality, but I was and remain sceptical that it reduces cost.’

And indeed, as others have said, the report got caught in the crossfire first between Alan Milburn and Gordon Brown, and then between John Reid – Milburn’s successor – and the Chancellor. And, indeed, in the steadily deteriorating relationship, with some big ups and downs on the way, between the Prime Minister and his Chancellor.

Richard Douglas, the department’s longstanding director general of finance, judges that the national IT programme would not have launched without Wanless. But, he says, it was always clear that the department was going to decide how to spend the money. ‘I remember being told that “We are very happy to use your spreadsheets to get the money, but once we have got it, we tear them up.” And a minister saying during a Spending Review that “I want you in and out of the Treasury every day. But once we have got the money I never want you to talk to them again.” It was “do anything to get the money, but then don’t tie us to anything, don’t tie us to how we spend it.”’

David Nicholson, who became chief executive of the NHS Executive within the department in September 2006, says at that time the department operated as ‘a wholly owned subsidiary of Number 10, and Wanless was seen as the Chancellor’s’. But, like others, Nicholson points out that Wanless did not contain a plan about how to achieve a fully engaged scenario. ‘There was no machinery to make it happen. Nor was it part of a conversation I ever had with a secretary of state… or indeed with Paul Corrigan [Blair’s health adviser at the time].’

But, oh boy, did the money make a difference

The impact of the spending decisions that flowed in the wake of Breakfast with Frost and Wanless were, however, profound. Carol Black, president of the Royal College of Physicians when Wanless reported, recalls ‘It was a time of real hope. It provided the money for the National Service Frameworks. Cardiology was transformed from being a speciality that really couldn’t cope because it didn’t have the equipment. Before Wanless, if you weren’t near a major teaching hospital your outcome was likely to be worse, and cardiology just blossomed as the money started flowing. Geriatrics went from being a really miserable dead subject that nobody wanted to do, to one that enabled people to study interesting neurology in the elderly because you had much better scanning and much better interventional radiology, and that led to better treatments. Across specialist medicine, we got the scopes we wanted and modern MRI scanners. All specialist medicine benefited, and we had fallen so far behind. There was a real sense of energy and of advance.’ General practice, and much else, was also re-energised.

The inputs included a rise of a third in NHS staff in England – up from 893,000 in September 2000 to 1,177,000 by September 2009. These inputs produced both outputs (more activity) and better outcomes (better results from treatment). Outcomes for a whole range of conditions improved and waiting times tumbled. To the point when in 2008 – excluding a couple of specialisms, such as spinal surgery where there was a worldwide shortage of surgeons – the NHS largely hit the 18-week target. Namely that from GP referral to diagnostics being completed and substantive treatment starting, 90% of patients should wait no longer than 18 weeks if admitted to hospital. For those not requiring admission that target was 95%. And that, of course, meant that the average (median) wait was way shorter. Around 8 weeks for those admitted and 4 weeks for those who did not require admission.

Patients were no longer regularly dying from their condition on a cardiac waiting list which, for urgent cases, no longer really existed. On the OECD’s calculation, the median wait for a hip replacement – one of the high volume waiting list procedures that had proved harder to crack – had gone from more than 7 months in 2001 once it had been decided an operation was needed (ie not counting the additional waits for an outpatient appointment and subsequent X-rays and any other diagnostics), to 78 days from the GP’s referral to the actual operation taking place. There is no easy way to compare waiting times internationally. But, taken as a whole, this looked likely to be about as good as anywhere in the world.

Furthermore, the public recognised that this was happening. In November 2001, as the interim report was published, 70% of those questioned in an Ipsos MORI poll said that the state of the NHS was the most important issue facing Britain. By 2008 that had fallen to 12%, the lowest in decades.

Source: Ipsos MORI. Base: representative sample of c 1,000 British adults aged 18+.

Satisfaction with the NHS, as measured by the long-running series in the British Social Attitudes Survey, was to soar. In 2001, those dissatisfied with the NHS marginally outnumbered those satisfied with it. By 2010, 70% declared themselves satisfied – a record high – and barely 20% were dissatisfied.

Source: British social attitudes 29; 2012.

Could the money have been better spent?

All that said, as Carol Black among others put it, while hospitals were transformed and general practice received a big investment, ‘Hand on heart, I don’t think the money was spent as well as it could have been.’ Derek Wanless’s warning proved prescient. Increases of around 7.4% in real terms over 5 years were ‘… at the upper end of what should sensibly be spent. Indeed, to be wisely spent, they already represent a very considerable management challenge’.

The troubles with the IT programme have already been mentioned. A big pay rise for NHS staff was clearly needed. But a lot of money went into pay by way of new contracts for all the staff groups, each costing much more than anticipated. To the point where, very briefly, outside of the United States both consultants and GPs became arguably the best paid doctors in the world. Steps were taken to integrate hospital, GP and community services better, but progress was limited. It was not helped by the NHS achieving the remarkable feat in 2005/06 of overspending by £570m at a time of record growth, having to take £1bn out of the next year’s budget to rebalance the books. The NHS did an awful lot more and did it better – but it tended to be more of the same. Ara Darzi, the distinguished surgeon who became a became a health minister in 2007, and whose 2008 report also argued for better integrated care, has judged that, ‘We missed the best opportunity in the history of the NHS to actually reform it… we just threw money at it.’

That has led to debate about whether the service might have been better served by a slower rate of growth – say 7 years of 5% a year real terms increases, rather than 5 years of 7%. That is certainly the view of Adair Turner. Alan Milburn concedes, ‘The system found it difficult to manage the sudden increase in resources after years of drought. So I think that is a reasonable critique to make. I have mixed views about it.’

As do others. There is an argument that a longer, slower rate of growth might have seen the money better spent. But politically, it was never going to happen. 5 years of 7% in real terms took Labour to 2007/8 – beyond the next election, but an election it looked to have a reasonable chance of winning (as indeed it did). Anything longer felt as though it stretched too far out into the distance, and Labour wanted results. Furthermore, as Richard Murray puts it: ‘If you are a spending department and it is jam today or jam tomorrow… well jam tomorrow never arrives. “I want this frontloaded so I have got it in my pocket.” If it is backloaded the fear, and too often the reality, is that it never arrives.’

The view of Richard Douglas, the head of finance, on whether slower, longer growth would have been better is that: ‘It is quite hard to say. There was this incredibly naïve belief, which I shared, which was that if you only had the money you could do anything. And there just wasn’t the management bandwidth, either nationally or locally.

‘If you are trying to change the structure of the NHS, bringing in foundation trusts, bringing the independent sector in, doing the biggest PFI programme we’d ever done, changing the contracts of all your staff, trying to get at least some better integration, doing the national programme for IT… trying to do all that stuff at once was absolutely insane, however much money you have got.

‘If it had been 5% over 7 [years] rather than 7% over 5 , would we have tried to do anything different? No, probably not. We would probably have tried to do all that stuff and would probably have failed in a similar way, with an even higher level of optimism bias!’

Wanless on public health and social care

On public health

Securing our future health was not the last of the Derek Wanless commissions from government. In 2004 he produced a further study for the Treasury: Securing good health for the whole population, looking at what needed to happen to public health if the fully engaged scenario from the 2002 report was to be achieved.

This subsequent review also started out with something of a row, according to Alan Milburn. ‘The original terms of reference were not about public health at all. They were about trying to improve efficiency within the NHS. Which was entirely, of course, an attempt to land grab the implementation/operational agenda from the department. I saw the terms of reference and I went ballistic. With Gordon directly, and more generally with the Prime Minister. And we vetoed that. Simon Stevens, who was at Number 10 by this stage, was instrumental in rewriting the terms of reference so that it became about public health, not about the system.’

Over 185 pages, plus annexes, the public health report came up with 21 recommendations. These called for much better cost/benefit analysis of public health programmes; targets for the reduction of smoking, alcohol consumption and obesity; better understanding of what motivates the public to accept or reject healthier styles; improved evaluation of public health programmes once up and running; some restructuring of the arm’s-length bodies involved in public health – and the potentially rather more controversial recommendation that ‘The right of the individual to choose their own lifestyle must be balanced against any adverse impacts those choices have on the quality of life of others.’

The report has a lengthy chapter on the wider determinants of health that are beyond the reach of the NHS – income, education, housing and other elements of the broader social and economic environment. It cites developments following on from the Black report of 1980 and the more recent Acheson report of 1998, which was within Labour’s time, both of which focus on the wider determinants. It notes initiatives taken by the Labour government, in part as a limited response to the (very expensive) Acheson proposals. These included the introduction of Sure Start, and measures to reduce unemployment, pensioner poverty and the number of children killed on roads. But its focus is much more around what might be dubbed ‘classic’ public health issues, such as smoking and obesity. And unlike Black and Acheson, it does not propose specific new measures to tackle the wider determinants. It was followed by a white paper on public health – subtitled Making healthy choices easier – in November 2004. That led, among other things, to the ban on smoking in public places in England (Scotland having already pioneered it), along with improved food labelling to help consumers make healthier choices.

The fact is, however, that for many but not all of our interviewees, the public health report had almost entirely faded from memory. It still resonated most strongly, and unsurprisingly, with those who had a public health background – or who went on to work in the field.

Sian Griffiths, president of the Faculty of Public Health at the time of publication, remembers spending many hours with Wanless working on the report. ‘The public health community,’ she says, was, at the time, ‘a bit of a shambles’ and needed a review of its work. There was also the attraction that the fully engaged scenario was ‘a public health agenda, not just a health service one. That you needed to think about the economic determinants of health, and about reducing health inequalities’.

When the report was published, Griffiths welcomed it in the British Medical Journal as a ‘once in a lifetime chance’ for public health ‘to be taken seriously, not seen as a bit of froth on the side. We have to use this report to engage not just those of us who are enthusiastic about public health but a far wider audience’. But she acknowledges that others, in the same BMJ piece, were more critical, arguing that it was short of details on how the changes were to be achieved. Looking back, Griffiths says, the fully engaged scenario was always ‘more of a mantra than a programme… You needed to win hearts and minds, and there was not a lot on how to do that. But it did push public health up the agenda to another level and got the attention of the Treasury, which it had not really had before.

‘But public health then got a bit fractured in the big reorganisation of primary care trusts that subsequently happened. And it got a bit lost in the choice agenda and in the public/private partnerships that were being used to drive activity in the acute sector.’

Sally Davies, who was radically revamping the NHS’s research and development programme at the time of Wanless and would serve as chief medical officer from 2010 to 2019, says, ‘I think it really woke the health community up. The sense that, if we get the engagement, we will get a return on our investment. When I look again at the 2004 report, so many of the recommendations that I made in my annual reports [around tackling excess alcohol consumption, obesity and junk food for example] he made first. If I had realised I would have attributed it to him […] So I think he shaped much more subliminally than we give him credit for. It kind of went into our inner brain, and it is interesting how much many of us have since been basing on it, but not recognising it.’

By contrast, in the annual reports of Liam Donaldson, the chief medical officer at the time of Wanless, there is merely a passing reference in 2003 to the original Wanless report. And only then to the extent that it ‘… has also emphasised the importance of better population health and prevention of disease to the sustainability of the health service in the future’. But there are no further references either to the original report or, perhaps more remarkably, the subsequent public health one in Donaldson’s succeeding reports which run up to 2009, although he does reference Wanless’s work elsewhere.

On social care

Derek Wanless’s other contribution was a 2006 study on the future funding of social care, commissioned by The King’s Fund – once it became clear the Treasury was not going to ask him. A comprehensive piece of work, the report went through the myriad funding options, concluding that there was no such thing as a perfect system, while coming down ‘on balance’ in favour of a partnership model involving contributions from both individuals and the state. A full reform of the funding of social care is, of course, still awaited.

In addition, Wanless advised on a review of health and social care for the Welsh assembly published in 2003. But as with any detailed account of his social care report, that falls outside the scope of this study.

Legacy version one: ‘The memory lingers on’

As with the origins of the Wanless review, there are essentially two views of its longer term legacy for the UK. One can be seen as somewhat dispiriting. The other, for those who believe in the NHS model, is much more positive – if essentially political. We start with the more dispiriting view of its UK legacy. But it is first worth noting some international impact.

As already noted, the OECD had been putting more emphasis on the outcomes achieved by health spending: its analysis having, for example, shown the NHS was coming up short. But ‘the Wanless report definitely put wind in those sails,’ according to Mark Pearson, for a long-time head of the OECD’s health division. No country directly copied the Wanless exercise, Pearson says. But. ‘The UK had a leading voice in health discussion globally at the time. It did encourage people to move away from debates about “What is the latest on co-payments?” to “Why are our health systems not delivering?”, and to more talk about effectiveness and outcomes. Some of what happened afterwards also had an impact, almost as a cautionary tale. A lot more money was going into health in other countries at the time. But what the UK did in terms of pay and conditions – the new contracts in particular, with too much extra pay without enough in return in terms of changed work practices – that had a very big effect on many countries. They talked about what not to do, as well as what to do.’

The money in the medium term

The Wanless review provided the justification – as it was designed to – for the huge spending increases, and for the National Insurance increase needed to pay for those. There is an argument that the money could have been better spent. But there is no doubt that the money made a profound difference to the quality and accessibility of NHS services.

To that extent, the Wanless review can be seen as one of the most important documents in the history of the NHS – even if, as Milburn and others including this author believe, huge increases would have had to flow anyway from Tony Blair’s commitment as Prime Minister on Breakfast with Frost. The medium-term picture is more nuanced. The money was meant to be the first tranche in a 20-year programme. Derek Wanless’s recommendation that the whole exercise be repeated every 5 years or so was not followed up, nor his recommendation that social care should be subject to a similar analysis and included in future reviews.

One of the reasons a 5-year follow up did not happen was that after the 2005 election, Tony Blair was under growing pressure to go, with Brown ever more forcefully pushing to take over. ‘There were two problems,’ Nick Macpherson says. ‘One was that the fiscal situation was more of a constraint. But the real blow was the 2-year period after the 2005 election when Mr Brown was waiting for Tony Blair to go. Blair was busy thinking about his legacy. There was not, by then, an appetite for another big round of tax increases, and the period 2005 to 2007 was in my view an opportunity missed. Because Brown did want not to do anything to rock the boat, but he also did not want to do anything that could be used by Blair to promote his legacy. And then Northern Rock took place at the end of 2007…’ (The collapse of Northern Rock being the first UK sign of the global financial crash to come in 2008.)

Had the exercise been repeated, the forward projections of necessary expenditure would no doubt have been revised. But under the fully engaged scenario from 2002, spending would have continued to rise from 2007 by 4.4% in real terms out to 2012, and by 4.7% if the NHS and health care more generally was making solid progress. The 2007 Spending Review does reference the Wanless report at some length, while delivering promised increases of 4% in real terms out to 2010/11 (see also Box 4). This was, as was then standard, a 3-year Spending Review rather than another 5-year award. Local authorities, who commission social care, were treated much less generously, receiving a 1% per annum real increase. The Spending Review also promised a green paper on the options for social care funding reform, referencing among others, Wanless’s report for The King’s Fund. So, within government, the memory of Wanless did linger on, but without anything substantive being done to pursue its longer term funding approach.

Source: House of Commons Library briefing paper. NHS funding and expenditure; 17 January 2019 (

The second 5 years of generous funding, as envisaged in the report, was not delivered in full. The global financial crash of 2008 was to usher in, from 2010, the better part of a decade of austerity. The NHS, while faring better than all other public services, still saw historically low rates of expenditure increase.

Box 4: Expenditure

It is beyond the purpose of this study to analyse in any detail what has happened to health expenditure following the projections in the Wanless report. But it would be incomplete without a glance at what has happened.

Table 1 compares Wanless’s three scenarios against actual data across a range of health spending measures. Note, we make no attempt here to incorporate recent spending on COVID-19, even in projections. This is both because this does not yet feature in the relevant data series, but more importantly such emergency spending would obscure any comparisons.

Table 1: UK health spending – Wanless vs actual/projected






Total health spending (% of money GDP)


(1) Solid progress






(2) Slow uptake






(3) Fully engaged












Difference vs (1)











Total public health spending (% of money GDP)


(1) Solid progress






(2) Slow uptake






(3) Fully engaged












Difference vs (1)






Total public health spending (£bn, 2019/20 prices)


(1) Solid progress






(2) Slow uptake






(3) Fully engaged












Difference vs (1)






Average annual real growth in public health spending (%)


(1) Solid progress






(2) Slow uptake






(3) Fully engaged












Difference vs (1)






Direct comparisons are not easy. There are discrepancies in the base year (2002/03) – Wanless figures for that year were estimates and public health spending came in slightly lower than expected. In addition, more complete data are now available from the ONS to describe all health spending, including a breakdown of private and other spending. These factors help explain the higher total health spending figure for 2002/03.

The pattern, however, is clear. Growth in health spending quickly fell short of all Wanless’s projections. As Figure 4 shows, the shortfall accelerated after 2008/09, such that by 2017/18 a £45bn gap had opened between annual spending and that projected under the solid progress scenario – a 22% shortfall. This illustrates how, despite health continuing to receive modest real-terms increases after the financial crash, a near-decade of austerity took its toll. Even now, increases in line with the NHS England settlement (our projected values for 2022/23) will do little to close that gap.

The broader legacy

For some – including Anita Charlesworth – a rereading of the main Wanless report on funding is, as she puts it, ‘a slightly depressing exercise’. Wanless does not use the precise phrase ‘integrated care’, although it clearly is talking about that when it refers repeatedly to a ‘whole systems’ approach to health and social care. It says much better IT is needed, and much better workforce planning, while the public health report underlines the need for healthier lifestyles and improved prevention. ‘When I reread it,’ Charlesworth says, ‘I have the mixed feeling of “Gosh, I am quite proud of that,” and then I am really quite depressed about how much of it you could still write today.

‘There was not some big reaction against what it was saying,’ she says. ‘It had, certainly among the public health community and the clinical community, an awful lot of support. And I still get invited to speak to people now about it. So it is kind of weird that something that could not have had a better following wind led to so little progress.’

Likewise Nigel Crisp, chief executive of the NHS and permanent secretary at the Department of Health at the time of Wanless, says: ‘I am very depressed. It was a fundamentally sound piece of work. But we are still hung up with 20th century health care systems. Why has more progress not been made? In terms of the NHS it took the money and concentrated on its priorities. “Thank you Wanless, and goodbye,” is more or less what happened.

‘We did try to return to it, around 2005, shifting the focus from targets to health. But we didn’t put the energy behind what was then called the patient empowerment agenda that we had put behind the service improvement agenda.’ In some ways, Crisp says, the timing was wrong for the report’s broader health agenda. ‘The right time to do something about it was when we had beaten the waiting lists into submission. What everyone wanted at the time – and I include myself and the public in this – was to get waiting lists down and to stop people dying on the cardiac waiting list.’

Paul Corrigan, who in 2005 moved from the health department to be Tony Blair’s senior health adviser, says: ‘I remember reading the report with this idea of the fully engaged scenario and thinking this could be really important, but then just going back to the choice and competition agenda and getting on with it. To be fair, we were really, really, busy implementing a whole bunch of things designed to make the NHS work better.

‘If we had engaged with it, I am not sure we would have known, back then, quite how to do it. We do know now, for example, that if people with diabetes do more self-management that it is both better for their health and cheaper. And, while this comment is slightly ridiculous, if the report had not just talked about the fully engaged scenario, but had said “Here are 10 different thoughts I’ve had about how we might do that,” while asking “How are choice and competition doing to do that?”, we might have got to the issue of long-term conditions and better integration much sooner. But that is our fault, not his. By 2005 we were, with Patricia Hewitt, starting to talk about long-term conditions and better integrated care.’

As already noted, a public health white paper did follow the public health report, and in 2005, in Patricia Hewitt’s day as health secretary, a large public engagement exercise was launched. This concluded in a 1,000-strong ‘Citizens Summit’ that led to Our health, our care, our say. That white paper continued to put a strong emphasis on patient choice. It addresses the need to concentrate tertiary services in fewer hospitals, while moving others out of district general hospitals and closer to home. But it also refers extensively to integrated health and social care. ‘Far more services will be delivered – safely and effectively – in settings closer to home; people will have real choices in both primary care and social care; and services will be integrated and built round the needs of individuals and not service providers,’ it says, to quote just one example.

Patricia Hewitt says: ‘I thought the device of the fully engaged scenario was absolutely spot on. And it remains true today. Public health was part of that, and we did make commitments on public health. We already knew we had to do more on prevention, and Wanless strengthened that. We also saw some emerging partnerships between local councils and the go-ahead primary care trusts who did really good work on prevention locally. And we did put a lot of effort into Our health, our care, our say.’

But while the fully engaged scenario was, Hewitt says, ‘… an interesting analysis, and we all agreed with it, sadly, in the end, it got put on the shelf. The service demands of the NHS itself were just so inexorable.’

Part of the issue may have been, as Corrigan hints, that while the original report made plenty of recommendations around what the fully engaged scenario would look like, it had nothing substantive to say about how it might be achieved. Essentially the three scenarios were concepts, the ‘how to get to them’ remaining in the province of the Department of Health.

Furthermore, the challenge of assessing the scenarios is shown in work that Derek Wanless himself undertook, again with The King’s Fund, in 2007. In the absence of a further government-commissioned review, Our future health secured? sought to assess progress since 2002, although for much of the performance data it had to rely on 2005/6 figures, and occasionally from 2004. The report does not present an overall conclusion. But on key elements of the service – input costs, IT, services delivered, population health and productivity, for example – it puts progress at somewhere between slow uptake and solid progress, at times veering more towards one than the other. But what is clear from the report is that these are – indeed had to be – perceptions, rather than judgements made on predetermined metrics. The three scenarios remained, essentially, concepts.

There are other circles where the memory lingers on. Norman Lamb, the Liberal Democrat health minister between 2012 and 2015, says he regularly referenced it in opposition up to 2010. And when he stepped out of line as a health minister in 2014 to call for an immediate cash injection for the NHS, ‘I am not sure whether I referenced the Wanless report, but it was in my mind.’ Likewise, Lamb says, when again in opposition after 2015, he referenced its work as he sought with others to build a cross-party consensus for a long-term settlement for the NHS. But against this, aside from the attention paid immediately after the main report’s publication, Wanless did not cut through with the general public in the way of the Beveridge report, or the Turner pensions commission report – although, in fairness, few such reviews do.

Looking back from today’s vantage point, almost 20 years on, it is possible to take a rosier, if mixed view, rather than an entirely depressing one. The impact of the money – whether you believe that stemmed from Breakfast with Frost or Wanless – has already been discussed. The picture on public health is nuanced. Some trends have headed in the right direction – smoking and drinking among younger people, for example. But health inequalities have widened, and since 2010 past increases in life expectancy at birth appear to have stalled. Even so, public health is better than it was in 2004. On IT, the NHS still lacks a fully integrated electronic patient record, but the use of IT within the NHS is appreciably better than it was. There is, at the time of writing, the glaring absence of a long overdue workforce plan for either health or social care, but on the plus side the drive towards integrated care systems does appear to be making some progress – although a fuller analysis of how they are doing is beyond the scope of this report.

Mark Pearson from the OECD agrees that there is a long way to go on two of the review’s key themes – IT and integrated care. But he notes that while there are good examples of both within various health systems around the world, ‘I am not sure that any country has made really good progress. The UK is not alone. These are quite difficult things to do.’

Furthermore, someone being generous could, on better integrated care, draw a line of inheritance that stretches through Patricia Hewitt’s Our health, our care, our say (2006), on to parts of Ara Darzi’s High quality health for all (2008), on in turn to David Nicholson’s Call to action (2013), culminating in Simon Stevens’s Five year forward view (2014) and the subsequent documents that have led to the drive for integrated care systems.

There is, however, another way entirely of looking at the legacy of the Wanless report.

Legacy version two: ‘It’s the politics, stupid’

The other version lies in the view of Ed Balls who says, ‘When I think back on my time in politics it is, I think, the thing that I am most proud of. You have a left of centre government that set out to make the case for a tax rise. Not because it had screwed things up, but in order to spend more on a key public service at a time when the main opposition party is trying to undermine – in fact to destroy – the post-war consensus about the National Health Service being the best funding model.

‘The strategy is, you can make the NHS perform much better but it needs to be properly resourced. So we have this twin track. Derek does a report which is well received. It is absolutely the platform for the National Insurance increase to deliver the longest, most sustained increase in national health spending in the history of British health policy.

‘And that in turn delivers enormous improvements in health outcomes, in terms of waits and a lot of other things as well. There is an absolutely legitimate debate about whether the money was spent as well as it could have been. But that is a second order question.

‘Look at the 2005 election. If you go back to the Conservative’s statements on the day Wanless reported, you would think the report would be at the centre of a massive row – in which the betrayal of the economy, through this terrible tax rise from a Labour party that always wanted to raise taxes, and then wasted the money, would be central to the election campaign. Nothing.

‘The Tories still clung to the patient passport in 2005. But they were not saying that Wanless was wrong. That we should not be spending all this money on health. That they would reverse the tax rise. They did not because it was hugely supported in all the opinion polls. So in the 2005 election, the most controversial thing we had done in tax and spending policy is barely mentioned. Because we have massively won the argument for a tax rise to improve the health service with Derek’s report at its centre.

‘It was a triumph of public policy and politics. In 2005 Michael Howard [Conservative party leader] found he could not fight the election on “The NHS is a failed model” and by the time you get to David Cameron in 2010, he is telling the public that he can do his priorities in three letters – N-H-S – and that “I will cut the deficit, not the NHS.” That was the biggest tribute to Wanless and to Anita and everything we did.

‘It transformed the whole debate about the National Health Service. You have to go back to the bitterness of the autumn of 2001 to see quite what a journey has happened. When I think back on reviews I have been involved in, and I have been involved in some really good ones over the years, the Wanless review is by far the most politically significant with the longest lasting effects.’

Nick Macpherson concurs, at least on the tax raising point. With 30 years’ experience at the Treasury behind him, it is, he says, ‘The only serious, discretionary, non-forced tax increase in my life. All the other ones were forced. So it was a political achievement.’

‡‡‡‡‡ These assessments come at different stages of the programme. But see eg, The National Programme for IT in the NHS: Progress since 2006, Commons Public Accounts Committee, January 2009; The National Programme for IT in the NHS: an update on the delivery of detailed care records systems, National Audit Office, May 2011.

§§§§§ As they did in other countries. The UK’s performance in terms of outcomes lagged and still lags some other countries on some measures.

¶¶¶¶¶ HM Treasury analysis was that only in the US were doctors paid more on average. For nurses only those in the US and Australia were better paid. See Treasury stalls on pay rises in the NHS, Financial Times 17 March 2006. For salaried doctors see OECD Health Data 2007 ( The BMA conceded in its evidence to the DDRB in 2006 that earnings were ‘broadly comparable with their compatriots in other countries’ ( (para 2.29).

****** For figures see 17th Report of the Commons Public Accounts Committee; February 2007 ( and The five giants, ibid, (pp 635–639) for a fuller account of cause and effect.

†††††† 2002/03 figures in Wanless are estimates.

‡‡‡‡‡‡ Source: ONS, Healthcare expenditure, UK Health Accounts: 2018 (2020). Data are reported according to system of health accounts (SHA). Financial years are calculated pro-rata from calendar years.

§§§§§§ Wanless figures all include an assumed constant of 1.2% for private sector health spending.

¶¶¶¶¶¶ 2002/03 figures in Wanless are estimates.

******* Source: ONS, Healthcare expenditure, UK Health Accounts: 2018 (2020). Data are reported according to system of health accounts (SHA). Financial years are calculated pro-rata from calendar years.

††††††† Health spend defined as government-financed only. Wanless figures are all minus 1.2%.

‡‡‡‡‡‡‡ We have estimated future total health spending using the real-terms growth from the NHS funding settlement (3.4% per year) as a basis for DHSC health spending only. Other aspects of health spending from SHA assumed stable as proportion of GDP. GDP deflator from HMT (2020).

§§§§§§§ Source: HMT, Public Expenditure Spending Analysis (PESA), public sector expenditure on services by function. Actual data up to 2019/20.

¶¶¶¶¶¶¶ Source: Growth figures are annual averages for the 5 years up to that date (Wanless figures are for 4 years in the period up to 2002/03).

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