Conclusion and coda


What was the Wanless report about? That was the opening question put to the interviewees for this study. And, as has become clear, the answers are many.

It was indeed a ‘His Master’s Voice’ report, commissioned by the Chancellor to produce the outcome he wanted, as Andrew Turnbull, permanent secretary at the Treasury at the time of the Wanless reviews, dubbed it. But to see it only as that is to do it an injustice. Within its terms of reference, it was an independent review. Witness not least Wanless’s re-raising of the issue of social care at a time when the government had only recently made a controversial decision to do little about it.

The Wanless report was both a product, and in some ways a victim, of the politics of the day. A product of the internal tensions within the Labour government, Blair having promised to raise spending to the EU average with Brown seeking to wrest back control – but with Blair and Milburn determined that reform of the management of the service would be theirs. But seeing the report only in these terms would also be an injustice.

At the time the NHS model was under attack from longstanding opponents, but was also subject to continuing worries that it might not be sustainable even among some of its natural supporters. It was also the case that the Conservative party’s formal position was that the NHS was a failing model and that the answer was to inject higher private spending. Thus the argument presented here by Ed Balls has weight – that, at least from the Treasury’s point of view, a Labour government had not only to make the case for additional sustained increases in NHS expenditure, but also the case for a tax rise to pay for it. It did, as Nick Macpherson observes, lead to the only serious, non-forced, discretionary tax rise since at least 1979 – and one that proved electorally appealing.

The least generous view has to be that it was, at a minimum, a stepping stone to a predetermined shore: the big increases in NHS spending that Tony Blair had promised.

But regardless of whether the increases are viewed as inevitable (given Blair’s promise) or as the product of the review, the money that flowed into the NHS made a real difference. If there is a case that the Griffiths management review of 1983 rescued the NHS, there is equally a case that the money rescued an NHS that was in fact failing – falling behind international standards and leaving dissatisfied large elements of the public, whose support as taxpayers was crucial. By the end of the spending periods that the Wanless report affected, public satisfaction with the NHS was to reach a record high.

None of what might be dubbed the report’s key operational themes were new. What we now call ‘integrated care’ had sailed under various banners beforehand – coordinated working, inter-agency working, managed care – and, indeed, as far back as 1974, that year’s mighty NHS reorganisation was intended to make hospital services, community services and primary care work better together. There had been an understanding for some time that the power of computing – already widespread in GP practices – needed to be harnessed to deliver not just better data (which has happened) but a fully interchangeable electronic patient record (which remains a long way from completion). Indeed a £1bn 7-year initiative to achieve that had been launched in 1998., The absence of proper workforce planning had become a recognised problem, not least since the abolition of the Regional Health Authorities in 1996. But the Wanless report underlined each of these and put fresh energy into them all. Even if the national IT programme proved anything but a huge success, workforce planning has gone missing again, and social care remains a problem to be solved.

As to why the report did not have the wider or more lasting impact that many wished for it, four factors were in play. The first three are interrelated. First, it was both a product and to some extent a victim of the Blair/Brown tensions. The Department of Health never owned it. And, perhaps most importantly, as several interviewees noted, while it provided a broad description of what fully engaged looked like, it did not provide a plan, blueprint, or route map of how to get there. To be fair, it was not asked to. But in the absence of the blueprint, the first two factors ensured that one did not get built. The fourth factor, as Patricia Hewitt puts it, was that ‘The service demands of the NHS itself were just so inexorable.’ The primary focus – rightly at the time – was on waiting times, compounded in the short term by the need to tackle the NHS overspend (which was not, it must be said, Patricia Hewitt’s fault).

For those who want to take a more optimistic view of its impact, a line can be drawn, as already noted, from the Wanless report’s call for better integrated care through subsequent initiatives and on to the integrated care systems of today.

Most importantly, however, the Wanless report was the only serious attempt by any government since 1948 to make an independent assessment of the NHS’s likely future needs, and likely cost, over the next 20 years. That alone makes it a landmark report. An exercise that, for all the very real difficulties in forecasting medical advances and other changes over such a long timescale, has to be worth repeating. Not least because the data available to do this are so much better now than they were at the time.


1: Could it be done better next time?

If there were to be a Wanless-type exercise at another time, could it be done better? There is no easy answer to that question.

In 2018 the Institute for Government, with support from the Health Foundation, looked at the many ways governments have sought to use inquiries to solve knotty public policy problems, though with varying degrees of the success. The methods range from Royal Commissions to various other types of independent inquiry. The 20 case studies it examined included the Beveridge report, the Low Pay Commission, the Pensions Commission, the Dearing and Browne reviews of higher education funding, the Armitt review that produced the Infrastructure Commission, the Dilnot inquiry into social care and the Committee on Climate Change.

Among the study’s key conclusions relevant to a Wanless-type exercise were that to be successful, at a minimum, such inquiries need the full support of the Prime Minister and Chancellor. In addition, inquiries often seem to work best when they publish an interim report that prepares the ground ahead of final conclusions. By the time Wanless reported, it met those criteria.

The fact that it was a Treasury-led review, however, proved to be both a strength and a weakness. The strength was that this was the Treasury untying its own purse strings, rather than an outside body persuading it so to do. The weakness was the ownership. The Department of Health provided much key statistical support and indeed had its own civil servant working on the review team. So to that extent it was shared. But all the department really wanted was the money. It never owned the review in any wider sense, and Labour’s internal party politics meant that once the money was delivered, health ministers and the department were never likely to own its other recommendations, apart from where they already fitted with the department’s own agenda. As Nick Macpherson puts it: ‘You want departmental ownership. The only way anything really happens is that the department really owns something.’

It is on occasion possible to reverse engineer a Treasury review into the heart of departmental policy. For example, the Treasury-led 1997/98 Review of services for young children resulted in the Sure Start programme, where large amounts of Treasury cash became married to the objectives of successive education secretaries, backed up by a cross-departmental Cabinet committee. This ensured that the Department of Health and others played their part. The slow burn effect of the Committee on Climate Change is another example, as is the Treasury inspired creation of welfare-to-work programmes, again in Gordon Brown’s day. It is not possible to legislate such ownership. It is a product of the internal politics of the government of the day.

Given this, there were few suggestions from our interviewees about how the Wanless report could have been given a greater impact than it had. The main suggestion was to do something rather different. Not so much for government to repeat the exercise but to set up a standing review of likely future health and social care costs, undertaken either by the Office for Budget Responsibility (OBR), or an equivalent body.

Chris Ham, who ‘lived and breathed the review by proxy’ as head of the department’s strategy unit says: ‘It would really only have had a lasting impact if you had institutionalised the Wanless process. Effectively, it was a one-off. So long as Blair and Brown were around, the commitment was there. If it is not institutionalised, then with a change of government, or just a change of Prime Minister or Chancellor, there is always the risk it will go in another direction.

‘It might have been more sensible to have an OBR-type arrangement that would be charged with doing it on a regular basis. I am not sure that doing it again 5 or 10 years later would have been sufficient.’

Nick Macpherson likewise judges that such an arrangement could work – but work best if there was some form of soft hypothecation – some form of earmarked tax – for health and social care, and if the UK sticks with fixed-term parliaments. That, he says, ‘… would create clarity about the medium-term pressures on health and social care, to better inform a debate about funding. We have defence reviews as a matter of course to ask what do we want to fund our armed forces for? There is a genuine advantage in reasonably transparent reviews of pressures that better inform funding, but which also debate what the state should be doing, and whether there should be changes in the way the state delivers things. I think that has a wider application, beyond health.’

The Treasury, Macpherson says, will always be worried that such an approach would become a permanent source of even greater pressure on it to ‘reconcile the irreconcilable’. ‘But I think, just as the OBR has created better decision making, so should a better quality, better informed set of projections on health and social care. The lesson of Wanless is that getting things out into the open, ensuring that there is some debate, is likely to improve the quality of decisions.’

Hugh Taylor, who was permanent secretary at the Department of Health between 2006 and 2010, says that if there were to be another Wanless ‘The one additional thing I would like it to do is make the economic case for health spending. Not just in the sense that if you have a healthier population you keep people in work and reduce benefits, but the investment it brings in science and technology and the life sciences. When push comes to shove, the Treasury always treats the NHS as an overhead, not as a key area of wealth generation. But two of the unique selling points of the UK ought to be the excellence of its universities and the capability of the NHS, which has access to patients and data in ways that make doing the science easier.

‘To be fair, when I was in government, the Treasury was incredibly supportive of the R&D agenda. But at the simplest level, the NHS employs a lot of scientists, it does a lot of construction work, and it plays right at the edge of technological change in almost every dimension you can think of. Part of the economic success of the state is the spending on health, which in turn has given pharmaceutical companies, and potentially the wider life sciences industry, a hugely strong base in the UK. There is a strong economic case for investing in the NHS, and it needs to be better understood.’

Medical advances

It is clear that one of the biggest challenges in such an exercise is predicting scientific and medical advances – over 5 years let alone 20. And then assessing which, if any, are likely to have a significant impact on the overall cost of health care.

As already noted (see Box 2), the Wanless report, entirely forgivably, failed to spot the impact of the rise of interventional radiology on cardiac surgery, or the NHS’s much greater adoption of talking therapies (such as CBT), both of which happened within 5 years of the final report. Both clearly affected the shape of the workforce that would be needed. The former clearly improved productivity as well as clinical outcomes. The latter is judged to be cost-effective in comparison to other treatments for certain conditions. Neither, of course, was of sufficient scale to alter the quantum of funding increases that Wanless recommended.

A combination of many such things, however, might well affect productivity significantly. And productivity is an element that needs to be assessed in judging the scale of future spending increases likely to be needed.

Take a couple of examples from well before the Wanless report. The arrival of more modern anaesthetics and of laparoscopic surgery not only improved patient outcomes but raised productivity. Both reduced the trauma that patients undergo thus allowing swifter discharge from hospital and a much faster return to normal life. It would have been mighty hard, however, to project the remarkable speed with which laparoscopic surgery came to be adopted once it was available.

Anyone producing a Wanless-type report in 2019 would, of course, recognise that gene therapies may well change the way medicine works profoundly. Whether in the longer term they will prove to be cost enhancing or cost reducing remains, however, very hard to predict., Equally, a 2019 study would have registered the potential of mRNA techniques, given that these have been studied for decades. But it would have taken remarkable foresight to predict that mRNA technology would be capable, within a year, of producing new vaccines to counter a pandemic.

The Wanless review was not short of clinical engagement. A glance at those who not merely delivered written evidence but who were met for discussion shows that (pp 129–135 of final report). But it is worth observing that despite the inherent difficulties of projecting the impact of medical advances, any future exercise should work hard to ensure that it can make the best possible judgement.

2: Lessons for a post-pandemic world

Are there lessons from the Wanless review that could apply during the COVID-19 recovery and beyond? The short answer is yes. Three stem from the report itself. But two others relate to the broader context in which the report was produced.

The three that stem from the report have already been covered – the 25-year failure to find a new settlement for social care in England; the continued absence of a fully integrated electronic patient record; and the lack, once again, of a decent attempt at some form of effective workforce planning – understanding the pressures and putting policies in place to tackle them.

The two others are capacity and bandwidth. Workforce, of course, is part of capacity. But with NHS waiting times sharply on the rise as a result of the pandemic, it is not clear that the government fully grasps the scale of the challenge of getting them back down again.

The goal of achieving the 18-week target was first announced in 2004 by John Reid, Alan Milburn’s successor as health secretary. It took 4 years for that to be reached. It took 8 years if counting, more realistically, from the NHS Plan of 2000. This had set the initial target of a maximum 3-month wait for an outpatient appointment and 6 months for subsequent inpatient treatment – goals that were well on their way to being achieved by the time of Reid’s announcement. In other words, cutting waiting times took many years to achieve. In addition, it cost many, many billions of pounds. It is close to impossible to calculate how much of the extra money went on cutting waiting times as opposed to other improvements to the service. But it is entirely clear that the cost ran into many billions.

Furthermore, the backlog this time looks likely to include many, many thousands of patients whose delayed assessment and treatment is urgent – cancer and cardiac cases, not just the hips and cataracts and similar elective procedures that made up most of the longest waits by the mid-2000s. These, while painful and/or life limiting, were by and large not life threatening. David Nicholson, who lived through that period first as a strategic health authority chief executive and then from 2006 as NHS chief executive, says, ‘It will take years and years of sustained investment to get this into any kind of order.’

It should also be underlined that the time it took in the 2000s was not for want of effort. As already noted, there were the targets themselves, the Prime Minister’s Delivery Unit driving their achievement, the introduction of the competition and choice approach which included the tariff, the arrival of the independent sector treatment centres, and the ability of patients to go to any private hospital willing to treat them at the NHS price. Quite how big a part each of these played is open to debate. But it is clear that the targets and the tariff drove up activity, and all of it was backed up by some pretty vigorous performance management. It still, however, took years and cost billions. If much shorter waiting times are once again to be achieved, the same is likely to apply.

Closely tied to the issue of capacity is the question of bandwidth. The key priority was waiting times. But as Richard Douglas underlined, alongside that, and in some cases in support of it, the Labour government undertook much else. The huge IT programme, wholesale renegotiation of staff contracts; the creation of foundation trusts and of the tariff; a massive PFI programme to build hospitals and some surgeries; greater involvement of the private sector, including the creation of independent sector treatment centres; revamping the inspectorate, first into the Healthcare Commission and then into the Care Quality Commission, while at the same time seeking better integrated services and putting the NHS through another big structural reorganisation in 2006.

After it was elected in 1997, Labour abolished GP fundholding, replacing it with an initial 481 primary care groups which morphed into primary care trusts. In 2002, Labour abolished the 95 district health authorities, replacing them with 28 strategic health authorities and 300-odd primary care trusts. In 2006, however, it reduced the number of strategic health authorities from 28 to 10 and the number of primary care trusts from 303 to 152, while at the same time seeking to develop ‘practice-based commissioning’ for GPs as a sort of watered-down version of GP fundholding. A huge amount was achieved. But there was quite simply not the bandwidth, either nationally or locally – where the management reorganisations consumed much time and effort – to achieve all of that successfully.

It was made clear at the outset that this study does not attempt anything like a full account of the management of the NHS post-Wanless. But to jump forward briefly to today: the government is promising legislation to unscramble much of the 2012 Health and Social Care Act. This involves some structural reorganisation that will itself have opportunity costs at a time when the service will still be coping with COVID-19 and the huge backlog awaiting treatment. It is also worth noting that while the 2012 Act has played out very differently to the way it was envisaged, its creation of what is now NHS England has led to a consistency of purpose in working towards better integrated health and social care for the better part of a decade. There should be no shift from that. And it could be concluded that in tackling the recovery from COVID-19, more is likely to be gained by a few clear-cut priorities than attempting everything that anyone could wish for. The phrase ‘to govern is to choose’ comes to mind.


This study would not have been possible without the time, insights, recollections and reflections of a whole string of people involved, in one way or another, with the Wanless reports. The author and the Health Foundation are immensely grateful to them all. In the above text, titles have not been used because at the time these events took place they had not (other than professorships) been awarded. We trust no one feels insulted. They are spelt out here. In alphabetical order, those who generously found time for interviews were:

Ed Balls, Dame Carol Black, Anita Charlesworth, Paul Corrigan, Lord Crisp of Eaglescliffe, Dame Sally Davies, Richard Douglas, Stephen Dunn, Professor Sian Griffiths, Sir Chris Ham, Patricia Hewitt, Robert Hill, Norman Lamb, Sir Nick Macpherson, Alan Milburn, Ed Miliband, Richard Murray, Sir David Nicholson, Mark Pearson, Sir Hugh Taylor.

Others who helped in various ways, not always consciously, either because we were able to draw on earlier relevant interviews, or who pointed us to key issues and sources, include Professor the Lord Ara Darzi, Frank Dobson, John Henderson, Rudolf Klein, Sir Alan Langlands, Ben Page of Ipsos MORI (who filleted years of opinion poll data), Clive Smee, Lord Turner of Ecchinswell, Lord Turnbull and John McTernan. Dr Liam Fox declined an invitation to be interviewed. There were others who we would also like to have interviewed but who failed to respond.

Drafts of this were read by a goodly number of the interviewees whose comments and suggestions decidedly improved it. To their absolute credit, none sought to withdraw or amend any of their quotes, other than by way of minor clarification.

At the Health Foundation thanks are due in all sorts of ways to Anita Charlesworth (whose idea this was) and to Hugh Alderwick, Jennifer Dixon, Pete Stilwell, Tim Gardner and Ruth Thorlby, while Stephen Rocks undertook the calculations and did much to draft the expenditure box. Sean Agass is, as ever, an excellent and constructive editor. Despite all this assistance, any errors of fact, interpretation or judgement remain those of the author.

******** Always assuming that a fully engaged scenario would in fact reduce the rate of growth in expenditure.

†††††††† For an account of cause and effect see The five giants, ibid, (pp 635–639).

‡‡‡‡‡‡‡‡ The OBR provides independent forecasts for the economy and for the public finances. It was created in 2010. It does already make some forecasts of likely health and social care expenditure. But not in the detail or on the scale that is presumably envisaged here.

§§§§§§§§ Macpherson favours an extended version of National Insurance.

¶¶¶¶¶¶¶¶ A draft bill proposes abolishing fixed-term parliaments.

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