To those interested in policy who aren’t long in the tooth, the word ‘Wanless’ may not mean much. But it should. Named after its chair, Derek Wanless, it was a landmark review of NHS funding, published nearly two decades ago in 2002.

Why is such an old review so important to revisit? Wanless was the first serious attempt to assess objectively the long-term funding needs of the NHS. It unlocked not only unique levels of growth in funding for the NHS, but also helped justify the tax rises to pay for it. And since policymaking is mostly about human behaviour, Nick Timmins exposes how politics ‘acutely intersects’ with the issue of NHS funding to wrestle progress out of conflict (although Nick uses more vivid language). As we exit from the pandemic, these issues are even more important to understand than they were in 2002.

Three surprises

If you think of the UK NHS as one ‘industry’, it is the largest in Europe. Now in its seventies, it is also one of Europe’s oldest. Polls consistently show the NHS is a national treasure in the public’s mind, top of the list of reasons they are proud to be British, and tops priorities for extra public funding. Not surprising then that the NHS successfully extracts extra funds from the Treasury each year, to a greater extent than most other areas of the public sector. But three things are surprising.

First, for such a national treasure, the year-on-year funding growth over the years has varied wildly – from 11% to -1% – making anything other than short-term planning a challenge. This matters in a service where demand for care only grows and can’t be suddenly turned off: more staff are constantly needed who take many years to train, the public expects new technologies it sees elsewhere in life, and clinical staff know that new technologies are being used to good effect in other countries, all of which need investment.

Second, other European countries have managed to invest more in health care over time – the Wanless review calculated even between 1972 and 1988 this totalled £220bn–£277bn relative to the EU average. Whatever the public and political importance of the NHS over time, paradoxically this has translated into chronic underinvestment. By 2002, this showed in a raft of unflattering international comparisons on performance, most visible in long waiting times for planned care, and winter crises in A&E.

Third, until the Wanless review in 2002, there had not been a full, objective, and published analysis of the demand pressures on the NHS under various scenarios for the long term, costed out, for the government or by the NHS itself. Wanless was a serious attempt to do that, in part made technically possible because data were increasingly available to analyse. Data, and modelling techniques, are much more sophisticated now, and yet even today there is no regular Wanless exercise for the NHS akin to the long-range projections for the economy by the Office for Budget Responsibility.

Clues as to why can be gleaned from Nick’s rollicking account of the politics surrounding the conception, delivery, and outcome of the Wanless review. For sure, by 2000, recognition was overripe that the NHS needed a major slug of investment, and not only over the short term. This wasn’t just politically needed in New Labour’s first term, off the back of a decade of the NHS being ‘under attack’ by market-based ideology following introduction of the 1991 NHS reforms, and inadequate funding growth. But also because cracks in the NHS were showing, not least with ‘never never’ waiting lists, winter crises and, of course, heart-rending individual cases of lapses in care in the late1990s as Nick documents – all translated into damning headlines.

Contested origins

Absent any substantive projections as to the funding needs, in January 2000 the PM announced the European Union average (health spending as a percentage of GDP) as the target for NHS spending by 2005. The Wanless review was then commissioned by the Treasury, examining resourcing the NHS and social care, and published as Securing our future health in 2002.

Whether or not the Wanless review came about to give retrospective credibility to the PM’s target, or to give advantage in a feud between Number 10 and the Treasury, its objectivity based on evidence made the case for a substantial increase in funding, further reform and justified increased taxes to pay for it. For 5 years following Wanless, the NHS was awarded well over twice the long-run average in real-terms growth in funding. Social care received a significant boost in funding for 3 years. National insurance was raised by 1%, and this tax rise was tolerable electorally. And a day after Wanless reported, Alan Milburn (then secretary of state for health), announced not only increases in staffing and equipment, but a significant set of reforms, in part centred on reducing waiting times.

As Nick Macpherson notes, the Wanless review, ‘… led to the only serious, non-forced, discretionary tax rise since at least 1979 – and one that proved electorally appealing’. And in Ed Balls’s words, ‘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.’

‘Doing a Wanless’

Which still leaves the surprise that ‘doing a Wanless’ is not a regular feature of planning today. To help, in 2020 the Health Foundation launched the REAL Centre (Research and Economic Analysis for the Long Term) to provide objective projections of supply and demand, and funds needed for the NHS under different scenarios. Unlike Wanless, REAL gives full consideration of social care funding as well. And neatly, the Director of the REAL Centre, Anita Charlesworth, was the senior official at the Treasury who led the secretariat supporting Derek Wanless two decades ago.

As the UK exits the pandemic, it faces not only the backlog of unmet demand for NHS care, unreformed social care, and investment sorely needed elsewhere in the public sector. For long waiting times and winter crises not to be the norm, the political pressure for more investment in the NHS will be intense. The large debt overhang from the pandemic, and justifiable demands for investment elsewhere, will mean competition for resources will be acute as will the pressure to raise taxes.

Perhaps time then to consider another Wanless? Waiting times for elective care had steadily increased before the pandemic, and the NHS faced 100,000 in staff shortages. The pandemic has further exposed the NHS’s Achilles heel – a fundamental lack of capacity. This was also on full view with respect to shortages in staff and equipment in social care. Any review should examine not just the capacity the NHS needs to address the backlog of care, but also unmet need and inequality in access for the NHS and social care. Both are needed to build care that is more resilient to future health shocks, as COVID-19 is sadly unlikely to be the last. Such a review might give more objective credibility to assessments of how much funding is needed for care over the next 5 years; and justify that to the public, to politicians and the Treasury, especially if tax rises are on the cards.

For the NHS this time round though there is already a clear reform agenda, in the form of the NHS Long Term Plan, which commands widespread support. It will be more difficult to justify the case for further significant reform. It is the pandemic that has caused the backlog, public perceptions of how the NHS has managed the crisis and vaccine rollout, and the obvious staff commitment to duty, are favourable. And the last round of reform was costly, distracting, and of questionable impact. Instead extra resource may be better targeted directly at more basic issues that will limit progress on waiting and wider performance – such as staff shortages, insufficient technology and other equipment

For social care, the task is larger as there is currently no reform strategy, there is an urgent need for investment, and outside of a pandemic there are few screaming headlines to prompt action. It is here that political leadership, deal-making and creativity, of the sort Nick notes in this study, is sorely needed most to ‘fix social care once and for all’.

Dr Jennifer Dixon CBE

Chief Executive,

The Health Foundation