Report of a Harkness Centenary Discussions on the challenges for the NHS which took place on April 24th 2025
Fiona Godlee, former editor in chief of the BMJ and author, moderated a varied group of health and non-health experts during a wide-ranging discussion with introductory contributions by Becks Fisher, Director of Research and Policy at the Nuffield Trust, Kevin Lavery, CEO of NHS Lancashire and South Cumbria Integrated Care Board, and Nason Maani, who lectures on inequalities and global policy at the University of Edinburgh. This is a summary of the points discussed.
Football analogies are never very far away when complex issues are being discussed and never more so when the NHS is in the spotlight. Nason Maani, inequalities expert, set the reference point for the evening when he likened NHS healthcare to “the goalkeeper” in a game of football. He had studied the effects of COVID in America and there were lessons for the NHS in this.
Nason had wanted to know why, when America was originally predicted to cope with the pandemic very well, it did so very poorly, concluding that there were factors outside of healthcare that had a significant impact. These included a large population with little savings to weather gaps in employment, a large number of people already in poor health, gaps by race and ethnicity in income, ability to work remotely, single parent households, a large undocumented migrant workforce who distrusted authority, and a big unhealthy prison population who were unable to socially distance.
It didn’t matter, he said, how prepared the health system was because, ultimately it wasn’t possible to “treat yourself out of those upstream problems”. Too much emphasis was being put on what the healthcare system does – in isolation of the health of the population.
“If population health is a football team then the healthcare system is like the goalkeeper,” he told the meeting. “We all want a really good goal keeper for when people get sick, as they inevitably will – but all the other players on the pitch, social care, education, equality, benefits, health literacy, healthy food environments, ability to ensure physical activity and green spaces; if we neglect these as we did during austerity, it really doesn’t matter if you ring fence the goalkeeper. If the other players aren’t doing their jobs, any goalkeeper will be overwhelmed, no matter how amazing.”
The worst thing to do would be to see what else the goalkeeper could do – perhaps get more expensive gloves or an AI assistant. While there was merit in making the goalkeeper as good as possible, England could never win the world cup without all players on the pitch playing their part.
Moderator Fiona Goodlee wondered how the NHS could succeed in an environment where it is expected to do everything while government and policy makers are unwilling to tackle what we know to be key underlying causes of ill health – many of which are beyond the scope of individual action. These were still largely uncontrolled; alcohol and drug misuse, gambling addiction, social media-induced mental health problems, obesity, poor nutrition due to junk food, lack of access to green and blue spaces, lack of social care and media-led expectation. Why was there still so little recognition of the link between people’s environment and the burden on the NHS?”Was it Government failure or market failure? Lack of political will or was more evidence required before action is taken? Or did we need to shift the public mindset?
Kevin Lavery, CEO of NHS Lancashire and South Cumbria Integrated Care Board, said he joined the NHS three years ago having worked in councils and the private sector. He said he wasn’t naïve when he took the job, using another football analogy to explain that he had grown up a Newcastle United fan, so he was used to failure – but he never stopped believing. That said, from day one, it felt like “slash and burn”. Many non-NHS services that supported people in the area he worked in were hammered during the austerity years and this had clearly taken its toll. Cuts to local authorities were effectively deeper in areas that relied more on government funding than they did in say, Surrey, where there was more reliance on council tax. There were also lots of strikes as nurses, paramedics and junior doctors all came out and taken together, people had started to lose confidence in the NHS and wider public services.
Certainly, the effect of COVID on the NHS in the years since the pandemic had affected how the NHS was now viewed in the country. Real terms cuts during austerity in those services supporting NHS efforts, together with stagnating funding for the NHS, had further damaged its reputation. At the same time there had been large increases in demand for urgent and emergency care, continuing healthcare, learning disability support and mental health issues. He said it was easy to get fixated on the money at the expense of the patient and inequality, or to park long-term reforms to the frontline. But that would have been the wrong thing to do. Instead, he focussed on projects that helped patients – and reduced costs – treating people in the community rather than in an acute hospital and prioritising the long-term sick so that they could work in the burgeoning naval industry in Barrow.
Despite such successes the NHS’ hard-fought place as the nation’s sometime favourite British Institution has been seriously dented with survey after survey finding taxpayers disappointed. Indeed, public satisfaction with the NHS and social care was now at a record low, said Becks Fisher, pointing to the latest British Social Attitudes survey published just a few weeks ago. This showed just over 20 per cent of those polled in October 24 were very or quite satisfied with the way the NHS was run. More worrying, while the public as a whole still believed in the fundamental principles of the NHS, free at the point of use and taxpayer-funded for everyone, when separated out for voting intentions there were real splits. This was particularly the case with Reform voters who were much less likely to want to fund the NHS and much, much less likely to think it should be available to everybody – prompting her to add that she was beginning to wonder whether the support for the NHS was as unshakeable as she might have hoped it would be.
Becks then changed tack; speaking as a GP she said that she wanted to talk about the social and commercial determinants of health. A growing percentage of adults were obese with the latest health survey for England suggesting it’s around 28 per cent with an additional 36 per cent overweight. Millions were living with the consequences of obesity. It was hardly surprising though as we also lived in an obesogenic environment with little attempt at regulation. Until last year there was relatively little a GP could do, but now there were injectable medications which were very effective. On average weight loss was 15-25 per cent a year. She commented that the medications were also very effective for the pharmaceutical companies as once patients came off them, they tended to gain weight, suggesting long term demand for the drugs. That aside, she wanted to know how the NHS should deal with these drugs. The access threshold was still quite high which meant that potential patients had to have failed behaviour management approaches, be obese enough and have additional complications – but even if they were eligible, could only have it for two years. But lots of people were obese at a young age and didn’t qualify, yet. “I don’t know what we do about that”, she said.
“Is that a failure of prevention? Am I just waiting for that person to become ‘obese enough’?
And she wondered what the advent of injectable diet drugs did for the food lobby. “If you manufacture medicines that treat obesity you have no reasons to want to treat obesity in the first place – and every reason to oppose sugar taxes and advertising bans.”
The wider group picked up on many of the themes raised by the speakers. One member suggested that unlike the reforms to education in the Blair and Brown years, more money had been given to the NHS without fundamental reform of the principles that underpinned it. Another argued that despite reforms to the NHS, it had made little difference and that it was clear that the NHS could not solve all the problems in society. It was important to have a clear vision, and this was currently missing with everyone seeming to work in silos. Another noted that she had worked in the NHS most of her life and that the point made by the panel about the lack of regulation was an important one. “Why are we so resistant to regulation that will help us be healthier and give business a level playing field?” she asked. A later speaker noted the pressure put on individuals to be responsible when the system makes that hard.
A member describing himself as a scientist said that the NHS was suffering from mission creep but that the biggest issue, as he saw it, was social media’s role. It was allowing drug advertising outside the strict regulation of drug promotion in the UK, let alone spreading discontent and affecting mental health. Commenting on how social media was creating greater cleavages between different social groups, a participant noted – alongside others – that people are often very happy with their individual care, but unhappy with the NHS, perhaps influenced by messages from others. Out-of-pocket spending on health care is increasing, especially in dentistry, exacerbating inequality and discontent. A Harkness Fellow from the late 60s said that politicians weren’t really addressing the fact that the population was getting older and the numbers just didn’t add up. We had to be realistic and say that it’s not realistic to provide healthcare that is the best in the world to everyone in the UK. This was picked up later by another member who said that people didn’t normally speak about these things in a ‘polite forum’. He considered that senior healthcare managers certainly would not question whether we could continue to fund the NHS through taxation or stopping giving everything to everyone. It was suggested that we need clearer articulation of the whole model.
Fiona Godlee noted that this was not new and suggested that perhaps the media could be invited to explore this. For another Fellow the issue was addressing low satisfaction levels with the NHS. It was important to make the argument for the NHS as a model of healthcare, he said. If we don’t make the argument we will lose it. A former lawyer, now educator, raised the practical aspects of regulation. Car regulation protected people from other people; food and gambling regulation was the state protecting people from themselves. It all fell into the category of the nanny state which was unpalatable to many. And yet, as another colleague raised, going back to before the NHS was created, during the war when food rationing was in place, state direction was commonplace. We’d lost that and it had been replaced with either no regulation or regulation capture – in effect limited regulation.
For a Fellow who lectured in politics, the fact that the NHS was suffering, was a political failure “by the people”. We choose the government we get. There is a lack of general education about the way national choices are made and how politics works. It was important therefore to ensure that schools play a greater role in educating young people about this. Whilst one participant had raised issues of mission creep for the NHS, the meeting also heard from a former medical director in the NHS who said he and colleagues had tried to research housing and smoking in the North West to try to address the issues but had found that the funding was pulled. He’d also suggested having fewer licences for takeaway outlets but this had been roundly rejected by the local council. He left the NHS soon after. How far should the NHS use its resources to prevent ill health when others fail to do so?
Summing up Nason picked up the football analogy again to say that one of the roles of the NHS was to shout like a goalkeeper at the other players, telling them where they needed to be and what needed to be done. There was clearly support for greater regulation among the public and this needed to be pushed if the NHS was to thrive in its environment.
Becks felt that more honest conversations needed to be had. Maybe part of improving public satisfaction with the NHS was to have a better collective understanding of what it was and what it was not. If we viewed the Secretary of State as the goalkeeper and other government departments as the players, perhaps the SoS needed to start ‘shouting’ at the rest for a proper cross-government effort – particularly in tackling the social and commercial drivers of ill health.
Kevin summarised by noting that his local health system spent £600 million a year on just 9,000 patients needing continuing healthcare and that this was growing by 5 to 7 per cent each year. Large numbers of people were costing £250,000 a year and quite a large number, £1 million a year. He questioned whether this was affordable. Likewise, 33% of their in-patients were elderly people who did not need to be in hospital. Should NHS money be spent this way?
Fiona thanked the three speakers and participants for an interesting discussion, adding that if she were still the BMJ’s editor she would be commissioning the main speakers for an article about what the NHS is and what needs to happen to make it sustainable for the future.
Biographies
Moderator – Fiona Godlee (HF 1994-5) is a medical editor, writer and campaigner. She was Editor in Chief of The BMJ from 2005 to 2021 and now works to highlight the links between public health, climate change and nature recovery. Fiona has written on a wide range of subjects. She holds fellowships with the Royal College of Physicians and the Academy of Medical Sciences and is a Trustee of the Eden Project. She helped to establish and is an ambassador for the UK Health Alliance on Climate Change.
Speakers
Becks Fisher (HF 2022-23) is Director of Research and Policy at the Nuffield Trust. Previously Becks was a senior policy fellow at the Health Foundation, where she led the organisation’s primary care portfolio. She is also a salaried GP in a deprived urban area and is co-founder of Next Generation GP – a national leadership programme for early-career GPs.
Kevin Lavery (HF 1994-5) has been CEO of NHS Lancashire and South Cumbria Integrated Care Board since March 2022. Before this, Kevin had worked as CEO for the City of Wellington in New Zealand, and CEO in Newcastle upon Tyne and Cornwall Councils, gaining extensive experience of working with deprived communities, regeneration initiatives, child protection, adult social care and public health. A former consultant with Price Waterhouse, he was CEO of technology firms Agilisys and Serco Solutions, and Enterprise PLC which was headquartered in Leyland.
Nason Maani (HF 2019-20) lectures on inequalities and global policy at the University of Edinburgh. His research centres on the structural and commercial determinants of health and how they shape public understanding and policy. He is the deputy director of the local health and global profits theme within Population Health Improvement UK, a UKRI-funded initiative that enables multi-disciplinary research to improve health and reduce health inequalities. He is the lead editor of the Oxford University Press book “Commercial Determinants of Health and is host of the podcast “Money, Power, Health”.
Report prepared by Nick Pearson of Pearson and Pearson (communications) Ltd
Source of Football Analogy –
https://www.bmj.com/content/bmj/379/bmj.o2953.full.pdf
https://academic.oup.com/book/36759/chapter/321866437
Photo of Goalkeeper is licensed under the terms of the cc-by-sa-2.0.