A Royal Commission to tackle long-term health

There has been growing speculation that the government is considering plans for a cross-party Royal Commission (a government appointed ad hoc advisory committee for a specified investigatory purpose) to look at future NHS provision. There has been mounting concern about the long-term sustainability of health provision, but is such a commission the right mechanism to broker a cross-party agreement?

Looking back throughout history, Royal Commissions have not always delivered the intended outcomes they were tasked to deliver.

Royal Commissions mixed history

There is a precedent for Commissions looking at health and care services. A Commission on the NHS was established in 1975 by the then Prime Minister, Harold Wilson[1]. Sir Alec Merrison, reporting the Commission’s findings in 1979, highlighted the main concerns were Accident and Emergency waiting times, excessive bureaucracy, layers of management and the breakdown in communication between hospital staff and community services – this all sounds very familiar.

Almost a quarter of a century later, the then Labour Government led by Tony Blair, established a Commission to look at the long-term care of the elderly. The government did not accept any of the recommendations made by the Sutherland Report two years later, although the Commission’s suggested approach to care was used as a model in Scotland.

There’s no other way to put it – Royal Commissions have fallen out of favour. There were 34 between 1946-1977, and only three since then. The only Commission since the turn of the century was almost two decades ago, looking specifically at reform of the House of Lords, publishing a report in 2000.

Deliver real change?

The 24-hour media cycle has seen politicians change tactics, adopting ways that help them find quick answers, create soundbites and obtain media coverage, often to the detriment of finding longer-term viable policy solutions. One of the drawbacks of Commissions is that they are often dependent on the political climate at the time, how sensitive or controversial a topic is and how practical the recommendations are for a government to accept. The trend is that such Commissions are no longer the preferred way of working, particularly for modern day prime ministers who seem to favour smaller, quicker and more narrowly focused inquiries to address issues.[2]

What should be the remit of a Royal Commission?

If the government proceeds with a Commission, its remit is a crucial factor that, if defined clearly, could make the inquiry a success. The Commission will need to think outside the box and embrace change. Here are some potential areas of focus:

• Approaches to integrating health and care;
• a national response to public health issues – to compress morbidity;
• intergenerational fairness – ensuring everyone in society contributes in an appropriate manner and is able to access the healthcare that they need;
• independent living – addressing the built environment and developing digital infrastructure so that both are responsive to age and mobility; and
• enabling a work-life-care balance – looking at people of working age and, in particular, unpaid carers to address the pressures this group faces and make recommendations to improve their mental health and/or overall quality of life.

Cross-party approach to achieve political buy-in

If a Royal Commission is going to succeed it must work hard to achieve cross-party support. One way to do so is to bring together independent and authoritative experts to sit on the Commission. This is no guarantee of success, but it could be a way to distinguish the Commission as an independent voice that is looking to put forward recommendations in the national interest.

Another important factor is the leadership of the Commission. The Chair is usually drawn from the House of Lords, and with such a sensitive and complex policy area to navigate, a no-nonsense negotiator without the baggage of a party whip to conform to will strengthen the cross-party approach – appointing an expert in health policy would obviously be an advantage too. Senior NHS and Local Authority representatives also need to be involved in the process in order to achieve sectoral buy-in.

The ultimate test for Royal Commissions is the extent to which the government of the day is fully committed to the process and keen to pursue the final recommendations. This has always been a major sticking point as governments are not legally obliged to act on a Commission’s findings.

Timing can make all the difference

Royal Commissions can be long-term commitments, taking on average somewhere between 1 and 4 years[3] to deliver their final recommendations. On this basis, there is every possibility that such a Commission might not report until 2022 – the year currently scheduled for the next General Election. This would risk the Commission’s report being used as a political football. If the Commission is going to be workable, it needs to have a shorter timeline with an interim report, followed by final recommendations soon after.

The Prime Minister has not been drawn on the idea of setting up a Commission, but the Secretary of State for Health and Social Care has recently indicated the need for the NHS to have a much longer-term 10-year spending plan. Jeremy Hunt is also seen as one of the driving forces in government for a comprehensive review.

Where are we now – will we see a revival of Royal Commissions?

Critics of Royal Commissions say they cause ‘policy paralysis’ and they fail to deliver workable recommendations. It is argued that we run the risk of more lost years talking about NHS pressures and not actually dealing with them if a Commission goes ahead. It is also the case that political parties are deeply divided over the direction of health policy. One of the current stumbling blocks is the perceived lack of political will in Parliament to see a Commission through on non-partisan lines. Navigating such political tensions would almost certainly be one of the toughest challenges in politics in recent years.

One of the drawbacks of focusing a Commission purely on the NHS is that social care and the challenges to better integrate are forgotten. Given the clear and growing pressures on health and care provision associated with an ageing population, it would be a missed opportunity not to look at how to deliver a joined-up approach. It seems that the only avenue for change is to focus on the government’s adult social care consultation expected this summer as it could be one of the last opportunities in a generation to address future care challenges.