Tackle funding, organisation and priorities head on

Is there a case for a government-funded health service in the 21st century? The short answer has to be yes, but current uncertainties around funding, organisation and priorities need to be tackled head on if confidence is to be restored in the public, the healthcare workforce and its observers internationally.

The NHS needs to address several challenges in the next decades: huge demographic changes that are likely to continue for the next 50 years; new "epidemics" relating to complex social changes (in particular, obesity); advances in medical interventions and technologies; and continuing increases in public expectations. Mortality may be declining from some of the big killers, such as heart disease and stroke but, with an ageing population, we are seeing an exponential rise in the need for preventive and curative health services, along with social-care needs that government has failed to tackle in a joined-up fashion. We need skilful mining of governmental and NHS data on the sociodemographic profiles of populations and their change over the next 50 years.

Public expectations are likely to continue to increase, especially as the baby-boomers reach old age. To enable choice, access and quality issues to be addressed effectively, we need health solutions based on robust analyses of population data, and centred on the individual in society.

Prevention is said to be better than cure, yet solutions are thin on the ground in cardiovascular heath, cancer and mental health. In some areas, the broader inequalities in health are worsening. Any government serious about reducing these needs to implement major strategies to tackle the well-known wider determinants of health, such as education and employment, rather than expecting the NHS to reduce inequalities, as is currently the case.

Balancing priorities arising from rapid development of expensive drugs and treatments will be increasingly difficult. The NHS currently responds rather randomly to emerging evidence on drugs, medical devices, and novel technologies. There are incredibly tortuous and lengthy processes to get new drugs and devices into clinical practice, yet novel approaches to minimal-access surgery have pretty low hurdles, diffusion into practice moving often uncontrollably swiftly. There is also a bottleneck blocking good innovative ideas on the ground in the NHS being developed into a product the NHS can use. There are supportive proposals to facilitate innovation in the NHS but the bureaucracy associated with innovation must not be allowed to stifle it.

However, the NHS should not just focus on improving medical technologies but also on putting "patient experience" at the fore, such as making services more accessible or improving communication between patients and professionals.

Ways of improving implementation of evidence into practice for both clinical and service innovations are required - developing more sophisticated financial incentives might facilitate this.

Professor Charles Wolfe is professor of public health and head of the division of health and social care at King's College, London

Professor Naomi Fulop is professor of health policy and director of the King's NIHR patient safety and service quality centre at King's College London

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