The Minister for the Future is a different kind of governing politician. Armed with the power and authority to look beyond electoral cycles and to break free of departmental silos, the minister is judged on a single criterion: an ability to deliver game-changing ideas.
The Minister for the Future is not yet a cabinet regular. It remains an abstract notion conceived by Prospect and Nesta, the project’s sponsor, and is designed to be the perfect vehicle for debating and thinking about long-term ideas. In this fourth and final debate, healthcare occupied the agenda. The proposer: Dame Sally Davies, UK Special Envoy on Antimicrobial Resistance and former Chief Medical Officer for England. The proposition: the establishment of a National Health Bank designed to protect the country’s most vital asset – the health of its population.
Putting life into life expectancy
“I’m not here to talk about our national sickness service, the NHS,” said Dame Sally, by way of setting out the context for her proposition. “I’m here to talk about our health, an asset in which we should be investing.” A National Health Bank, she said, would not act as a savings bank but would rather be an institution with powers of investment and oversight.
Why is it necessary? For two reasons.
First, because health is not only essential to our individual “wellbeing and contentment but it’s also vital for the strength of the UK economy,” argued Dame Sally. “Ill health harms our productivity, decreases our tax take, increases public health expenditure.” Good health, by contrast, strengthens society and strengthens the economy.
Second and related, some indicators suggest things are getting worse, not better. Moreover, the UK is emerging as an outlier. “Last century we had the greatest increase in life expectancy and health due to slum clearance, the Clean Air Act, tobacco control, child immunisation, better food,” noted Dame Sally. “But healthy life expectancy didn’t keep up. And healthy is what really matters. Today people live longer in poor health than they did in the 1990s. So how do we, in this century, shift that unhealthy lifetime and make it shorter? We need to put life into life expectancy.”
Consider some practical indicators. From a productivity perspective, health inequalities could explain up to one third of the difference between the North of England and the rest of England. From a public finance perspective, worse overall health increases NHS, social care and welfare spending. From a labour market perspective, 500,000 more people are reporting sickness as the primary reason for their economic inactivity compared to 2019. And from an income perspective, research has linked the onset of a new health condition to an average loss of earned income of £2,200.
Inspiration, willingness, and funding
Dame Sally’s idea takes its inspiration from two sources. First, and most obvious, is the Bank of England, given independence a quarter of a century ago. For independent financial and monetary committees with the power to set capital requirements and interest rates, she suggests a National Health Bank with a policy committee seeking a return on investment of health interventions over time. Notably, this would be a 15-to-30 year timescale rather than an electoral time scale of two-to-five years. The Prudential Regulation Authority provides a model, too, in its supervision and stress-testing role. The application of data would, in turn, be key to both the National Health Bank’s monitoring and investment roles.
Second, she is inspired by the Climate Change Act which has allowed the UK to focus minds on an overarching environmental goal: net zero carbon emissions by 2050. For net zero, Dame Sally suggests we should aim to become the healthiest country in the world within the next 30 years. “We know what works,” she says. “But what we have a problem with is willingness.”
In terms of practicalities, Dame Sally says the bank’s funding would come from three sources: from the public by way of a flat, ringfenced 1 percent inheritance tax; from employers; and from companies that create harms, following a “polluter pays” model. As for timescales, Dame Sally offered a bullish assessment. “If you were really minded to do it, you could get it going in a couple of years.”
The danger of regulatory capture
Following the proposition, three health experts offered their own assessment. All were broadly supportive but each had their own reservations. First up, Dame Carol Propper–Professor of Economics at Imperial College Business School in the Department of Economics and Public Policy–expressed concern that the ambition might be too great. “I don’t think putting spending and regulation together is a good idea,” she said. “You end up with what economists call regulator capture–big lobbies lobbying the regulator to do what they want. And one of the big lobbies is the NHS.” Housing quality and targets were among the contentious issues the Bank would be likely to encounter.
Dame Carol had a second reservation–the introduction of a ringfenced, or hypothecated, tax. There are two problems with this approach, she said. Firstly, people are “very happy to hypothecate their taxes when it’s something they care about” but not when it’s earmarked for something unpopular. Secondly, guaranteed revenue in one policy area is likely to mean less spending power elsewhere.
The fictions of accountability
Martin McKee, Professor of European Public Health at the London School of Hygiene and Tropical Medicine, shared Dame Carol’s reservations about hypothecation. He argued that an upsurge in health issues tends to run counter to economic growth. “So at a time when you need money, revenue is falling.”
Professor McKee offered two other challenges to the proposition. First, he questioned whether investment was absolutely necessary for much of what Dame Sally wants to achieve. For example, he said, a polluter pays model doesn’t require investment. Rather, it needs regulation. Second, he worried about “fictions” of accountability, suggesting that most public bodies are not accountable to anybody. Before introducing another regulatory body, he said, we first need to sort out our constitutional settlement. “We have a crisis of governance.”
The need for public engagement
Dr Victoria Betton – a social worker by trade and practitioner of people-centred design–offered two further challenges to the proposition. First, she expressed concern about the centralising effect of a National Health Bank. “I’m very worried about any money going anywhere national when everything is on fire at a local level,” she said. “If I had to choose where the money went, I’d want it to go where it can help localities thrive.”
Data provided a second concern. While she was in no doubt about the effectiveness of high-quality metrics to inform better decision-making, she reflected “huge public concerns about the secondary use of data”. For such a project to work, she said, necessitates a wider consensus. “It requires public deliberation and public engagement.”
Responding to the expert pushback, Dame Sally said she was willing to take many of the ideas on board. However, she remained convinced that her central mission was sound. Namely, to create something that is “sufficiently disruptive that it stands a chance of having an impact. We do need some disruption to move away from the sickness paradigm.”
The verdict
After the discussion, the decision. It was up to the Minister for the Future, in the guise of the Prospect audience, in person and online, to choose one of three options. Option one–support the adoption of a National Health Bank by 2040–won the day with 52 percent of the votes. Option two–expedite the adoption of a National Health Bank aiming to achieve its objective by 2030–gained 35 percent of votes. A third option–to explore alternative approaches to the challenge–was supported by 13 percent.
Dame Sally’s proposal, if not in its most radical form, prevailed.
‘Healthcare in a modern age: why we need a National Health Bank’ – the fourth in a series of Prospect/Nesta ‘Minister for the Future’ debates – took place on 28 November 2023. It was introduced by Alexandra Burns, director of discovery at Nesta, and hosted by Prospect editor Alan Rusbridger.
