John Oxley: The NHS is there to make you better, but is it there to get you back into work?

John Oxley is a consultant, writer, and broadcaster. His SubStack is Joxley Writes.

Anyone with a sub-optimal approach to home maintenance will know of the WD-40/Gaffa tape heuristic.

If something should move, but won’t, give it the spray. If it shouldn’t move, but is, tape it down. The whole concept is a bodge: it neither fully fixes the problem nor uses these products as intended. But it gets it off your “To do” list for a few months, until it eventually breaks down again.

For the government, it appears a similar approach is emerging, giving problems to the NHS. While you might assume the Health Service is focused on fixing injuries and curing illnesses, that would be naïve. Instead, various governments have expanded their remit to include aspects of ill-health, becoming catch-all social programmes. In some parts of the country, the NHS will, in certain circumstances, deep-clean your house, pay your bus fare to appointments, or even wash your clothes.

Now, ministers are looking to add to this burden by setting NHS Trusts targets around getting people back to work. Under plans announced this week, Trusts will take some of the responsibility for reducing out-of-work benefit claims. Measures will include not just treating conditions that keep people out of work but also providing external support and job coaching. As an initiative, it will place additional responsibilities on the Health Service that should really be picked up elsewhere.

Now, there is some logic here. The NHS should know who is unwell and should be able to have a proper understanding of how their disabilities impact their ability to work. It is sensible to join up elements of government that interact, rather than them becoming siloed and contradictory. Yet the scheme risks further diluting the NHS’s performance, introducing a new layer of bureaucracy, and undermining our democratic choices about how money is spent.

After all, it is hard to ignore the role that funding plays in all of this. NHS funding occupies a special place in our political consciousness. It is almost sacrosanct. Few governments would dare to impose real-term cuts in it. Even during austerity, spending on health was ringfenced, though it increased less than during previous governments. It makes it tempting to stretch the definitions of where that money can be used.

We all know that governments are fiscally constrained. Raising new money through taxation, or reallocating it to different departments, is fraught. Stretching the edges of the NHS budget is politically easier. As a result, more responsibilities that would have fallen to other departments are lumped into the NHS. As local authorities have seen their budgets consumed by social care, other service gaps have been taken on by health.

This starts to feel like a bait-and-switch for voters. People voting for greater health spending envisage it going on, well, health, not a broadening backstop for the rest of the state. It seems especially galling when frontline services are still stretched, with long waiting times and struggling A&E departments. When people say the NHS is important to them, they are thinking about addressing these issues, not using its expanding budget as a catch-all. Voters waiting for a GP appointment or operations might reasonably wonder why the service is being asked to become an employment agency.

There are also questions of accountability. These sums are relatively small in NHS terms and can easily get lost in the overall budget picture. They may not receive the same scrutiny if they were being spent by other arms of the state, with a clearer focus on the objective at hand. Should the NHS fall short in getting people back into work, it is unclear who will bear the blame. It becomes easier to shift it between the DWP, the Treasury, and now health bodies, which have expanded their remit.

This mission creep also risks undermining the competence of public services. Organisations tend to work best when their objectives are clear and stable. The health service already juggles prevention, acute care, chronic disease management and mental health support. Each of these domains is complex and resource-intensive. Loading on extra pastoral responsibilities will draw away both resources and attention. Rather than doing a few things well, the expanding health state is likely to do many things badly.

Every extra thing we ask the health service to do detracts from its core mission. It adds in extra functions, extra people, and new levels of bureaucracy. Often, this ends up duplicating what happens elsewhere in public services, or something that was cut as part of a broader strategic review. Instead of reducing silos, it just increases the number of state functions trying haphazard solutions to a problem, rather than an integrated approach.

It is the sort of thing the Conservatives should be resisting if we are serious about delivering a smaller state. Often, our attempts to reduce government spending have been hampered by a lack of honesty about what “doing less” entails. The result is a state that tries to carry out ever-growing functions, but with less funding and less effectively. Indeed, many of these additional duties for the health service were introduced during our time in government. If we genuinely want the state to be leaner, we should have better ideas about providing limited but more effective interventions.

Like with WD-40 and tape, it is easy to reach for the convenient solution. For politicians, lumping more things into the NHS is a bodge. It allows them to skirt some of the tightness in public spending and shift more things onto the part of the state allowed to expand. If continued, the NHS becomes a catch-all solution for every problem. Rather than properly deploying other bits of the public sector and working out how to have them operate effectively, we shoehorn extra things into health. To butcher a famous phrase, we cannot successfully roll back the frontiers of the state to see them reimposed through the health service.

A system that routes every difficult question through the NHS is not integrating government; it is shirking harder decisions about how the rest of it should function. If employment support is underpowered, it should be strengthened. If local authorities are overwhelmed, that should be confronted openly. Continually expanding the health service’s remit may be politically convenient, but convenience is not reform. WD-40 quietens the hinge for a while. It does not fix the door. And sooner or later, the door still needs to be repaired.

The government is right to be concerned about worklessness.

Equally, there is nothing wrong with thinking about how health impacts the economy. Making the health service the actor of last resort for every social problem, however, is a misuse of its political capital.

Services are best when they are focused – not when they are trying to do everything.