Senior Audit Manager Natalie Low gives an NAO perspective on the NHS as it turns 75. What has many decades of the NAO auditing one of the largest employers in the world revealed?

The NHS turns 75 on 5 July, an amazing milestone. Our role as the financial auditor of central government pre-dates even the NHS, so we – and our predecessor the Exchequer and Audit Department – have audited every set of accounts for the Department of Health & Social Care and NHS England (and their predecessors). Since the National Audit Act 1983, we have also used our powers to carry out value for money examinations to look at many different aspects of the NHS.

The NHS is a complex entity. It is not one single body, but national bodies, principally NHS England, working alongside hundreds of local NHS bodies and trusts, GPs and other healthcare providers.

Although we do not audit those local bodies, getting the perspective of local clinicians, managers, staff and service users, through interviews, surveys and case study visits, is a critical part of our work.

So how do we go about auditing such a complex and critical system? A content analysis of the titles of our reports on the NHS since 1983 provides some clues.

A word cloud. The largest words are care, management, hospital, progress, improving and social.
A word cloud of titles of NAO reports on the NHS

To start with, care is literally at the heart of our work, a fitting reflection of the fact that the NHS is primarily about people giving care to people.

Through our work, we aim to assess and report on whether and how the NHS provides the care that people need as effectively, efficiently and economically as possible, and highlight any barriers and facilitators to doing that.

Our independence and statutory access mean that we are uniquely positioned to see and report on the inside of the NHS and the Department of Health & Social Care. Other bodies like the Care Quality Commission will cover important issues like clinical safety and quality. By contrast, our focus is on system performance and finance, and how the NHS is progressing against its own plans and ambitions.

No surprise then that our reports often refer to finances, sustainability, performance, progress, improving, systems, management and contracts. For example, our series of reports of financial sustainability from 2012 – 2020 drew attention to challenges such as the impact of short-term funding settlements on workforce, public health and capital spend.

The breadth of the NHS means that many of our audits have to focus on particular types of service. Our very first value for money report on the NHS in 1984 actually covered dental services, when the health department was grappling with the – maybe now unfamiliar – issue of how to restrict growth in dentist numbers, alongside more familiar issues such as reducing variation in availability of services across different areas.

We have gone on to look in depth at many aspects of hospital services and acute care, alongside reports on ambulance and primary care services.

Since 2011, we have increasingly covered the important area of mental health services, most recently in February of this year. Another way of looking at NHS performance is through the lens of a particular condition. We have most often done specific audits on cancer services, but other examples include our studies on services for diabetes, obesity, neurological conditions, stroke and dementia.

The COVID pandemic dominates our more recent work, reflecting both the central role of NHS during the pandemic and the rapid studies we did to provide scrutiny and transparency during that time. In our final COVID-related report on the NHS, we looked at the vaccination programme and concluded that it had provided value for money during the pandemic. A rare but merited case of the NAO giving praise.

From my own experience on the Health value for money team, I know that staffing issues are an important and enduring factor in our work. While we have done relatively few reports that are exclusively about staff and workforce-related issues, nearly all touch on those issues in some way. I have also realised, however, that many of our early reports looked at something called “manpower” – not how we would describe NHS staffing nowadays!

As we look forward to future years of the NHS, and how we will audit these, we come back to some current and enduring themes: for example, waiting times, sustainability, access, performance, staff.

The relationship between health and social care is a fairly recent focus for our work, which will only increase in importance. I would expect digital and IT issues to feature larger, building on the reports we’ve done on the previous national programme for IT and digital transformation, and maybe terms like technology and AI will appear too.

Whatever other terms may come and go, I know that care will remain central – to us and to the bodies we audit. Happy birthday, NHS.

Explore our reports on the NHS

Natalie Low

Natalie is a Senior Audit Manager in our Health (Value for Money) team.