We need to talk about the NHS but our political culture prevents it.

Many Britons complain that political correctness stops important issues being talked about. By that they usually mean immigration and cultural integration. Now we talk about these things all the time, and we are coming to understand why that culture of political correctness was a good idea. Pointless, nasty behaviour to immigrants and people from ethnic minorities is on the rise, while yet more rubble is strewn in the path of necessary economic development. But there are issues that are important but where there is a conspiracy of silence. Foremost amongst these is Britain’s National Health Service (NHS). This is not a good idea.

Well it isn’t that politicians don’t talk about the NHS. It has become a central theme of Labour’s election campaign, and the Green party, in their bid to harvest left-leaning voters, have jumped in too. But these campaigns challenge the very idea that the NHS should be reformed. Any suggestion that elements of the NHS should be run by private businesses, or that a local facility should be closed, is attacked virulently. The idea behind these campaigns is that the NHS is under attack, is being “sold off”, and needs to saved by a government that will let our heroic doctors, nurses and ambulancemen get on with their jobs unmolested by rapacious hedge fund managers and bankers. The government’s response to these challenges is distinctly muted – they try to deny that much is changing at all, and point out that they are recruiting more these wonderful doctors and nurses and keeping the money flowing.

But senior NHS professionals are worried. Today it is the turn of Professor Sir Bruce Keogh, NHS England’s medical director, to speak out. He warns that without major changes to the way care is carried out the service will collapse. That means that many existing facilities will have to be cut in order to make room for more cost-effective ways of treating illness which do not involve big hospitals. You don’t have accept Sir Bruce’s prescription to understand the nature of the threat.

The first problem is demographics. The proportion of elderly people in Britain is on the rise. This is increasing the number of patients, and presenting the service with more complex cases that it is difficult to deal with adequately. It is also undermining the tax base from which the NHS is funded and the pool of workers that the NHS needs to recruit. The next problem is a change to the economics. More advanced and effective treatments cost more money. Rates of pay, especially for skilled staff, are getting higher.

These problems are well understood, even if politicians and public alike would rather talk about their implications another day. There is a third problem too. And that is management. Dealing with health issues is a very complex matter, and it is becoming clearer that the way we try to go about it isn’t really helping. Our default method is to break the task down into a series of specialisms and give each a separate autonomous organisation. Primary care is split from acute hospitals which are separate from social care, with mental health handled by yet another set of organisations. But all these things interrelate, and good patient care depends on getting the coordination right. For example the current NHS crisis in hospitals is presented as overflow in Accident & Emergency, but it has its roots in the inability to move older patients into more appropriate social care settings when the acute phase of their illness is over.

I am very familiar with this type of management problem, albeit in much simpler contexts. It was the focus in the 1990s of a management revolution that went under the name of Business Process Reengineering.  The key insight here is that one of the main obstacles is the shape of the organisation itself. Pouring more resources into it won’t help, or not help by much. If you fix a problem in one area, it simply pops up in another. That means that the shape and structure of health care has to change in order to cope with the extra pressures being thrown at it.  That in turn means politically sensitive closures and, almost certainly moves that can be described as sell-offs. It is worth pointing out, though, that simply outsourcing an element of the service without restructuring the way care is delivered is just as fallacious as pouring extra funds into existing structures. This is a point that some on the right, and in government, have not grasped.

I think this is reasonably clear; there may even be consensus about it amongst those that try to look beyond the short-term politics. But the fog then starts to descend. The problem is highly complicated, and the costs to failure very high. The way forward is not obvious. Both this government and the preceding Labour one grappled with it. Both got some things right; both have made mistakes. But it is a debate amongst a small elite of policy wonks and senior professionals, when broader engagement, to prepare  the political ground, is what is required.

Is the basic model of the NHS under threat? This is an open-ended commitment by the taxpayer to fund health care for all citizens. This has some obvious problems – there is no clear way to limit demand. Health care, it turns out, is not like the drains, where once you have fixed the basics, people forget they are there. That was what some people thought when the NHS was set up. People don’t like getting ill, so, said the optimists, that would limit demand. Alas longer life and reduced pain are consumer propositions to die for; potential demand seems endless.

This is the key to a further insight which few seem to have grasped. People often talk of high levels of health care spending being unaffordable. This is untrue. People prize healthcare above many other things, and are happy to give up these other things for less pain and a longer life. You only have to look at the enormous sums spent in the USA on health care to understand that. The problem is how, exactly, do you get the money from people’s pockets and into that of health service providers. The critical question for the future of the NHS is how much more can be raised through taxation.

Which is another area that we should all be thinking about. Could we raise a lot more through taxes if the process was more transparent and people had more confidence in it? Or should the NHS start charging for more things? Should we develop a model of “basic cover” vs “luxury cover”, and bill for the latter? And what could the latter include (anti-cancer drugs that might prolong life but aren’t deemed cost effective?). And that leads to another series of questions we would rather not ask, about the meaning of life and death.

And there’s a further problem. How much do we focus resources on where the demand is currently, or and how much to where we think the areas of greatest need are. The last government talked often of rectifying “health inequalities”, and started a process of shifting resources to poorer areas with worse health outcomes. That put facilities in areas with high current demand, but less actual poverty, under pressure. Most of the NHS’s big disasters, like the failure of Mid-Staffordshire Trust, occurred in areas that had high demand, especially from elderly residents, but which were not classed as being in poverty.

If we don’t fix the NHS, a parallel private health system will build up beside it and undermine it. Something like this has already happened with dentistry. We have little chance of a serious, mature political discussion this side of a General Election. But the sooner that the public demands their politicians address such issues the better. Rejecting the facile slogans of Labour and the Greens would be a good start.

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One thought on “We need to talk about the NHS but our political culture prevents it.”

  1. Some further problems:
    The causes of ill health are, to a considerable extent, problems which are not about the delivery of illness services. Bad housing, unemployment, air quality, poverty, the stresses which make it difficult to stop smoking or eat in a healthy way, inadequate heating at home…………………….these are all the “Social Determinants of Health” (Michael Marmot’s reports on the UK for the government and for the WHO globally). It follows that substantial reductions in local government spending (explicitly in order to ring-fence NHS spending as well as reducing the deficit) will increase ill-health amongst the poorest. Another key feature of bad health is a lack of control over one’s own life – the more you are in charge, the healthier you are.
    The NHS is one of the world’s largest bureaucracies and, like the others, it has immense political significance. Aneurism Bevan talked about “every dropped bedpan reverbarating around the corridors of Westminster”. Unfortunately, there is no way of preventing that as long as we have a single national structure, free at the point of delivery, financed from general taxation, a horror of local difference and innovation, and with national politicians necessarily at the head of it. It also means that the power of organised professional groups is immense: the BMA is a trade union, dedicated to improving its members income and using a spurious claim to be primarily concerned about patient health in order to bolster its claims. It undermines real accountability (as distinct from occasional scapegoats) – see my failure as Chair of the Department of Health’s Nutrition Delivery Board to improve practice in any significant way. I also note that the appallingly bad practice of “do not resuscitate” notices without consultation are creeping back. I also note the fast declining quality of primary care interfaces with patients in many areas.
    Comparisons with other systems tend to be one of two: nineteenth-century Britain and the US’s vastly expensive system which is very bad for poor people. What about the rest of the world, particularly the developed world – looking at them does suggest that there are better ways of improving health, managing total costs and reducing health poverty.
    If Wales can run its own health service, why not Yorkshire?

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