Talking about the NHS

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Having spent a whole day at an event talking about the NHS yesterday I think it appropriate to summarise what I learnt. What follows is not scientific. It cannot be complete. It is my impression from a day of discussion. And it is, of course, biased by my own preconceptions. The discussion is, of course, on the NHS in England. Scotland and Wales are not suffering all the problems referred to. I am not sure about Northern Ireland: it got almost no mention.

  • Where we are
    • The NHS is under funded.
    • In cash terms budgets have increased but by rates far lower than population, demand and medical inflation requires, delivering an effective cut in capacity to meet need which is having a severe impact on a system where there was very limited excess capacity.
    • Social care has come out of this particularly badly.
    • Integrating social and health care will be hard because of differing payment models.
    • Holistic approaches to issues are but distant memories.
    • Super-specialisation may be leading to over medicalisation and excess treatment on occasion.
    • Generalism is now an undervalued discipline. Nurse led systems may help restore balance on occasion.
    • No one has a clue who is in charge in much if the NHS Ministers are reduced to campaigning for reform in the system for which they are no longer responsible. There is no co-ordinated planning because no one knows who can do it and no one knows who picks up the cost.
    • Despite this health and social care employs more than 3 million people: about 1.5 million in the NHS and the rest in social care. Many are on low pay. Increasing numbers work in outsourced posts.
    • Despite the claim that privatisation is not happening increasing numbers of contracts are being given to private providers. This does, however, remain a minority of service supply and is rarely in the most complex areas.
    • Back door privatisation, for example via the Naylor Report, is, however, possible.
    • Staff morale is very low.
    • There is a recruitment crisis.
    • There is a pay crisis.
    • Patient satisfaction remains incredibly high despite this.
    • There is fear of another NHS reorganisation: on average organisation structures in the NHS are lasting less than five years: many cancer patients have significantly better survival chances.
  • What politicians say
    • The NHS is in crisis.
    • All politicians think they have the solution.
    • According to the Tories (and in English politics they really matter) this solution quite emphatically does not involve privatisation, but then they quite emphatically said there would be no top down reorganisation of the NHS in 2010 and then delivered the biggest and worst one there has ever been in 2012.
    • In general, an assurance from a politician is not treated as of value.
  • What think tanks say
    • There appears to be little confidence in the medical think tanks. The Nuffield Trust did appear at the event whilst others were more notable by their absence.
    • The think tanks that were felt to be timid, too pro-market, too uncritical of ministers before the event, especially in 2012 and lacking backbone and vision in general.
    • I think there was a feeling that many felt the medical Royal Colleges had shown some similar traits. In their defence it was said that they had immense difficulty appearing apolitical as required by their charitable status but there remained a feeling that they were reactive, and too slowly, and that the medical profession had not been willing to deliver an alternative vision for the NHS that might solve the problems many could diagnose.
  • What the medical profession says
    • That it's tough at the front line.
    • They are not driven by money but need to be paid.
    • Many are concerned junior staff are being underpaid,
    • Almost everyone in the NHS could find alternative employment involving fewer body fluid discharges that many in other professions would find unsettling.
    • There was an over-arching theme of getting back to a past where there was a clear NHS management structure from a minister downwards. There is now just a sense of hopeless, unco-ordinated drift.
  • What I said (for what it's worth)
    • See here.
    • I added in discussion:
      • The current confusion is deliberate: it evidences that the invisible hand is at work.
      • Ministerial absence is deliberate: it is meant to indicate shrinking state control.
      • Uncertainty is deliberate: the system is designed to create the possibility of failure. You are meant to fear it because you will not behave appropriately unless you do.
      • A shortage of funds is deliberate: you cannot fail if you are properly funded.
      • The current NHS crisis is planned and working as anticipated.
  • What Stephen Hawking says
    • A publicly funded and publicly provided health service is the most efficient way of providing health services to all that are free at the point of supply and which do not discriminate on the basis of ability to pay. Private sector involvement distorts this outcome, unavoidably and so is to be resisted. This service will however not be perfect. Seven day a week service would be optimal. The reality may well be that social (i.e. staffing) and cost constraints will prevent this, even if he would like it otherwise. These compromises are necessary. The current direction of travel, which appears to be towards privatisation and more insurance involvement is a threat to the NHS model and universal healthcare as well as efficiency: insurers do not like paying. (I précis, I hope fairly).
  • The legal opinion
    • David Lock QC, who is also a former Labour MP, offered an opinion on the current NHS reform programme reflected in the STP (Sustainability and Transformation Partnership) programme, now well under way. This is my summary of what he said and my not entirely reflect his views.
      • This programme is crippled by the fact it needs legislative backing and the government has neither the the will, the majority or the time for another NHS reform.
      • STPs are meant to take markets out of some aspects of NHS management (although it was pointed out that STPs are designed so that they can be delivered by private companies).
      • Whether it is legal to now take market contracting out of some areas of NHS supply is doubtful: STP programmes may be a potential source of litigation as a result.
      • The STP programme has been under-publicised and needs to be subject to much more analysis. Local authorities have a duty to do this as they are involved and so access to this issue via local councillors should be possible.
      • The STP programme could open up a whole new hornet nest of problems by being done without statutory backing and by creating another layer of reorganisation without necessarily attracting funding to do it, whilst subject to legal risk.
  • Where to go from here
    • It is apparent that people want NHSD reform, with a passion that is rare in much of politics.
    • It was also noted that much of this was specifically focused e.g. on a hospital closure and not on systemic issues that often have much higher health impact e.g. the closure of smoking cessation campaigns and issues to do with preventive medicine in childcare (let alone child poverty). Fox hunting delivers bigger mails bags to MPs than the NHS still does.
    • Campaigns are not co-ordinated.
    • There is no central vision of what is required for a good NHS. We can look back to learn lessons but change only takes place in the future.
  • The challenge
    • Building that vision. At which point I say this blog has been long enough.

For these who prefer this in mind map format (which is how it was written) this is  available as a PDF, here.