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.
- 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.
- 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.
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The NHS is invaluable, but we miss the bigger picture, if the NHS was fully staffed and had the state of the art equipment/drugs, there is still a underlying problem, millions of people with a poor diet who don’t exercise.
We need to improve the nutrition and exercise elements, keeping people healthier is far more cost effective.
Preventive education is part of the NHS
And needs to be a bigger part of the NHS. I remember Lord Coe saying he was against Sport For All initiative, until he understood it improved the general health of people.
Until we invest more in better nutrition advice, and prepared to make sure people can access leisure activities, the debate over NHS funding is sterile.
Thank you Richard – I’m using the NHS at the moment and can attest to some of these issues by what I’ve seen and the general feeling I get. For the Tories to wash their hands of a service that was created by Government in the first place is just another act of Tory vandalism on democracy and society.
My view is that we seeing a typical British way of manufacturing consent to change things (or shall we say ‘bring the market into play’?). I think Theresa and Co want the NHS to wither on the thine.
The simple fact that if (1) there was more intervention and encouragement about diet and exercise (lower sugar in food/better PE in schools to name but a few) allied to (2) proper funding (which we know any British Government can do if it wants to) and a stronger policy link between the two, we’d have the sustainable solution we need.
Thank you once again for your summary that is measured and well reasoned.
Richard
You know as accountants, we suspect there are too many managers and not enough front line staff
Did you get any feedback on this – are there areas where management could be trimmed/made more efficient/productive with any savings being ploughed back in to front line staff?
Get rid of the internal market
I am not saying KPIs are not needed, but they are clinical, and not financial
FlipchartRick ran the numbers of NHS staff:
https://flipchartfairytales.wordpress.com/2014/01/15/is-the-nhs-really-over-managed/
Rick was spot on. It’s always an easy, and lazy, accusation to throw at the NHS and comes from the left and right. The NHS is highly complex in terms of management and logistics and that requires a distinct set of skills which you dont get at medical school. That’s not to say that everything should be compartmentalised but scarce, valuable, trained-medic time is probably better spent dealing with patients’ medical problems. The idea that one can cut the people who make sure that the patients are there, supplies are in place, facilities are available and so on, and that the medics can do it all in their spare time is faintly ludicrous. It’s also destructive to the NHS. Arguably it needs top grade, operational managers and there may well not be enough of them in the NHS.
Its a different context, but I’ve seen the massive difference made to health programmes in Africa when a bit of professional logistics management was added to the mix, where previously there were just medics and development workers.
As an aside, Roy Lilley’s blog on the NHS always seems pretty pragmatic and realistic. Though I’ll defer to Pilgrim’s experience …
Annual grants are increasing but so is total debt.
The only way to ensure liquidity in many trusts is to increase the size of the Revenue Support and Capital Loans from the sponsor Department.
Trustees must then decide whether to set budgets at a level that would generate a surplus thus enabling debt to be repaid from retained liquidity. Given the increase in demand for NHS services such budgets would be unrealistic. If set they will be exceeded; if budgets are set at break even they will be exceeded.
The reality is that indebtedness will accumulate to absurd levels at the same time that staffing cost pressures are being artificially suppressed.
Trustees cannot therefore operate a Reserve Policy strategy in line with the Charity SORP.
Surely the Tories and Austerity (Media) economics have reached the end of the road.
What this proves Keith is that the model is simply wrong and creates perverse and wholly inappropriate behaviour
Trusts are not independent units requiring their own capital: they should be part of a single NHS allocated capital to suit their needs
And of course that brilliant creation ( and billionaire maker) PFI is in the mix.
Where were the accountants when the decisions to use PFI were made?
https://flipchartfairytales.wordpress.com/?s=NHS
http://www.independent.co.uk/news/health/nhs-hospitals-private-tax-breaks-business-rates-hikes-charitable-status-discounts-jeremy-hunt-a7903926.html
Noted
Maybe a bit irrelevant but the remark about think tanks caught my eye, as it’s occupied my mind a fair bit recently.
My experience of think tanks is that they exercise a self-denying ordinance to operate within the Overton window: either to give voice to ideas for minor or administrative change, or to explore how existing policies could be delivered, however crazy they are. Most of the people within them are gamekeepers turned poachers – they’ve been in the Treasury or the Cabinet Office at some point in their careers. Their operating model depends upon influence within government, and that in turn depends on sticking to ‘thinkable thoughts’. I would not go as far as to say that they’re useless but it is certainly true that, collectively, they lack vision.
A Special Purpose Vehicle (SPV) which are necessary for the PFI ‘deals’ is now being integrated into partnership with a NHS Hospital Trust.
The Northumbria Foundation Group has set up a “Strategic Partnership” with Ribira Salud in 2016. Ribera Salud is the Spanish public/private partnership (or Accountable Care Organisation) that pioneered a form of Private Finance Initiative that covers not just buildings but “integrated” health care delivered by hospitals, GPs and community services for the whole population in designated areas.
https://calderdaleandkirklees999callforthenhs.wordpress.com/2017/08/18/weird-goings-on-in-northumberland-tyne-and-wear-sustainability-and-transformation-partnership/
Although they have proved to be very bad value for money, the Calderdale and Huddersfield NHS Trust(CHFT) has been told it has to have a PFI arrangement for any new Urgent Care Centre it needs, following the closure of Huddersfield Royal Infirmary (HRI).
https://calderdaleandkirklees999callforthenhs.wordpress.com/2017/08/01/calderdale-and-huddersfield-hospitals-estate-plan-is-it-a-scam-to-profit-the-pfi-companies/
http://peoplevspfi.org.uk/2017/08/17/queen-elizabeth-hospital-woolwich-hospital-mergers-do-not-solve-pfi-problems/
Thank you for this excellent summary. (Why is it so rare to get this quality of information from newspapers? And this is actually part of the problem … it seems that the media have long given up on scrutiny and information.)
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