The NHS crisis has produced a strange consensus. From the Daily Mail to the FT via the Guardian there appears to be agreement that a wise government would agree now that the health service is under-funded.
This consensus appears to be based on three ideas, even if they are not explicitly stated. The first is that those in the health services are genuinely doing their best with the resources available to them. There appears to be an acceptance that the capacity for savings is being reached within the current organisation structure.
Second, although that not stated explicitly as yet in most cases, clear doubts about that structure are emerging. A system that fractures responsibility into as many different areas as seems to be conceivably possible with no budget or care responsibiluty that demands congruence of objectives for overall patient care has led to ambulances being used as A&E waiting rooms because ambulances are run by different organisations to hospitals and patients being forced to stay in hospital by social care organisations unable to cope within their own massively constrained budgets. A structure better designed to fail is hard to imagine.
Third, it is obviously agreed that the people of the UK expect and deserve better than this.
These ideas are, however, indication of other new strands of thinking, even better hidden as yet within the conciousness that recognises there is an NHS crisis but which has yet to come to terms with what it means. Again I suggest there are at least three.
First, there is an acceptance that public servants can and do work incredibly hard to the limits of human efficiency in organisations where profit is not the motive for action.
Second, it is apparent that marketisation hinders their chances of succeeding in supplying the service the public need in these cases.
And third, there are absolute limits to public tolerance for austerity politics and the NHS crisis is the point where that is being realised.
I suspect those around the prime minister are amongst the few who truly appreciate these points. Attacking an individual, Simon Stevens, is their response to the first. The implication is there is nothing wrong with the team and it is the manager at fault. It seems very likely that this argument has run out of mileage and that, rather surprisingly, Simon Stevens not only knows this but intends to ride out the storm. I hope he does.
That said, the reason why the outright denial of the crisis is so clear from Number 10 is implicit in my second and third points. It's not just they would have to admit Lansley and Osborne were both fundamentally wrong by agreeing to these arguments: I doubt May would have any difficulty doing that. The issue is bigger than these two failed men: the ideas associated with them,which are now so obviously creating the current crisis, are core to Tory belief. If markets can't make the NHS work then the state does, after all, have a purpose. And in that case cutting tax may be destructive. If those last two sentences are true the whole reason for a Tory government is at an end.
Those two realisations are at the heart of May's denial of an NHS crisis and she has virtually no choice if all she and her party stand for are to continue to carry weight but carry on suggesting that the NHS crisis is indeed the fault of those who are not true believers in the failed ideology that is at the heart of it (hence the treatment of Simon Stevens).
The difficulty for May is, however, that Simon Stevens is a proxy for all those whose pragmatism, empathy and outright concern about very obvious NHS failure over-rides any ideological faith in small state, market driven solutions to any known problem, which in practice means most of us. Dogma in the face of corridor deaths is deeply unattractive. With a functioning opposition it could be all but politically fatal. Even with Corbyn in place public pressure alone might force a choice from May. Will she decide to declare an end to austerity, or not? And will she concede that NHS reorganisation has, yet again, to be on the cards? If not she will lose the public for good, I think.
It's always events that expose a government's faults. Few events come bigger than a health service melt down. Right now there is no sign May knows what to do about it. And that means it may not be Brexit that will be the undoing of her. Something even closer to people's hearts may be.
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May faces a double hit from the NHS funding failure: backlash when patients die on trolleys; and another backlash when the quick fix – a nine-figure cash topup for staff numbers – is greeted by no immediate improvement…
…And headlines about prominent members of the Conservative Party pocketing enormous profits from their financial interests in medical staffing agencies.
Her instinct is to sit tight and wait for the winter rush to go away: and we know something about the figures that she doesn’t, because I doubt that mrs May read yesterday’s Tax Research blog.
My partner was at CALOW hospital in Chesterfield with her Mum yesterday and she said that the hospital was ‘packed’ (hers was a pre-arranged appointment).
You make some really salient points here about the denial mechanism at work in this stupid Tory administration – nice work (as always).
I think that you speak the truth. The problem is that the Tory friendly media will produce enough hot air for May’s ideological blindness to keep going and float on regardless and the people will continue to sup it up.
You may well be right
But things can’t last forever if things are really wrong: this crisis did not happen at peak time. It is ongoing. And people will realise that
As so often Richard, you sum up the situation beautifully. This crisis is solely the fault of the right wing nonsense pursued by the Tories (albeit in coalition from 2010 to 2015) for the last 6 years. And as you say, rather than admit that austerity and ‘private good, public bad’ is wrong, they’ll look to blame anything and anyone for a situation they created.
I’d love to believe that this NHS crisis will force them to finally admit they’re wrong, or even better, destroy them as a government; that would prove there’s some justice in this world. Perhaps you’re right; maybe there’s only so long the right and their allies in the press can blame a failing NHS on ‘health tourism’ or people not ‘standing on their own two feet’ blah, blah, blah.
Perhaps if enough Daily Mail readers die on hospital trolleys ………..
I do share your optimism but these Tories are literally getting away with murder in my view – the murder of the NHS and the responsibility of people dying because the service cannot cope.
In the meantime we have to put up with this so-called expert from the Guardian of all places:
https://www.theguardian.com/healthcare-network/2017/jan/13/nhs-crisis-more-money-linked-reform
All I see here is unquestioning adherence to to some dodgy thinking that is destroying jobs and depersonalising services because it ignores the fact that the reason they cannot be afforded is because the Government refuses to pay for them.
In a supposedly Left wing newspaper!! Please tell me – have I got this wrong?
I note that Vize’s bio lists his interests as ‘independent travel, photography, and contemporary history’.
If so, I wish he’d go away and write about these instead of writing woolly nonsense about a subject I do not really think he is interested in at all.
For many years there has been talk of co-ordinating health and social services. I know about this as a social worker who has spent decades working alongside health colleagues in multi-disciplinary teams. One problem goes back as far as 1948, a critical date in the founding of the postwar welfare state.
Health practitioners are accountable to the central or devolved government and funding comes from that government. Some charges apply but most services are “free at the point of delivery”.
Local government employees are accountable to local councillors. The funding is mixed and includes council tax (unpopular!), central or devolved government grants, and also charges. Many local government services are means-tested and have been since 1948.
Series of politicians have urged services to work together – and to a large extent they do. But in my opinion the issue of the different funding streams and lines of accountability needs to be addressed. Social care and social work have their own ethos (more a social than a medical model) and they should not be seen merely as an adjunct to health care. These professionalisms need to be recognised, just as much as occupational therapy, physiotherapy, clinical psychology, general and psychiatric nursing and medicine and surgery (etc).
At least the structure is somewhat simpler in Wales (where I live), as the internal market in health has been abolished, and health boards both commission services and provide most of them themselves.
Let’s guard against ill-thought out re-organisation, anywhere.
The Welsh model would do for me
If Daily Mail readers die on trolleys, they’ll blame immigrants, tourists and overpaid management elites 🙁
I don’t trust the co-called consensus. People (apart from Ms May and Mr Hunt) can’t deny what’s happening, but they will apportion blame differently.
Yes Sue, that’s what the right are, and have been doing for ages, I agree. They howl with indignation about the state of public services, while ignoring the fact that those services are in the state they’re in because of the policies of the political party that those same rightists always urge people to vote for.
As Richard said, I wonder how long they can get away with it? Perhaps even DM readers might eventually realise the state of the NHS is down to underfunding.
As both this blog and Simon Stevens have emphasised the raw numbers are clear: we do not spend enough on our health.
The World Bank figures for 2014 are UK 9.1% of GDP whereas Germany and France are both over 11%
http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS
My policy position would be to say I want to increase spending to over 11%. We will not see all the benefits immediately but at least we know we are moving in the right direction.
Where does the money coming from – GDP of course? And having a healthy population (and more health support workers) will create more of that.
Agreed
Spending creates wealth….it’s the only way it happens
Austerity destroys it
I believe it is a strong manufacturing base which creates a nation’s wealth! Problem, we no longer have a manufacturing base. Over that last 4-5 decades we have allowed it to be exported to other lands, China being the biggest. They say the slave trade is over. It most certainly isn’t. Years ago we used to import slaves to our manufacturing base. We now export our manufacturing base to the slaves. We are now paying the price for our short sightedness. Immorality doesn’t pay!
The relative spending on healthcare is not quite what it seems. France and Germany spend roughly the same amount as us from the public purse. Their extra spending comes from their much larger private health sectors. This is what the Tories would like to see here. As Peter Wilby suggests in today’s NS, ‘The Conservatives’ goal is … to reduce the NHS to a condition in which the middle classes abandon it, leaving a rump service for the poor.’ Their problem is that the middle class is shrinking and, like the majority of Mail readers, couldn’t afford full blown private health insurance. Instead we will probably increase the amount of non-funded/rationed ‘affordable’ operations like hip replacements where the moderately off/desperate will find the cash.
The NHS will always be underfunded. I suspect the latter is made worse by 1 – the inordinately large amount of fleecing that seems to go on unfettered and 2 – the £bns of pounds of assets e.g. operating theatres, laboratories that are underused. The doors of our hospitals and health centres could remain open for longer, if, in any one working day, or week, the most powerful union in the land – the BMA were to allow.
That is nonsense
The BMA permits within the limited of the system
The system needs more total staffing to open more though
And fur the rest ord, most of it is open on demand 24/7 365 days a year and people do not want to visit GPs at the weekend
I don’t believe it is nonsense. Maybe you need to give more considered thought to what I have said. Are you sure the BMA permits within the limits of the system. Have you ever wondered if the BMA set the limits? The BMA will no doubt be wanting to ensure that its members continue to practice in a manner to which they are accustomed. No?
Demands on the health system are growing, they have, most probably, been growing year on year since its inception. My logic may be wrong but a system that makes greater use of its resources, in any working day/week would/should/could lead to a quicker processing and hence throughput of patients.
Yes, we are led to believe that ………..most of it is open on demand 24/7 365 days a year …………… What I am saying is it needs to be open and working to process patients. Not just A&E but conducting minor or major operations.
……….. people do not want to visit GPs at the weekend. The issue is, people don’t have the option. The sick can’t always see a doctor within a reasonable space of time during the week. Consequently, many have no option but to present and overload the A&E service.
In short, the NHS system needs to cast off its outmoded practices and ways of operating and move into the 21st century. It is the only way it can make more efficient use of its resources – human and physical.
Sure
But the BMA is not controlling things – I have been married to a member for a long time and know that is not true
The limit is physical – you may not know it but even GPs are people and I have seen them broken by the demands of work
If you want a mature debate then recognise a reality – that the vast majority of doctors work to the limits of their endurance now – and too often beyond it
So sure you can open more but now answer the glaringly obvious question – who is going to do the work? And don’t you dare say it’s existing doctors because that would not just be callous – it would be a sign of crass ignorance about the limitations on human capacity
And yes I am angry with people who make such stupid comments about the NHS and doctors and I make no apology for it
I sense the whole issue is a bit too close to home and I sincerely hope that you are suggesting that I am stupid! You must allow others to challenge your views even if you do think you are right.
Please read what I say. I am not saying there should be no more doctors and I am not suggesting doctors should work any harder. Yes, I am very aware that GP’s are people and that some may well work to the limits of their endurance. Indeed, some may even choose to do so for quite a lucrative remuneration. Whatever, it is an unacceptable state of affairs. Yes, there should be more doctors BUT, their current working practices need to change in order to make more efficient use of resources and cater for the needs of the sick. If that means working anti social hours; shifts, weekends etc. then so be it. Many people do!
Oh for heaven’s sake stop talking cap
Go to a hospital now and you know what, it’s open and staffed with all specialisms available
And call a GP and the same is true
But you know why there are fewer than in the day? Because only the really sick go at night and doctors avoid doing things at night for good reason: they are not as safe
You are, very politely, talking complete drivel
If no one has said so befote I am happy to be the first
My local General Practice considered opening longer hours, specifically until 2100z.
They had to ask the immediate residents that would be affected by the traffic. The residents complained. The practice opens until 1900z, the latest allowed. Recently, a member of staff was subject to extensive verbal assault and minor physical assault by an inebriated member of the public. The staff will no longer work to 1900z without a security presence. Assault within NHS hospitals at night is a large concern, it is extremely hard to secure every access.
You want a fully-operating hospital, then you have to be able to staff it, and fund it. You may think that having a few doctors work 90 hours every week is an acceptable way to do it, but it is not. A hospital functions as a team, and all the daytime teams are required at night. Cleaners, catering, portering, nursing (and nursing now comprises several specialities..with fully qualified and partially working alongside..and niche specialties such as respiratory nurses)
X-ray/MRI/CT scanning/HDCT scanning, one presumes that 24/7/365 would need all these, day times certainly does. So all their staff would need increasing/training/educating. Back room staff for these specialties as well…
As recent eerie cue shows, once people are to be discharged, their care after needs to be considered, and funded.
Every skill you need at day is also needed at night. And the funding is insufficient to fully staff the hospital during the day. Even then, hospital doctors work excessive hours; frequently. A GPs’ day starts at 0600 or earlier, the 10 minute slots last longer most times, and inbetween there are phone calls to make ( phone triage) and other aspects of care to consider (existing patients in hospital/test results to be looked at and acted upon)
Even lunch break is more like a sandwich and cup of tea while phoning around.
I suppose people think that once the patients are asleep, the hospital closes?
Nightime admissions need to be treated/looked-after (planned and unplanned).
Seriously ill admissions cannot wait until day staff arrive, so consultants are available online or by phone. And that too has to be planned.
Seriously: a hospital can be broken into two basic sections: seriously ill/dying patients. And ill patients. One needs 24/7, the other needs it too, but gets a lesser amount.
I know technical staff who work shifts…not eight hours on sixteen off..but rotating twelve-hour shifts…for weeks on end. Good family life! And that takes its toll.
About 40% of GP time is seeing patients face to face
Referrals, results, travel to patients, meetings to make sure the system works, action with other agencies and more take the rest
It seems none of this is known to most people
This was the Tory plan as Noam Chomsky wrote: “That’s the standard technique of privatization: defund, make sure things don’t work, people get angry, you hand it over to private capital.”
What they are now doing is creating a diversion, the STPs (Sustainability and Transformation Plans), which are, on the face of it, all about saving money by creating “footprints” of delivery services in definable areas, eg. Lancashire and South Cumbria, which need to work collaboratively. It has McKinsey written all over it.
However, I think it is more Machiavellian, worthy of Operation Bodyguard in WWII, i.e.keep the executives in the Trusts and CCGs distracted by the demands of setting up the patently unworkable STPs while continuing to demoralise and defund the NHS – and then deny it!
What is incomprehensible is that these executives go along with this strategem. Why has not even one just said NO?
Simon Stevens may be saying the time has come when they can say No
Couldn’t agree with you more.However as all the STPs include reducing beds I think the public just might rebel after this ongoing crisis.
I partly blame Simon Stevens for ever committing the NHS to finding £22 billion in savings – even if Social Care hadn’t been cut it was always unrealistic. If, as I’ve heard, he agreed because he couldn’t get Hunt / treasury to give any more money then he should have gone public at that point and not given the Government an excuse to point the finger at the NHS.
So he made a meitake
We all do
Now he has to make amends
I hope so. I shall be participating in rallies on the 21st (Labour) and March 4th (Peoples Assembly) wielding a Nancy Reagan banner JUST SAY NO. Hopefully to more effect than her’s.
What is really depressing is the narrow economic analysis being used to find solutions.
I listened to bits of Any Questions and Any Answers on Radio 4 yesterday and the whole debate centred on tax and willingness to pay arguments. The framing that suggests the NHS, which is so valued by society, is some massive drain on the government’s budget is stifling.
I think this crisis offers a real opportunity to crack open the Overton Window and look at a new value system and economic thinking that we so desperately need. What if three callers and phoned in and started questioning the argument with a very intuitive cost benefit analysis of what the NHS provides society in addition to improved health outcomes, e.g. in terms of employment; use of equipment and drugs we could make; an opportunity to increase the value of social care within society etc? What are the real resource constraints that stop us being able to organise a great system that is seen as a real boost to an economy that works for people rather than the other way around?
The huge costs of fragmented services are very real to me. A distant relative with heart failure and mental health issues who lives on his own has just revolved through the doors of our local hospital’s A&E for the 4th time since October. On one occasion he was in a heart unit for several days more than he needed to be because he had to wait for an occupational health assessment regarding his ability to live alone. At least we have reached the point where the social care and mental health system is working in coordination with the hospital. But that took 3 months to happen and has cost him and the overall health service much more than it should have done.
In the process I have gained more and more respect for people who work within the health services and the huge responsibilities they have This was already high as several close to me have received the most amazing cancer treatment in recent years. Those treating the relative mentioned above have to make decisions whether to try and keep him alive by depriving him of a drug that has kept him sane for 10 years and let him carry on being manic or whether to try and ensure he stays sane with risks to his heart. People doing this kind of work do not deserve to be told they are not efficient enough. Sure coordination is a problem, but The Hospital documentary on the beeb clearly demonstrated the physical capacity constraints they work under. Mistakes will happen. They are bound to.
Thanks
I completely agree about reframing and that it takes many people to be saying the same things in order to shift the Overton window, which is why is it disappointing that so few politicians seem to understand how money is created and circulates.
We need to talk more (as Richard does) about spend and tax rather than tax and spend.
About where growth comes from, how does the government expect the economy to grow when a fraction of the population is waiting to be fixed by the NHS.
As well as money I think we also need to talk more about public goods where the usual supply and demand rules of the market no longer apply. Everyone understands that you cannot put a price on life so creating a scarcity in health provision due to fictional financial constraints is clearly a nonsense.
A free market in health produces worse outcomes e.g. US with much higher spend per capita but lower life expectancy. The NHS actually does an excellent job, but the evidence is that more staff, more beds, more kit would mean more people would be fixed, more people would be happy and the economy would grow faster.