How to save the NHS
I’ve been away from this blog too long. The list of things I want to write about is also long: Brexit, of course, there’s much to say there. Russia, oh, yes, indeed, I’ll be saying things about that one, and then something that fascinates me, the term ‘liberal’, which is bandied about so, er, liberally by some Americans (?a lot) as a derogative, when for a Brit (this one anyway) the term conjures up an open-toed sandaled person (sorry don’t mean to be offensive to sandal-wearers) with rather weak and watery views! See – quite different, or is it? I will get to that. However, this post is about our National Health Service, which is in crisis – again. Why?
Well, at first glance it’s creaking at its seams because it’s winter and there’s a seriously nasty flu going around. Apparently, Accident & Emergency (hereafter A&E) is full of people who are having to wait a very long time – longer than ever before, as in, since records began. Then the people who are eventually seen can’t be admitted into a ward because there are no beds, because people who are waiting to get out can’t, because there is no social care available. (Btw, ‘social’ care is nothing to do with ‘socialism’ it’s just what we Brits call the care needed in the community, usually, but not always, for older people when they become frail.) Anyway, consequently, the people who’ve been seen in A&E are having to be nursed (hardly at all, it seems) in corridors and pop-up wards. Patients are dying there, say doctors. So, planned surgery is being cancelled to free up beds, and people are saying (mainly the media) that this 1st world country has now got a 3rd world health service.
Now wait a minute. What infuriates me is that this is a crisis that’s been a long time coming. In fact, did you realise there is a ‘plan’ to deal with this year’s ‘winter pressures’ (I’m using jargon here). But the plan hasn’t worked. I’ll give you an explanation in a minute. And readers from outside the UK, don’t think that this is about inefficient ‘socialised’ hospitals with bad underpaid doctors. Nurses are underpaid, of course, but our hospitals are mostly fine, and our National Health Service (thereafter NHS) is a modern miracle, that we all love, want and desperately hope remains as an absolute fundamental part of the British way of life. There you are. Not everything is rosy, but there is no dispute about the NHS. People from the right, left, and the middle all love the NHS, well not everyone who leans to the right – more about that in a minute.
Also, for those of you in the States, I understand that there is a view that the Brits can only use this free socialised medicine, which naturally is awful, because, where is the freedom to choose who you go to, and when you get your treatment. (I know this only through anecdotal evidence of conversations had whilst being the only Brit on board of an American cruise ship). Look, you can go private any time, it’s your choice. You want to pay, you can pay. Feel free to do that, anytime. Some Brits do pay, currently approximately 13% of the population take out health insurance according to government stats. And more would like the option, but don’t because of the cost of insurance. Yes, there’s always that – the cost.
But before I go on, did you know that a study found that in comparison to 10 other countries (in Europe, Canada and Australia and including the States) the NHS was rated the best in terms of efficiency, effective care, safe care, co-ordinated care, patient-centred care and cost-related problems. It came second in relation to equity.
Yes, the thing is our NHS is free to the whole population. It’s paid for by our taxes. But when you need anything medical, it is free. You name it, it’s free. You do not pay one penny. However, I will just say, that you can’t get absolutely anything you like on the NHS. There are limits, and I’m not talking about the crisis. In the UK there’s a body called the National Institute for Health and Care Excellence (NICE) which sets criteria for treatment and medications on evidence based research. It also calculates cost-effectiveness of treatment and medications in terms of quality-adjusted life years, which roughly means that very expensive new drugs and/or treatments aren’t always approved. We, the public, don’t know much about this until we hear in the media of a terminally ill patient who cannot get a new wonder drug. If you dig deeper you usually find that the drug is expensive and will only give 6-months or so more life to that patient. Difficult, and I wouldn’t want to be that patient (who would), but it’s fair. And that’s what we Brits like about the NHS. Overall, for all its faults, and of course, it has a few (some would say more than a few) we like the fact that everyone can get free treatment. Health care that is freely available for the whole of society, poor and rich alike, is not considered a bad thing here.
But now we’re in the middle of a crisis, which our Theresa says is due to the ‘flu. No, it isn’t. There’s always flu. This is a bad one, but it’s the winter and as per usual people are being admitted for winter illnesses. No, top doctors (68 of the most senior emergency medical specialists around England and Wales) are saying that things are beyond bad in A&E, plus the body that represents all NHS providers is saying that most hospitals are now breaching their constitutional obligations. That’s jargon, but I think we’re talking about safe medical care here.
So, what’s up?
OK, I’m going to be blunt here. And don’t read on if you’re easily offended. For a start, let’s scotch any ideas that this is about immigrants. That’s far too easy and not a good road to go down. Neither is it about so-called health tourists! I mean, what do you think, is happening? That the A&E is full of wealthy tourists wanting operations? If you have an accident and you are a tourist you would be billed. Ditto, if you need an operation.
So, let’s take easy steps (btw, I’m writing for dense politicians when I take that tone) First, there’s been an incremental increase in technological and research based improvements in health care. I nursed in the day when they used red rubber for all sorts of tubing. I was on duty when they did the first heart valve replacement in the UK, ever. I wore a freshly starched white apron every day, and had a frilly white lace cap with a butterfly bow on my head. Things have changed, a lot, and cost more money. (When the NHS was launched in 1948 it had a budget of £437 million. For 2015/16 the budget for the whole of the UK was £116.4 billion.) Then, forget immigration, there has been a natural increase in population AND, there’s the increase in the longevity of the ageing population. All of which means an increase in the use of the NHS.
So, the NHS needs more money BUT somehow it isn’t being given. And you don’t believe a word of any politician that says, ‘but we’ve given x amount which is so much larger than before’, do you? Any statement along those lines is a basic out-and-out tampering with the truth and utterly meaningless. Quoting an A&E doctor, please note that, “Every year, the total number of patients requiring admission to hospital has gone up, the total number of beds has gone down and the total amount of money that we’ve had available to spend – in real terms – has gone down.” The Observer, The New Review, Health, p13
This underspend is, now, at a tipping-point – it cannot go on. It’s a crisis that has come about through a deliberate under-funding over the years, ostensibly about ‘austerity’. Plans for winter pressures won’t work when the service is cut to the bone and then cut and then cut again. It won’t magic up more doctors in A&E, more beds on the wards, and more nurses to staff them.
Then, as if that is not enough, there’s the ideological tampering with the NHS. All done by the people, on the right, who do not wish our NHS to continue as it is. And if you feel hard done by about the NHS and want to demonstrate against a new contract you’ve heard about or start a campaign to save the NHS. I’m sorry that’s not enough. Because, why? Because everything that is happening behind the scenes, is legal. It is the law. And the only way to counteract this deliberate deconstruction of the edifice that is the NHS is to get rid of the current government and/or repeal that legislation. Yes, I’m sorry to say that a vote for the Conservatives is a vote to destroy the NHS. And I don’t apologise for being ‘political’, I am that angry.
So, what am I talking about?
A national institution that employs 1.5 million people and aims to provide health care for the whole population of a country cannot be anything other than complex. What goes on behind the scenes in the NHS is indeed hellishly complicated and for an easy guide you could take look at this short, animated video produced by the King’s Fund. However, these are dangerous times for the NHS because in 2012 the Health and Social Care Act brought about the most extensive reorganisation of the NHS since it began in 1948. I’m not going to give you a blow-by-blow account of what is in this legislation, apart from saying that this was yet another re-organisation of health service structures (from Trusts to Care Commissioning Groups, CCGs, led ostensibly by General Practitioners). However, the key to understanding the danger the NHS is in is that one section (section 75) obliges commissioners (these are the GP led CCGs) to put contracts out for tender and in so doing they come up against draconian competition laws. And I quote:
“The wording of section 75 requires commissioners to put out to tender everything that could be provided by an organisation other than the NHS. Private contractors are more likely to win these tenders…..The regulations would create rights for commercial providers under rules originally devised by US corporations to promote their commercial interests. If implemented, they will drag the NHS into a competition law regime which creates obligations for governments to compensate private providers in the event of services being brought back into public provision.” Kalish Chand,
And for your information, last year Virgin Care sued the NHS naming six CCGs, a county Council and NHS England after it failed to get a contract to provide children’s services in Surrey. There has been an out-of-court settlement to the tune of hundreds and thousands. And why has Virgin Care ‘won’ when it wasn’t deemed suitable to deliver children’s services? It got that public money, our money, because it’s the law.
These last few paragraphs almost need a separate post (one I might well do). But that section of the Health and Social Care Act came about through the outsourcing contract-culture that, up to a couple of days ago, was the so-called norm here in the UK for all its public services, including the NHS. However, a mega large company called Carillion has just gone into liquidation. Carillion unbelievably, started out as a construction company but is now is a multinational facilities management company as well as doing construction. I think the ‘common-sense’ view that private is better than in-house provision is going to go through a very nasty and expensive reappraisal. There will be a huge impact across the country from this liquidation, and people might just be thinking it better to keep services in-house. But don’t forget that, allowing for the current law, CCGs will be sued if that happens.
How to save the NHS
Yes, I hadn’t forgotten that this post has a title – how to save the NHS. Well here goes.
Let’s start with Jeremy Hunt, our Secretary of State for Health and, from January 8th, Social Care (more about that re-naming in a minute). In a word, he’s hated by the medics and rightly so, but astonishingly, quite a left-leaning journalist, Polly Toynbee, argues that better the devil you know. Yes, he’s a bully and he tries to control and cajole our medical profession, but at least, quite recently, he has said that the NHS needs more money, on a longer term 10-year basis. Now that really is better and don’t forget any new Secretary of State would start another re-organisation. Oh, please no, what the NHS suffers from more than anything, and doesn’t need, is politicians fiddling around with its structures for the nth time. However, calling him by a new name is interesting, but won’t work. Why?
A seamless partnership between health and social care is absolutely what we all want. But it won’t happen, truly, it won’t until that is, there is a mega change in funding structures and streams. First, of all, not only are they different disciplines, the NHS is funded from our taxes, and comes down from government, while social workers and the funding for social care comes from our local authority tax. And we all know that our local authority ‘council’ tax cannot cope and/or deal with libraries or fund the arts, let alone the ever-growing ageing population, so the criteria for getting help becomes higher and more rigid and very little is available. Then we get a ‘winter crisis’ with older people in hospital unable to get out and go home either because there are no beds for them in nursing homes or there is no help, or very little in the community to keep people in their own homes. So, there are no beds available for people in A&E to be admitted. And that’s the crisis we are in, at the moment. Can I just say (as I’ve witnessed this several times at one of the most expensive nursing homes you could find in the UK. Note that this is anecdotal, so..) these expensive nursing homes, which are supposedly for the very frail, don’t actually do nursing. They’re fine for day-to-day care, but if anything happens to an older resident or they get ill, where do they go? A&E.
And while there are many examples of health and social care working together in teams, and patches, and areas, in GP surgeries and so on. There is not a seamless progression from medical problem to extra care in the community, because GPs and consultants are not in control of the budget for social care, or in charge of the separate discipline and structure and organisation of local authority care, and don’t forget private social care. Should they be? Who and what would make the care of older people seamless? It’s a debate we ought to have. So, Jeremy Hunt – you’ve got a whole new name – what will you do?
And what about the cost of this social care? One element of this so-called crisis is because people are living longer whilst becoming frailer and frailer with consequent multiple morbidities. The resulting medical emergencies from these multiple morbidities bring people into A&E all the time not just in winter. So, let’s have a debate. Actually both George Brown (Labour) and Theresa May (Tory) tried to deal with this issue and failed miserably. Gordon Brown’s version got called a ‘death tax’ as he wanted the cost of social care taken from your estate. Theresa May’s effort was that your payment for social care would take account of the value of your house. (I went into some detail on this proposal in another post – click here) As it was a ‘tax’ that wouldn’t be paid by everyone, only those who were in need, it got called a ‘dementia tax’. Both of them in their clod-hoppering way, were actually doing the right thing. We, as in the people, as in, us, should be paying for this care somehow. We need a sensible debate on the cost of our frailty. But can I suggest it’s not done during a crisis, like now.
And while we’re at it, here’s the thing, do we carry on paying for the cost of the NHS through our taxes? My answer is yes, absolutely. Don’t forget it is meant to be the most efficient health service in the world. Well, at this precise moment, probably not! But it needs to paid for. And don’t tell me there’s no money for that when we can build an aircraft carrier with no aircraft that is obsolete and leaks before it is officially up and running. There is always money. There are always political decisions to be made on where money is to be spent. OK. You want a healthy nation – then we should step up and pay for it.
At this point I am going to mention something that needs to said. There is some misuse of the NHS. People can’t get to see their GP quite as easily as they used to. Our general practitioners are also under pressure. At my surgery I can’t just swan into see my GP. If you feel unwell or need a consultation a doctor will ring you to see if you’re ill enough to be seen face-to-face, if not, it’s a telephone consultation. That’s OK, it’s a good and fair system. But where do some people go? A&E. I really think A&E triage should weed out time wasters and people abusing alcohol. And then a humungous number of hospital and GP appointments are not kept – these missed appointments really should be charged for. I could go on, but I won’t.
Finally, I want people to think outside the box. Let’s have a partnership between the general practitioner and the patient to be coached to be well. Is it possible to have a national health service? I believe that should happen to patients of all ages, but particularly us older people. GPs don’t have time at the moment, so maybe this is a contract with your doctor while you see other people, like fitness trainers to get moving and exercise more. And with regard to older people on the brink of needing social care, has there been a cost benefit analysis on what reduction in public spending and personal expense there would be if older people had intensive physical fitness programmes??? And personally, I don’t think these programmes, this emphasis on moving and keeping well, should be voluntary and up to the individual to decide on participation – somehow I’d like to see some compulsion! I’m getting into awkward areas here which is why we need a debate. But all this banging on about, ‘we’re in a crisis, oh dear’! Look. Face it. Debate it. And do something radical, dear politicians, like funding the NHS properly.
No, you won’t? OK, continue with this crisis. And when I’m feeling kind, I see the ‘crisis’ as engineered by short-sighted short-term politicians, when I’m not so kind I see the deliberate destruction of a beloved institution by mendacious people, that we should not tolerate. However, I don’t know that I have quite as much energy as when I was younger and held hands round Greenham Common. My kids have many memories of me taking them on CND (Campaign for Nuclear Disarmament) marches. Where are the young revolutionaries of today – because somebody has to stop the rot. And don’t forget the change in the law that’s needed.
In the meantime – keep warm and above all, well!
Penny Kocher 18th January 2018
I’ve tried to avoid the entire post being a different colour with copious number of links, however, to better understand the NHS do have a look at the King’s Fund video, which is entertaining and highly enlightening.
I have read many articles and looked at government statistics. If you want more information or stats just ask.