The NHS – again!
Much has been written about the NHS these past few days as we’re approaching its 70thbirthday. There have been many congratulations and kind words for this venerable institution. Because understand this, we Brits love the NHS. We know what we like and this is what we like. You get sick, and it’s there for you no matter how rich or poor you are. Hey, that would seem like, well, socialism, but even wealthy and very right-leaning people who can afford insurance (you can take out insurance anytime here in the UK) would still expect the NHS to give them a GP consultation or two, free emergency services or have their expensive heart valve surgery on the NHS. You see, it’s just part of our British way of life to have the NHS at your birth, your childhood and adolescence, middle age, old age (more about that in a minute) and your death. In sickness and health. You. Do. Not. Pay.
But. Things are not actually as good as they could be. There is an understanding that the NHS is under pressure, visibly so in the winter. And that it is also significantly underfunded. And yes, that is so, definitely, and deliberately.
However, Theresa May is coughing up a huge sum. Her recent announcement of £20 billion sounds so good – but you don’t believe a word of it, do you? Because it is actually mendacious nonsense. As in, when? Oh, not now, but later, after we’ve left the EU because this is being paid for by the Brexit dividend. Well we can trash that for a start because that ‘dividend’ has been already promised to farmers and science. Then there’s the divorce settlement of £37bn plus and we’ll be £15bn down through slower growth after Brexit. Do not tie in this promised money with Brexit. Furthermore, the NHS has had year on year an annual growth budget of 3.7%, this pledge (I’m spitting at this point) would result in health spending rising by 3.3% – so this is actually a cut in spending. Anyway, today (21stJune) apparently our Philip Hammond (Chancellor of the Exchequer) is going to tell us the £20 billion needs to be funded by raising taxes. So, who knows. We are in the hands of politicians who seem to be making it up as they go along.
Then in the right-wing press there is a call for less bureaucracy because behind the scenes of A&E and the GP’s surgery there is indeed a dense thicket of bureaucracy. Furthermore, there is an alphabet soup of NHS acronyms to thwart any understanding or comprehension.
Once upon a time there were General Practitioners who got their funding as private contractors on a per capita basis from the government. They were the first port of call if you were ill. You were treated by the GP (to this day, free of charge) or you were sent to a hospital (or hospital out-patients department) who also got their funding from the government. By the time I was in my 20s bureaucracy had built up and there were Local Health Authorities, Area Health Authorities (AHA) and Regional Health Authorities all dealing with and administering to various parts of our health service and doling out the cash.
It seems that the idea of changing the NHS for the better has always been around as I was on the secretariat (as a clerical officer) of the 1975 Royal Commission on the NHS, which was set up to look at the “best use and management of the financial and manpower resources of the NHS”. There was some talk that it might recommend doing away with two of those three layers but, in the end, it recommended that AHAs should be abolished, which they duly were in 1982.
Oh, good, you might think, one layer of bureaucracy less, but the point I want to get over is that the NHS has been a political and slightly problematic football for a very long time and in the name of efficiency and effectiveness (or whatever the current word is that policy wonks are using) the NHS has become more and more complex, and the layers of bureaucracy are actually necessary to negotiate this complexity.
And always there is something that is on the ‘agenda’. Always there is the notion of ‘reform’, and that the NHS has to be made ‘better’. Because it’s not quite right, is it? Indeed, were you aware that currently overlying the Clinical Commissioning Groups (there are more than 200 of these) and the 135 Acute Trusts (hospitals) the country has been divided into 44 areas in which there has to be a ‘scheme of transformation’? These areas are known as STPs or Sustainable Transformation Partnerships or, confusingly sometimes, Plans. More about these in a minute.
If only doctors and nurses could be left to get on with it, you might think. I can remember the hospital where I trained as a nurse was administered by a ‘Board’ and the only non-medical person on that board was someone called a Bursar who ran the hospital’s finances. But those days have long gone, and especially so since the introduction of market values in the 1990s. And then there’s the most recent reform (the 2012 Health and Social Care Act) which makes it obligatory that CCGs invite private firms to bid for contracts. That legislation is the key to understanding how far the Tories will go in making our NHS a quasi-American privatised service. No, you still don’t pay, but behind the scenes it’s pretty much a disaster.
Is it all bleak? No. There are glimmers of hope. I won’t give you a blow-by-blow account of various developments happening, others have done it better – see the reference at the end of this post. But what about an intensive programme to keep unwell people out of hospital, even intervening in their own home rather than A&E so that people suffering emergencies don’t stack up in ambulances waiting to be seen. And a virtual-bed hospital? Where nurses and therapists drive to treat and care for patients in their own homes? This already exists, and has been tried first in Dorset and now Leicestershire which has 256 virtual-beds. However, the finances for this are complex and it seems this innovation was seen as an excuse to cut costs in acute services, while at the same time not boosting primary care sufficiently for this innovation. We have to be very careful as, what might seem blindingly obvious, that treating people in their own home must be better than admission to hospital, it is not cost-free, on the contrary, this is costly.
But going back to the STPs, did you realise that there is some understanding that STPs might transmogrify into Accountable Care Systems (ACS) which then in turn transform into Accountable Care Organisations (ACO). I wrote about the latter in another post that there is some trepidation about ACOs being a Trojan horse for American style medical care and so NHS England is now calling these ACOs ICSs or Integrated Care Systems. Politicians and policy wonks seem to have no sense whatsoever in this constant chasing after change. Nevertheless, just possibly ACOs, or ICSs, might just be the way forward.
However, before I note a few positives let us be absolutely clear that these organisations are unaccountable, they’re not elected, there’s no democracy here, these organisations are imposed on us, from above, from NHS England. Having said that, instead of the current warring fragmentation of health services, to have 44 areas each with one plan that breaks down the barriers between the professions, and, and social care? This, possibly, could be good. Yes, the elephant in the room, social care, which is totally differently organised and funded, and, do not forget, accountable through you electing your local councillor. If this happens, great, if it works, even better.
OK, health and social care is under threat. We know that. And we know why. It has been underfunded and deliberately so through austerity. And something needs to be done. That is a given. But could we be a tad more radical? Because all of this is based on an ethos of talking, discussing, sitting on committees, speaking and thinking in jargon and spending endless hours and energy on systems, processes, and structures.
Could we not do something different? As in, do you remember something called ‘lifelong education’? That disappeared at some point in the last few years, but what about introducing an idea of ‘continuing health’ or ‘lifelong health’ into the system? Because all that is being done in the outline I’ve given you above is systems and process change. What about a people change? Or. A change in attitude to patients? Hey, how about that for a start! And I don’t mean ‘patient choice’. I mean a complete change of attitude so that, and let’s take older people, as the example, there is, let’s say, a contract with your doctor that ‘I can do this for you, if you do this for your health’.
There are people in the medical profession who care a great deal about older people. I regularly read a blog that posts on this, and in particular on ‘frailty’ which seems to be the current ‘in’ word. And there’s so much written about good practice and doing things better. But, and I hate to say this, there’s a skewed vision wrapped up in their kind words. Because where are the posts on prevention of frailty? I don’t see a lot of those. No, there’s far too much emphasis about what can be done to and for these ageing frail people. It’s about how systems and practices can change but where does one’s autonomy go when you become frail. It’s all so unequal.
Hmm. I return to my first paragraph. We Brits love our NHS, but yes, at 70 it’s a bit in need of, not attention, oh, no, please not more attention and schemes and reform, please could the NHS be left the feck alone. But the constant underfunding, and the attitudes therein, and the being overwhelmed, and the winter pressures, there does need to be some kind of re-think. So, the next post I’ll write will be more on the positive and less of the negative. Let’s be radical and let’s do something different.
I have my ideas. What are yours?
Penny Kocher, 21June 2018
I acknowledge my debt to the article ‘End of an Idea. James Meek on the NHS’ in The London Review of Books. Volume 40 Number 7 5 April 2018.