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.



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14 thoughts on “The NHS – again!

  • 21st June 2018 at 10:38

    Well said Penny , I am going to put this up on my Free University Brighton intranet thread and also post the link on their FUB Facebook ! and my FB timeline to spread your comments …
    thanks for blogging about it .

    • 26th June 2018 at 12:23

      Thanks so much, Yok! And gosh, I write because something needs to be done!!!

  • 21st June 2018 at 11:14

    I always read this blog and intend to comment because these posts are guaranteed to make me think, along with a lot of nodding my head in agreement. As there is always so much thought provoking content, I need to read and read again to assimilate it all; this is good! But, of course, then the moment is gone and I end up not commenting . Not this time! I’m a passionate believer in and supporter of the NHS. However, since it was set up, society and the demands placed on the NHS have overtaken the original concept, not to mention critical underfunding. My admiration for the Drs and nurses knows no bounds. Interesting that so many of them are ‘dreaded immigrants’.
    All my working career was in education, first as teacher and then as a trainer. Education is another political football. I can’t begin to talk about the paperwork, continuous changes and burn out rate of young teachers. Sorry, I’ve hijacked the topic and gone off piste, onto my own personal soapbox.
    As for ideas, we are often discussing this with family and friends but I’m not sure what the best solution could be but I will go away and reflect!

  • 21st June 2018 at 17:11

    I think you are right Penny but just one point, the NHS is only free at point of service, we all pay for it with our taxes etc.
    There is far too much interference in the NHS and the constant changes, all of which cost huge amounts of money (remember PCTs?), just as the NHS gets to grip with a change along comes another one.

    Personally I think there needs to be a huge change in ‘management’s’ view and treatment of clinical staff so they respect and take into consideration that these people might actually know something about the services they offer, rather than believing that only ‘business’ degrees count!

    • 26th June 2018 at 12:47

      Yes, we, the patients, do pay for this service and it’s through our taxes.

      I think the health service is based on efficiency and cost effectiveness (where we do well against other health services) but we’re not a patient centred service and we’re certainly not guided by the medics and nurses. It is a service based on management of systems. Actually that has to change – not sure how!!!!!!!

      Just listening to the local news where next year adult social care is going to be cut by 10 million because of funding cuts from central government. Funny how we can afford expensive jets and aircraft carriers to defend our nation. Can we really afford these? No politician has the courage to move us on to a more Scandinavian style nation – instead we cut social and health care again and again. Not good enough in my view.

  • 22nd June 2018 at 10:01

    Thought-through and thought-provoking as always, Penny – a very good piece. I particularly like the notion of ‘lifelong health’ and focusing on wellness rather than illness.

    To my mind, the biggest issue by far for the NHS is underfunding. You’re right to point out the despicable dishonesty and manipulation by the Tory government, and the outright lies about how generous any proposed settlements are. But what’s absent is any grown-up debate about the how the NHS should be funded . A ‘free for everybody’ NHS has become a shibboleth and any discussion on funding presents a black and white choice – keep it free, as status quo, or plunge into a ghastly American-style insurance system. It’s very clear why the rightwing headbangers on the Tory benches favour the latter – there’s money to be made (by them and their mates of course.)

    But the American model is NOT the only alternative.

    Here in France, the health service functions on mixed-model funding. The state raises money through ‘social charges’ which everybody pays on a sliding scale according to income and resources – the more you earn, the higher your social charges. This funds the basic health service. Your entitlement to treatment is managed through various ‘assurance maladie’ bodies, not private for-profit companies, but state bodies. Your entitlements are based on the contributions made, and on enrolling, you receive a ‘Carte Vitale’, a smart card that manages every point of contact with the health services, including pharmacies and district nurses. The system is accessible to all – but not necessarily free. There are charges e.g for seeing a GP – BUT those with limited financial resources pay nothing. There are also significant rebates, again managed through the Carte Vitale – so, in my case for example, when I visit my GP I pay 25 euros at the the time of visit; but about two thirds is rebated back to my Carte Vitale account. And important to emphasise that if I were less well-off, I would pay NOTHING.
    Alongside the Carte Vitale system, inexpensive top-up insurance is available but not mandatory – but apparently 90% of French people have a ‘complementaire’, which covers things that aren’t necessarily covered by the state.
    Overall the system works very well. My own experience of it is a good example – I was hospitalised following a minor accident; two operations, a 10-day stay, home visits by nurses and physios and then a whole year of twice-weekly physio sessions… the whole thing at NO CHARGE whatsoever; my Carte Vitale and complementaire covered the lot. So the system works. It’s pretty efficient, it’s benign and my impression is that it’s the clinicians in charge, not managers, nor bean counters nor (as in the States) the insurance companies.
    Apparently France ranks quite high in health system outcome ratings – as does the NHS. But the USA with by far the highest proportion of GDP spent on healthcare – almost 18% compared to 11% in France – has one of the lowest rankings, right down there with Third World countries. Go figure…

    • 26th June 2018 at 13:07

      A study has just come out revealing that the NHS is not doing quite as well as it should (see below). We’re definitely have an efficient service, but being ironic here, as that’s all based on cuts in funding. Our current government wraps everything up in lies and especially about ‘investing in’ and ‘giving more’to the NHS. No, they’re not.

      As for funding the NHS differently, I do think we need to rethink some things including payment. I agree that the not paying for a thing has gone too far and we should look at how other European countries fund their health services. But that won’t happen while our current politicians look to the States – err, why, as it’s the least efficient health service? One can only think the worse, actually! To have physiotherapy for a whole year is amazing – not sure that would happen here, which is a shame. Also there has to be some way to get the drunks out of A&E and have something to incentivise people who won’t take responsibility for their health. Paying for a visit to the GP and then getting it refunded has to be one consideration.

      I shall revisit this!

  • 26th June 2018 at 04:29

    I live in Toronto, and am going through the process of breast cancer. I had my third surgery last week in less than 10 months. We have our own problems with our own NHS called OHIP here. The last year, I have spent countless hours sitting in hospital waiting rooms. One of my observations has been how grossly obese the majority of people sitting waiting to be seen are. The number of people who step outside to smoke a cigarette while waiting. Is also apparent. I think that people need to be made to take responsibility for their own health, and if the’re not prepared to do that then a fee needs to charged. I am having to make lifestyle changes to help prevent a recurrence of my cancer. I want to make them because I want to live, but if I am not prepared to make these changes, there should be some restriction on the medical care I receive. We have people here that turn up at the Emergency Room, with a sniffle, wasting valuable resources,, these people should be made to pay a user fee. The companies who push junk food on us, should be made to contribute to the health care system. The tobacco companies too. We need to accept responsibility for our own healthy bodies. The system is abused by many because it is free, a user fee might at least cut some of the costs, and make people appreciate how incredibly lucky we are to have it.

    • 26th June 2018 at 13:19

      Yes, the French system (see Christopher Gough’s comment) seems one way to go. Why the current government is so enamoured by the American system beats me (and others) as we all know it fails in so many ways – I mean good if you can afford it, but how awful if you don’t have insurance. What a way to run a health service! But we aren’t doing as well as we could – and that is entirely down to under-funding and too much system change.

      I am totally with you that we do need far more emphasis on health throughout one’s life and into older age – that’s what’s missing. Our GPs would probably tell you that they’d love to have the time to talk to patients about reduction in weight and health so on, but they can’t because they’ve haven’t got the time. That’s down to funding again. Sooo, I think we, need better and more consistent funding, and then as patients and citizens we need to take responsibility for our health. Actually there needs to be a complete change in government as the current politicians won’t go anywhere near the kind of sea changes that are needed. More to come about this in another post!

      And my very good wishes to you for better health – thanks so much for your comment.

  • 5th July 2018 at 11:26

    Hello Penny! I’ve been meaning to add to this conversation for a while but last week I spent hours reading the Gosport Panel Report. Much of what they write about concerns a period in the early 2000’s when I was active in the health sector and some of the people (not patients) were known to me. So terrible to hear of a new case of possible ‘unlawful killings’ in a neonatal ward – can we never learn from the very expensive investigations that have been done over the years? Successive conclusions & recommendations give such a sense of deja-vu that I feel not only disappointed but very angry.

    A bit about me – I was a member, later chair, of a Community Health Council (CHC) then a Non-Exec on the board of small hospital. I also acted as a panel chair/lay advisor for the local Deanery which oversaw & organised Drs training. Particularly liked that last ‘job’ and was sad when I had to give it up.

    With the NHS as a subject it’s hard to know where to begin, the size , the complexity, the continual process and organisational changes. I support the NHS generally, we must never go back to a system where upfront payments are needed. However, I think there is sometimes a rosy view that everything was so much better when the clinicians ran the show without the ‘interference’ of managers and regulatory bodies. Just looking at how difficult it was to get the N HS started in the first place tells you that was never the case. The reality was that doctors, and, in particular, Consultants (all male) who had almost a God-like status, often ran hospitals to suit their own convenience. This was especially true when they prioritised their private practices above their NHS work & beleive me it took more than one generation to change this. I’m not saying that they weren’t good at their job but the service was definitely not ‘patient centred’!

    Nurses and other health professionals were subservient to them and I’m sure a lot of mistakes were made and never addressed. This has changed profoundly but still not fast enough & the
    ‘whiff’ of old heirarchy still hangs in the air! I saw a lot of good things happen as in reduced waiting times e.g. hip ops in 1 year not 3, enhanced team working, consultant led emergency assessment units which reduced admissions, discharge lounges, a care home being built on NHS land by the local authority to help address delayed discharges, a brand new treatment centre at our crumbling old hospital. This was in the early 2000’s and I’m deeply distressed to see everything going backwards again.

    At the root of the problem if not really NHS failure but the abject failure of all governments to recognise and plan for the demographic change that everyone new were happening. This has been a particular problem for social care, exacerbated by austerity. There have been numerous reports and white papers that have been quietly ‘buried’ because no government has been willing to adverse risk public opinion and possible ‘electoral suicide’. I have no love for the Tories but Mrs May did at least try to come forward with something possibly workable, and where more saving would be discounted, only to be shot down with Labour cries of ‘death tax’. Shame on them. This notion that we should expect the state (i.e. the taxpayer) to fund all our care is unrealistic. Many of us ‘baby boomers’ have benefited from the incredible rise in land values and consequently of house prices without lifting a finger & have lived longer and more fulfilling lives than our parents. I don’t think asking for more money from people in their 40’s is fair, they at the most expensive time of their lives if they have children going to university and many support older relatives too. Our generation did not have to pay education feed ourselves or for our children. Putting money into the NHS won’t get people out of hospital when they need continuing help and support. Many hospitals have up to 60% of their acute beds occupied inappropriately – for both patients and the NHS – so it is obvious what heeds to happen.

    The NHS is not the best in the world for outcomes ( preventing death and disabilty) but it is more efficient and costs less than most. We have fewer health professionals and physical beds per head of population that other developed countries. I was around when beds were taken out to cut costs on the pretext that more care could and should happen outside. ( I argued against this but the drive to meet financial targets often overruled sensible concerns. I felt very sorry for the executives and specialist directors whose had to try to maintain quality and financial imperatives, many of their jobs were on the line at the time).
    However, the money was never there to really develop the necessary services, although there are a lot more than even 10 years ago. We do have fantastically dedicated and innovative staff who continue to care even though there are so many vacancies and constraints. The stress is enormous and in reality they are being abused by the system

    Other systems of healthcare delivery cost more than we are apparently prepared to pay either nationally or individually.( You just can’t get people to vote for tax rises whatever they say in surveys!) The French system relies on people taking out insurance policies , it is not all free at the point of delivery. Until quite recently it was providing spa ‘cures’ at the national expense ! In 1994 I was treated in an Austrian orthopaedic hospital – all bare walls and shiny floors, no screens around the beds, staff on ‘national service’ (not done now) plastering me up & disinfecting the door handles. We had to buy my crutches and the ‘hotel’ invoice was on the doormat the day after we got back!

    I think we would all agree that getting people to take better care of themselves would help enormously but studies have shown that concentrated and long term help and support is needed to bring this about. We have normalised being overweight in our society and the food and diet industries reap the rewards of the way they have insidiously manipulated our food choices. Selling off school playing fields and the roads being too dangerous for many children to walk or cycle compounds this. It is all POLITICAL, citizens need realistic support and can be ‘nudged’ towards healthier choices, as experiments have shown. Yet we still don’t have the comitment of any government, whose wishy-washy plan on tackling child obesity, for example, show how in hock they are to big business.

    I’m tired of typing now, not sure anyone will want to read through this long rant! As you can tell the NHS& social care are my ‘specialised subjects’ and I could go on and on…………but lunchtime calls!

    • 5th July 2018 at 11:47

      Thanks so much Linda. I’m in Suffolk at the moment and will reply at length next week. So much I agree with in your response – thanks again

    • 6th July 2018 at 10:46

      Re Lynda’s comment – “The French system relies on people taking out insurance policies , it is not all free at the point of delivery.”

      It’s not actually true that the French system ‘relies’ on insurance policies. The standard health service, funded by earnings-related social charges, meets all basic needs – nobody will go without treatment. The ‘complementaire’ system – insurance policies – enables people to ‘top up’ and cover things like the cost of prescriptions, opticians, dental care etc. There’s an enormous range of ‘complementaires’ available, from as little as 30 euros a month.

      The health service isn’t always free at the point of delivery – eg GP appointments are paid for at the time of visit, with a portion refunded according to financial status; ie those who can pay, do – and importantly, those who can’t pay, don’t. The system is geared to enable those on national minimum wage or below to get free treatment at all times. It seems to me to be fair and flexible – and in my own experience, very effective.

      I do think the NHS sacred cow of ‘free at the point of delivery’ does need to be re-examined… Free for everything? Free for everybody? Free all the time…?

      • 9th July 2018 at 09:17

        Thanks for explaining the French system further. You raise an important issue about ‘free at the point of delivery’ We should examine what we really mean by it & how important it is. It is something that comes up again and again when thinking about how we fund the service. Lots of ideas have been put forward but there are often practical issues which would create another layer of administration which itself costs money. It feels like a big headache is coming on when you try to work out how to sanction people who don’t turn up for appointments, pay ‘hotel’ bills in hospital, bring back equipment loans etc.
        I’ve never understood why bringing in insurance ‘business’ in health for almost everyone would help as the insured have to pay for the companies’ profits. ( We are of course already using private companies to deliver healthcare under the NHS ). You could say that its no different from insuring your home or car or taking out holiday insurance. However, many people can’t or won’t do these things and we know there have been scandals around refusal of companies to pay out on claims. My husband had company health insurance but when the lipoma on the back of his neck eventually grew large enough to need to be removed they refused to pay for the op. because it was a chronic condition.
        Of course there are different models but paying up front and claiming back is often a feature, which is very difficult for low earners. Free cover for these people seems sensible but then do we risk ‘second class’ citizens in a second class service? Lots to think about as ever!


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