Ten practical remedies for the ailing NHS
Published by CapX (26th January, 2018)
I went to hospital earlier this week for a small but troubling skin condition. Having expected to spend the morning stuck wearily as usual in dreary waiting rooms, I was seen immediately upon arrival and my problem dealt with by a friendly young doctor. She was unsure about one issue, so called in a senior colleague, who resolved matters rapidly before dispatching me for a blood test. I was out on the street again within an hour, clutching ointments and pills that cost £34.40.
This was a welcome contrast to my usual brushes with the National Health Service – and indeed, to a friend’s father who endured the most terrible service after suffering a stroke at start of the year. His saga of delayed ambulances, abandonment by medics and being stuck in a chair due to bed shortages was more typical of the current headlines about our most precious public service trapped in crisis again.
The cry has gone up again for more cash in a service that already soaks up almost one-third of public spending. Yet it is easy to forget Aneurin Bevan, Labour’s saintly founder of the NHS, resigned from the cabinet over the then-controversial concept of prescription charges, underlining the potential fluidity of political debate even on health. Not least since his fury was over dental care and spectacle charges, now two of the more expensive aspects of health care where consumers shell out huge sums for fashionable items or treatments.
There is no doubt the Tories are in a pickle over this issue, permanently on the back foot from Labour and mistrusted by most of the electorate. More than seven out of ten of their own voters cite it as a major concern, with most wanting to see more money put in and the health secretary Jeremy Hunt turfed out despite being one of the best holders of this post that is so blighted for a Tory.
So what can they do on this issue? Here is my 10-point plan:
Forget the politics. The Tories think the best cure to their health problem is to muddle along, constantly kicked as the party that allegedly wants to hurt poor people while endlessly expressing adoration of a creaking service. Under David Cameron, with his obvious personal concerns as parent of a child with profound disabilities, they briefly nullified the threat, before unleashing more botched reform. But how about trying something bold: actually trying to resolve long-term problems rather than usual sticking plaster politics when confronted by a gaping wound? Voters might even be impressed by genuine desire to do good.
Inject some money. Like it or not, the NHS is struggling – even if this has been almost always been the case since its birth. Cash given to tackle long-term issues is being squandered on surviving the current crisis. And just because Boris Johnson suggests something does not mean you should always do the opposite, even when he is playing his own silly games. Britain’s healthcare spending as a share of gross domestic product is falling at a time when demand from an ageing population is swelling. Chucking in another few billion will not solve core problems, nor get many thanks from medics or voters, but it might stave off a bigger crisis a little longer.
Insist on more efficiency. The NHS costs £125bn. It is an efficient creature compared with competitors. Yet it is far from perfect. Listen to the likes of Tim Briggs, an orthopaedic surgeon and national director of clinical quality and efficiency, who argued there should be no more money until waste is slashed. He points out, for instance, that an achievable reduction in infection rates to 0.2 per cent after hip and knee replacements would save £300m a year; one London hospital briefly hit rates of 15 per cent while annual rates vary across the capital between 0.19 per cent and 4.49 per cent. Or note how when a private firm was allowed briefly to run a small NHS hospital, managers cut £3m from procurement budgets by ordering their own supplies rather than through bureaucratic NHS bulk-purchasing schemes.
It is not all about cash. Just look at Scotland, with higher spending per patient but significantly worse outcomes – and that is not just down to drink and diet. Also never forget that when the Blair government ramped up NHS spending, much ended up in the pockets of public servants rather than boosting services. Indeed, arguably some of the current crisis is down to a costly deal with GPs that led to reduced services outside office hours. Doctors and nurses do crucial jobs, but they are not saints. We also need to discuss issues of personal responsibility. And not be scared to challenge the calcifying nature of risk-averse bureaucracy, since the NHS cannot keep spending billions more simply to stand still.
Demand more transparency. This is improving. But it remains a brilliant way to achieve improvements. Briggs also pointed out screws for back operations vary in price from £32 to £600 yet there is little data available, let alone shared, on ethicacy of patient outcomes. The cost of litigation is also snowballing with the NHS locked into a wasteful system of fighting claims that takes years and is distressing for all concerned. Meanwhile NHS chiefs talk of wanting whistleblowers, then crush those daring raise concerns. Mr Hunt says the NHS must learn from airlines, with strong emphasis on safety and staff encouraged to voice concerns, but progress is slow. Sharing data and accepting error leads to safer, cheaper services.
Fight for your beliefs. The NHS is a bureaucratic morass of mind-boggling complexity. Yet, as Robert Colville rightly argued on this site, it has hurtled into this quagmire after attempts to fuse market dynamics on to a sclerotic state-run system. The legacy is some elements of patient choice, yet stifling of market forces. This creates more bafflement and more bureaucracy. Labour’s solution is simple: return to full-blooded state control. The Tories should argue the opposite: more power to patients, more personal budgets for people with complex needs and more use of privatised firms to provide competition as seen in better European systems. At the same time pass more managerial authority where possible to those on the frontline, empowering doctors, nurses and therapists rather than armies of pen-pushers.
Take tough decisions. Some popular hospitals and services should shut as surgical services are centralised. This is unpopular, not least with backbench MPs and newspapers. But it makes sense on financial and medical grounds to have fewer places performing better operations. Meanwhile Bevan’s system created to tackle industrial disease and infant mortality needs to adapt faster when most cash goes on old and disabled people, speeding up the pivot towards community-based, multi-disciplinary centres for patients with complex – and often intractable – needs.
Underline reality. The NHS is rightly free at the point of use. But it is far from free. Yet the electorate seems to want low taxes, high state spending and perfect public services. NHS spending has grown 3.7 per cent a year on average since 1948 – but if there is over-demand from patients and under-supply of services, something must give eventually. I have long argued the starting point for a more sensible debate is to ring-fence a special tax for health so voters can see the cost in their pay packets, an idea now gaining ground. Only then might we strip away any illusions medical care is free and see rationality infect the health debate.
Stop the sanctification. How can we have realistic discussion when politicians feel they must parade their devoted love of a public service and never dare show the slightest dissent? Even the Tories tweet results from a comparative study of health services showing Britain does best on several indicators, ignoring the crucial one showing poor performance on the key task of keeping people alive. Our health service scores very poorly with rivals on a range of comparisons from cancer care to child deaths. And healthcare failure tends to fall with often tragic consequences on old and disabled people, from the deadly Mid-Staffordshire hospital scandal through to the current inquest into a man with Down’s Syndrome dying in hospital from constipation.
And stop ignoring the real crisis. Why does the state fund a woman dying from cancer but not one dying from dementia? This distinction between social care and health care is artificial and nonsensical. The NHS crisis is really a social care crisis. Crumbling services, cut budgets and closed care homes have left hospitals packed with people who should be in better and cheaper places. Sadly the coalition overloaded austerity on local government, yet the number of people aged over 85 is set to rise another two-thirds by 2030. Mr Hunt has already added social care to his job title. Now let us merge the systems and state fund the entire £20bn burden, not least by slashing the wasteful foreign aid budget. The alternative is simply to limp on, pretending all is fine and idolising grossly inadequate services.