Could digitisation help revive the NHS?

Published by The i paper (22nd August, 2022)

I went to Tallinn earlier this month to report on Estonia’s remarkable embrace of digital government. This Baltic nation has placed every state service online except for marriage and divorce – and they will soon follow suit. A young generation, taking power after the Soviet Union’s collapse, took a gamble on technology that paid off in spectacular style. Their system creates savings that fund the defence budget and relieves citizens of so much red tape that it is thought to save the equivalent of one day’s work each month, based around an edict that the entire government can only ask once for any personal data such as your address, birth date or marital status. Having emerged from the darkness of dictatorship, all data is controlled by citizens.

Even the health service is digitalised – curiously, based on the computer system abandoned by Tony Blair’s government after it spent £12bn trying the same in Britain. Medics can instantly access a patient’s history, whether in a surgery or at the scene of an emergency, while scans get shared fast and drugs automatically checked for safety. Patients decide who can access their records – so if they want a second opinion they can block a doctor from seeing their first diagnosis. Peeter Ross, a radiologist and professor of e-health, admitted there had been resistance at first. “Doctors are trained to think they’re the experts who make decisions but this is patient data. We must be equal partners. This works better for us all,” he said.

Intriguingly in a health system that bears similarities to the NHS, I kept hearing how people particularly enjoy tracking their treatment costs. This transparency was seen as helpful in keeping down spending by reducing any padding of bills by clinicians. It struck me that such a reform might have another benefit if it could be adopted by Britain: driving home to people that their beloved NHS is not free and that every call to a doctor, every consultation, every operation, every test, has a cost. For we need desperately to find ways to kick start serious debate over the future of our health service since it is sick and bleeding support from both citizens and staff.

There is a barrage of data to underline the crisis from the chronic staff shortages through to surging waiting lists, lengthening ambulance response times and the struggle to access NHS dental services. Yet the human tales of fear and suffering underscore the severity of the issue – such as the former NHS chief who last week told the Daily Telegraph he had lost faith in the system after being diagnosed with prostate cancer. Rob McMahon, 70. spent almost two decades as a top manager including heading up a primary care trust but felt compelled to spend £20,000 on private treatment to avoid a three-month biopsy wait during the pandemic.

The pandemic inflamed NHS pain, driving it to breaking point. Yet it mostly exposed issues clear long before Covid but ignored in a complacent country that preferred to cheer the NHS at the Olympics and clap it for doing its job in a crisis rather than confront realities. Rishi Sunak’s tired idea of a £10 fine for missed appointments is the only health reform proposal to emerge from the dismal Tory leadership contest, although there are suggestions his rival Liz Truss will tackle the pension restrictions that drive some high-earning doctors into early retirement. To her credit, Truss has argued in the past that the NHS should not be “put on a pedestal” – although as so often, she now seems to be disowning her own previously-held views.

Yet look at the problems. As the state struggles to cope with a society that is ageing and keeping more people with complex conditions alive, the central issue is funding. This is good news. But endlessly rising budgets for health look unsustainable. The NHS will soak up 44 per cent of the government’s total daily spending by 2024 – incredibly, 17 percentage points more than at the turn of this century. Two months ago, Tom Chivers pointed out here  that the number of medics in the NHS has actually surged over the past decade with almost one-third more doctors than in 2011. Meanwhile, both Sunak and Truss talk about cutting taxes and shrinking the state although defence spending will rise and many other public services seem in meltdown.

None of this adds up. We cannot keep throwing a steadily-rising share of state cash at the NHS without other public services suffering, especially if reducing taxes. We must also recognise blunt truths. The NHS performs badly in patient outcomes in many areas by international comparison. It is riddled with inadequate bureaucrats ticking boxes and managers failing to manage. Regulators are bad and vastly over-burdened. Front-line staff feel unloved and disempowered. Training shortfalls are patched up by foreign recruits. Patients are expected to be grateful, however long they wait or dire the service – despite a series of scandals exposing prejudice to women, old people and citizens with disabilities. Whistleblowers are crushed. Private firms run amok in mental health. Social care is shamefully underfunded.

For much of its 74-year history, the NHS has stumbled from crisis to crisis. Perhaps it will be patched up again with a few more sticking plaster policies, the dedication of staff and borrowed cash. Certainly, there are no simple solutions; many core problems can be seen in other rich nations with different systems. But this time, things feel different, more existential. Public faith in the NHS, for so long the national religion that unified the country, is faltering with dissatisfaction soaring to the highest levels seen this century. It will take much more than improving digital efficiency to save the service – but public recognition of the difference between free and free at the point of use might at least kick start the much-needed debate over the incompatibility between expectations and reality.

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