Making any kind of changes in the NHS has a long and troubled history. Decades of apparent consensus around key principles are undermined by huge disparities over how to deliver on them. There has been no shortage of plans, but most fail or get ignored.
The era of markets and competition from the 1990’s has come to an end with little clarity about what replaces it. There can be no return to the professional trust model that preceded it, no return to some golden age that never existed. The shift to syndemic care, the need for service integration, a greater role for patients, and huge technological changes (genomics, robotics, AI and more), new drugs and techniques, have added new issues to argue about.
And whilst we may have been smug in the 1940s, today almost every developed country also has universal comprehensive care, and we have much to learn from the best.
Whilst in 2010 the NHS had the shortest waits and the highest level of satisfaction on record it was still not fit for purpose. Outcomes were not good enough, the model of care had the NHS as an isolated chain of islands, and there was no coherent operating model with resulting major unjustified variations.
Deterioration since then has amplified the issues and we are way down the table on quality of care. Life expectancy has peaked and is falling for the poorest: inequality is increasing; and 2.5m are out of the labour force with health problems. Poor population health is a drag on the economy, slowing the growth needed to fund better services – a vicious circle. An ever less healthy population relies ever more on remedial care and hospitals, reducing funding available otherwise for prevention and better health care closer to home.
Even if the moral case for investment and change is not enough the economic case must be. There is little doubt the whole care system is at some kind of tipping point.
Public views and expectations are a barrier to change. Aside from the very poor understanding of social care (and its relationship to health care) the public requires more hospitals, more staff and more GPs but is less worried about inequality or better care or improved wellbeing. Moves to focus on population health, on prevention and on improving efficiency all must face political as well as organisational obstacles. Perfectly sensible well evidenced attempts to improve quality or drive efficiency are routinely denounced as “cuts”. Sensible moves to drive prevention are denounced as nanny state intervention. The two most recent attempts at a cross party consensus to try and address deep seated long term problems in social care were both torpedoed by political opportunism.
A huge amount of work has been done to understand the issues and suggest roadmaps or other forms of solution. There is a growing consensus on what “better” would be like in terms of improved healthy life expectancy, and an approach to outcomes best articulated by the various definitions of wellbeing.
How to improve social care and a credible roadmap to a better system has been set out; the work has been done to show the likely costs of improvement and the amounts involved are not prohibitive. The only thing lacking is the political will to do it and the management capacity (mostly within local authorities) to deliver the changes.
The new era of the NHS after markets is not yet defined, although nobody want top down redisorganisation. What drives improvement? How does accountability work across the Department, NHS England and the newly emerging ICBs? How are the vested interests of big providers managed in any system reliant on collaboration and cooperation? What is national and what can be devolved to local? How can an allegedly national system continue to have such wide variations in quality, productivity and performance? We need the Operating Model.
And behind the operating model how does the funding flow? The NHS has proved to be poor at allocating funding to where and what would be most valuable. Internal vested interests and external political and managerial pressures warp effective allocation. Gains can be made by better allocation rather than just increasing funding.
And how is any “reform” managed? Where are the people with the skills and experience to manage huge programmes and major projects? Or those to ensure the right data is collected, analysed properly and reported to those who may not like the conclusions? (If they exist, they are employed by parasitic major management consultancies whose multiple versions of wisdom have contributed to the mess we are in.)
The NHS cannot function effectively without a public health system to minimise the numbers developing avoidable health problems, along with proactive measures to improve the living standards and conditions of the poorest and reverse the recent downturn in healthy life expectancy.
Hospitals and primary care services cannot function effectively without the development of a universal and accessible National Care Service in place of the current cash-starved, dysfunctional, and largely privatised shambles that is social care.
Reducing the dominance of acute care requires a model for bringing primary and community care provision together in some organisational way so there is a collective voice absent since PCTs were stripped of the ability to deliver anything (PCNs may offer one route). The current GP small business model needs to adapt over time to reduce risks around property ownership and staffing and more salaried GPs will be required taking roles across the systems (we need more generalists).
Work is being done on a NHS workforce strategy that could result in plans at national and also at local level. Once some sort of target is established then there has to be a strategy agreed with the workforce itself as to what has to be done to address issues around retention as well as recruitment. There must also be a plan to converge terms and conditions across NHS and social care and to allow much easier movement within the system. And the NHS in particular needs a step change in its people management systems and an end to top down management by shouting.
The NHS and social care require higher levels of funding and a period of funding certainty to ensure management do not spend the whole time on day to day crisis management, but how much and when depends on the speed of economic recovery; no making promises that can’t be kept.
Crucially there is the wider issue of investment. The whole of public spending on care could be seen as just that – an investment in a healthy and more productive population. But the worst feature of recent years has been the failures around more traditional capital use – to make buildings safe, to increase and improve capacity around premises, equipment and technology as well as mythical hospitals. Without a shift in approaches investment in the NHS and far better (and faster) methods to evaluate investment proposals, “reform” is reduced to short termism and pointless system reorganisations.
Despite the enthusiasm for “integration,” hospital, primary and community health services cannot function effectively together when the NHS is carved up into countless legally enforceable contracts. Nor can we allow the private sector to be parasitic - PPP, PFI, test and trace, management consultancy and dodgy outsourcing deals. The value of what the best of the private sector can bring (rapid development of vaccines, diagnostic equipment, data analysis) should be understood alongside the principle that clinical services should not be outsourced to deliver short term costs cuts. NHS capacity needs to increase to reduce reliance on for profit organisations. And a far better appreciation of the value the third sector too.
On the bright side, answers are beginning to come along. There is a surprising degree of consensus on what the objective should be – a healthier nation! And also, agreement on some of the definite dos and don’ts to get there.
If we can park the worst of the political arguments and the conspiracy theories, then the solutions to the hard questions are known at least in broad terms.
Bringing all the analysis together into a programme that could be delivered by an incoming government with at least two terms is vital but possible.
Electing a government that cares enough to take the political risks to actually do the hard things as opposed to the immediately popular things is a bigger issue.