The Soul of the NHS

May 11, 2011 § 3 Comments

The battle that is raging across politics at the moment has some GPs and the government ranged against nurses, clinicians, and (often hypocritically) opposition politicians. Whilst it is clear there’s a lot to argue about, it’s often hard for a non-professional to get to grips with the arguments. Which is of course where the government is hoping to win the battle; they can’t win the professionals over, but they can outvote them.

There is no question that NHS money is often horrifically badly spent. Labour made vast, vast increases in the NHS budget and the results have been far less than stellar. In fact, it is probably symptomatic of Labour’s greatest failing; throwing money at problems does not solve them. Much of that money got thrown into PFI schemes, which commit money to a long-term plan whereby a private company manages resources in exchange for a long term spending contract and outsourcing some services. This can lead to huge waste if the company manages to get a good deal on the scheme; the private sector ends up pocketing the money it doesn’t spend on services, whereas in the regular NHS those savings would go back to service provision. A lot more got thrown on highly expensive medication, much of which was funnelled into the pockets of drug multinationals. About 60% of the NHS budget is staff, a further 20% on medicines, and the rest on buildings and other such expenditure.

The budget has ballooned, then, and to pay for treatment for an ageing population more value for money is needed. The 2008/9 budget roughly worked out at £2000 of tax money in for every UK citizen (including children); with such huge investment, it is very clear that results are needed.

The government’s “solution” to the problem is to give control of budgets from the Primary Care Trusts that currently regionally manage the NHS to “consortia” of GPs who would directly manage the funds. The GPs would have the option of shopping around between different hospitals and treatment options, directly funding the ones they felt were best for their patients. Those hospitals that were failing would have to improve or risk financial oblivion. The idea is essentially that in a market for care, competing hospitals will do better as they are under more pressure to cut costs and lower prices.

There are several major flaws to the idea, however. Some are easy to spot and the clinicians opposing the system have teamed up with the opposition and worried Liberals to trumpet them very loudly; this could mean hospitals literally going under, which would undeniably restrict A&E access for many people.  Releasing the hospitals from the main NHS could also (much like the academy system for schools) lead to a variety of anomalies such as performance-related pay for keeping costs down and other public sector ideas which, while helping resource management in a business, are alien to the task of caring for the sick where care must always be prioritised. Finally, there is a great risk of corporate providers being able to offer some more lucrative services at slightly lower cost, which would leave the former NHS clinics as the only places to get more mundane and less lucrative treatments. In turn, this could mean the NHS clinics did not get enough money from the GPs to survive independently. Strategy for healthcare will thus be haphazardly done without one consortium knowing what the next is doing; the lack of strategic authorities means that planning for geography simply is not part of the planned system. The whole plan is shot through with risk after risk, and without obvious plans for a long-term regional trial of the system it is impossible to say what may or may not come to pass.

There are even deeper concerns though, and those are about accountability. Healthcare is one of the most important functions of government for many ordinary people across this country, and putting it in the hands of GPs means that it is essentially outside any sort of accountable or electable structure. That could have damaging implications for people’s trust in healthcare and in their GPs; the bond between patient and carer must be one of total trust, and knowing the carer is also the banker of care will surely damage that. GPs need a strong voice on Primary Care Trusts, that is undeniable: the requirement for only one GP on a PCT board is visibly pathetic. However, the board as a whole being partially independent of the front line is also important. Any problems in funding will damage the standing of GPs and the GP-patient link directly; trust will be broken with the people patients need to trust most, while government ministers can show the world clean hands.

But, as I have just said, the NHS needs reform. Financial pressures will kill it if no action is taken. So what can be done? Well, quite a  lot actually. Giving shorter timeouts on drug patents (say, 5 years instead of the current 50) would give companies ample time to recoup their R&D costs by selling to specialised clinics & hospitals and the private sector, then open up the drug creation market to other competitors. Whilst clearly companies need incentives to develop new drugs, direct financial rewards from the state and a few years of “grace” to make quite a lot of private money would retain this incentive and reimburse companies. The fact is that most drugs can be made quite cheaply, and with 20% of the NHS budget going on them it makes so much sense to prevent companies charging through the nose for drugs they developed fifteen years ago and recouped the R&D for in the first five years.

PFI schemes, as I’ve mentioned, are the other major drain that needs to be reined in. Despite the clear failings of the scheme the Coalition have continued to pour billions into various PFI initiatives – when they go well there is clearly value for money, but in the long run the potential for real and pointless loss to the taxpayer is simply too great. The Private sector does not have a monopoly on efficient management; in the long run, the NHS needs its own trained in-field managerial staff coming from a background of care not cash. Renegotiation on many contracts should be looked into extremely seriously, and the government must halt any further expansion of a dangerous and costly programme.

The NHS has also failed to do some vary obvious things to make savings. Cleaning in the NHS has been often neglected; the cost of training in-house cleaning staff rather than subcontracting may look high, but the costs of treating patients with MRSA is yet higher. Similarly, “savings” by not treating a cataract (which some areas have decided to do as part of the government’s efficiency) could cause a fall and broken bone in an older patient which will be more expensive to treat. The pattern of efficiency is more complex than it looks to inexpert eyes, and that is why, again, it needs experts to manage it. GPs are too close to the front line and need to retain immensely high levels of trust (more than any other UK profession); there is a role for specialists, and the private sector and its ethos simply doesn’t cut it to plug the gap.

The bottom line is that NHS reform can only be achieved by recognising that healthcare is not the same as the provision of food or clothes or cars, and must only be achieved by looking at practical solutions to cut costs before looking at structural solutions with their dubious claims of efficiency. Healthcare is a public good; all of us benefit from having an NHS, and the economy benefits as well from having a healthy workforce which can work for longer and has less time off sick. It is therefore natural for it to be provided via government or local government as it is an economically cheaper and more practical and humane solution overall. It is also, therefore, not something where the usual impetus of supply and demand can reign supreme; the key elements of care and trust in the system have to take precedence. Choice is not what most people want in the NHS; people want effective treatment locally and free at the point of use. There are ways and means of delivering that, but financially threatening hospitals, subcontracting to cut costs, and endangering the link of trust between doctor and patient are certainly not those ways or means.

Why I am still an electoral reformer: After the referendum

May 8, 2011 § Leave a comment

So, that’s that. AV has lost the referendum, the rest of us can go back to nice safe FPTP which produces good clear results and everything will be fine. Or at least, that’s the narrative that the Conservatives and much of Labour, not to mention the press, would like to have injected into every household in our country.

Not this one.

It seems foolish, ridiculous, even quixotic for me to be making a post in favour of voting reform after it was rejected by 67% of the voters in a crushing referendum victory for our current First Past the Post system. It probably looks fairly churlish, the moanings of an upset loser. But then again, if I cared about any of that I wouldn’t be writing this now. What I care about, what I will always care about in regard to this issue, is working towards a future where people’s views really count. I am a democrat; I believe that we as the people of Britain have the right and the duty to self-determine our futures. It is obvious even from a fairly cursory glance that our current system is failing at that job.

It is, at its core, an issue of fairness against unfairness. The only argument that can be made for non-proportional, non-preferential systems is that they are simple and decisive. So is the one party state in China, a system which I eagerly await a referendum on adopting backed by those who believe that a decisive system is best. Yes, a change in voting system might mean more hung parliaments and coalitions; surely, that is a small price to pay for people actually having their voices heard. Anyone who’s watched the pantomime of Brownite/Blairite splits in labour will know full well that coalitions have no monopoly on split governance; in fact, by formalising it instead of forcing opponents into a few huge parties they often lead to a more professional approach. The worries about “backroom deals” are similarly groundless, as in a better voting system it’s far easier to vote a party out of existence if they’ve gone back on their election promises.

The fact is that First Past the Post (a misnomer in itself, since it doesn’t even HAVE a post) is an unfair and undemocratic system. There are people up and down this country whose votes will never send an MP to Westminster purely by accidents of geography; so much of the time people realise their vote means nothing, and so they simply don’t vote at all. The reason for this is that with First Past the Post as long as around 40% of voters support a party, it is rare in our current 3-party system for another party o be able to muster the same level of support. So even if the remaining 60% of voters hate candidate A and would all rather candidate B, unless they all vote tactically for B to keep A out (and so the views of voters for C, D, and E are wholle ignored) then A will win. When a candidate CAN get 50% of the vote the situation is even worse. The rest of the voters stuck in that constituency now never have a way of getting their voices heard; they stop bothering after a while. The seats become “safe”, party fiefdoms where only one party has any say at all. Voices are drowned in an entrenched system where to vote against the norm is pointless.

So how could the system be improved?

Preferential voting systems, such as AV or Preferential Voting or the Single Transferrable Vote, are an improvement in getting people’s voices heard. The simple reason is that they ask people what they prefer – they allow people to give their full opinion not just a single cross in a box. The voting is done in several rounds, with everyone voting for their top remaining choice in each round. When seen this way, the fallacy of “some people having more votes” is revealed as a myth; some people are forced to change to a lower choice, whereas others are able to vote for the same candidate in every round. They’ve all voted exactly the same number of times, and unlike FPTP a) there is actually a post, at 50% of the vote (less in STV as there are multimember constituencies) and b) the candidate elected is the one a majority of people prefer not just the person who has the largest individual mob backing them. A preferential voting system therefore clearly gives voters more choice, more ability to express their views, and candidates who can actually claim to represent their constituency not just a third of it. I won’t go into the realpolitik, but it’s worth noting that preferential voting makes gains for extremist parties harder due to their lack of plurality support. All these points, however, are really comparatively small changes.

The far greater issue, which this referendum did not cover at all, is that our voting system is not proportional. That is to say, the number of seats a party gains is in no real way linked to its vote share. Labour won over 50% of the seats in 2005 with 35% of the vote; on the other hand, 1951 saw the Conservatives gain a majority despite Labour beating them in the popular vote. I can continue the list: 1983 saw a vote to avowedly anti-Conservative parties of well above 50% yet Thatcher got a stamping majority, the Liberals got 9% of the seats in 2010 even though 23% of people wanted a Liberal MP. If we even pretend to want a democratic system, we cannot go on like this. It’s simply not true that FPTP gives most people what they want – in fact, FPTP gives most of the UK’s electorate an MP they’d much rather get rid of and shuts many people permanently out of the democratic process. By a simple system of decreasing the number of constituencies slightly and adding regional top-up lists for the votes that were not used up in constituency ballots, we could make a huge change to how representative our voting is even without switching to a preferential system.

Make no mistake, this matters.

Why? It matters because we will never engage people in democracy if we hold to a system where more often than not their votes count for nothing. It matters because a safe-seat system entrenches boring, managerial politics and drowns out other voices. It matters because nobody has all the wisdom, and only by hearing from everyone in this country will we be able to build a future that is better than our past.

Finally, it matters to a pensioner in Lincolnshire. My grandfather has voted in every election since the 1930s, and has not once cast a vote under FPTP that sent an MP to Westminster. He has believed in Electoral reform all his life – not in order to make things more complex, not to gerrymander results, not for anything more complex than wanting to be able to have his voice heard and be represented in our democracy. I don’t think I need to tell you that he doesn’t want to talk about what happened yesterday. Or that it’s now quite unlikely that he’ll live to see a system where he can fulfil the simple act of having his voice heard.

And so it’s important to me too. I believe in electoral reform for the sake of my family, for the sake of fairness, and for the sake of my country. The defeat of the AV referendum is a setback, and it shows among other things both the power of the vested interests who want to keep their safe seats and the work still to be done in showing the 27% of people who voted against reform (that’s not a mistype either, it includes turnout figures) of the benefits of a better system. It’s not time to give up hope though – it’s time to restart the fight in earnest.

As for myself, I am still an electoral reformer. I will be be fighting for a better system as long as there is breath in my body and blood in my veins. While it won’t be easy, I hope that in time all who are in favour of fairness will be standing with me.

Oh, and first post!

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