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.

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§ 3 Responses to The Soul of the NHS

  • Alec Young says:

    Great work James! Keep it up, a very interesting read!

  • Tom Young says:

    All sensible points but I think you underestimate two factors. Firstly and comparatively UK per capita health spending is not that high, certainly much lower than the US and secondly, and I think more importantly, the political class in the UK and the West generally are deeply hostile of the public provision of anything because they have bought into some very pernicious theories about ‘the market’, ‘producer conspiracies’ and so on. I am Alec’s dad by the way !

    • jubalbarca says:

      Very true on both counts, and I’ll be dealing with the public provision thing several times in other posts I’m sure. Because we’re doing health well doesn’t mean we can’t do it better though. What’s really needed is higher end income tax to be at a level that can sustain better services, but that’s not likely in the forseeable future sadly.

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