It is probably no longer plausible to claim we have 48 hours, one week or one election to save the NHS, but it does feel that in some sense we are at a significant juncture in thinking about the care system; a time for a fundamental rethink.
There are some things we don’t need to think about too much. There are some obvious fixtures that all but those on the fringes would agree on.
- Our healthcare service should be free at the point of need and funded predominantly through (progressive) taxation. (A big genuine question is why we think of social care differently.)
- We have a well-developed and mostly effective system of public provision of health care and there is limited scope and no economic rationality for its replacement by private organisations or for market competition being artificially introduced.
- Where decisions are made about health care resource allocation and priority setting then this must be through arrangements that are open and transparent and those making the decisions should be accountable through our established democratic structures.
- Care providing bodies which are publicly funded must be open and transparent in their decision making and must engage and consult with those who may be affected before making significant decisions.
- Patients have the right to involvement in their care and communities have the right to be involved in decisions about care services that affect them.
But even given a pretty wide area of general agreement in principle there is limited progress on making real all but the first bullet point.
But within the broad tent of agreement we are still faced with the need for a coherent answer to a few basic questions.
Should we have an NHS at all?
Why don’t we have a National Care Service alongside a National Education Service, and a National Housing Service? Why is remedial health care different? What glues health care into the rest of public services?
Is it really National, there are lots of local variations so what does the N mean?
What bits of our health does the H cover? Not public health.
Is it really a service or should the S now be for system?
What is the NHS for?
Mostly the NHS is thought to be for fixing illness. But maybe we want a wellbeing service which deals better with prevention and with broader care needs, with learning disabilities, with mental as well as physical health.
If the NHS as a major public body should it be an exemplar around good practice and should its contribution to public value be developed?
What is the NHS?
Most of the NHS is understood to be publicly delivered (through NHS Trusts and GP Practices), but much of it is not and never has been. Is the NHS made up of all bodies and organisations that deliver health services paid for by the state? Why are GP Practices which are bound to the NHS through contracts different from private organisations linked by the same (or very similar) contractual arrangements?
Is the planning/commissioning function part of the NHS? If it moved from CCGs to Health and Wellbeing Boards or was shared, is it in or out?
What are the boundaries of the NHS?
For historical but illogical reasons we have an entirely separate system for social care which is means tested and organised through local authorities and which is almost entirely privatised in terms of provision. But over time the boundary between the NHS and the rest of care is constantly moving – services that were free become means tested. Public Health is no longer within the NHS.
Does it matter? These are questions that don’t get discussed as even asking them tends to make some people cross. However it really is the time to think much more fundamentally about the NHS for two different sets of reasons.
First we are about to enter a new era. The NHS has always been separate in some sense – the fight to bring it firmly into the family of public services organised through local authorities was lost. In very general terms we had 4 decades of the initial Bevanite model for the NHS. This had some overall coherence as regards dealing with acute illness but was weak in terms of dealing with long term illness, had limited management, no real accountability, no public and patient involvement and poor and unequal access. It was probably inefficient in the way it allocated resources but we have no way of knowing as it was weak in terms of data and information.
We then had the era from the 1990’s which introduced both managerialism and marketisation, pretty well mixed up. It still left a separate NHS remote from other public service. It shifted the paradigm away from professionals and towards managers and (maybe) patients. Access and efficiency improved, regulation and public and patient involvement were introduced, planning (commissioning) was split from provision. This culminated in the Lansley proposals which were the first bold step towards an NHS that was a regulated market, with improvement driven through competition amongst providers and which opened the way to alternatives for funding and for a switch to an insurance system.
It is pretty clear the H&SC Act which emerged as a watered down and less coherent version of the Lansley ideas is not being implemented as conceived. All the evidence shows competition and commissioning does not really work and so the era of markets has ended. The Five Year Forward View which appears to be the current strategy for the NHS does not remove the market infrastructure it just ignores it.
The second set of reasons flows from the impartial analysis of what needs to be done? (Something must be done, this is something.) What is it that needs fixing? The recognised big issues are:-
- The NHS contributes very little directly to improving health (other than in the obvious sense of fixing illness) or to reducing health inequalities.
- The NHS has major unjustified variations in terms of quality, efficiency and outcomes generally. Variations in quality occur even within the same organisation.
- The professions and NHS managers are poorly adapted to the need for shared decisions making and for public and patient involvement.
- The cost of care rises faster than GDP growth and the tensions this creates are unresolved.
- We have an unstable system with no real strategic direction either nationally or locally. We have no idea around levels of funding even in the short term. We have poor management as many good managers have gone and there are too many organisations to supply good managers to them all.
- There is a growing realisation that organisational changes as such and especially major top down reorganisations of the whole system don’t work. There is also an understanding that stability is important. So how is change brought about?
Anyway that is a long way of saying that before we launch another reorganisation or another 10 year plan or a five year view or even a new party policy position there needs to be some new thinking and some new answers to the most basic questions.
Richard Bourne, September 2015