Lecture: The NHS - Things That Need To Be Said
27 Jan 2014 at 14:39
This is the text of a 45 minute lecture I gave today to an audience at Queen’s Hospital in Romford. It is the annual Leslie Oliver Oration. Every year the hospital celebrates the works of one of pioneers in Neurosurgery in this country. Leslie Oliver founded the Neuroscience unit at the hospital when he began Neurosurgery there in 1945. It is more than 7,000 words long and covers a lot of ground so you are forgiven if you don’t read it all! For those that don’t have the time, there follows a short executive summary of the main points.
1. You can’t take politics out of the NHS when it spends a sixth of all government spending.
2. Health secretaries are in office for an average of just over 2 years. That’s not long enough.
3. Politicians must be able to criticise and critique the NHS without being accused of wanting to dismantle it.
4. The ‘public good, private bad’ mentality must go.
5. The private sector is already an integral part of health provision (dentistry, pharmacy etc) and should be embraced.
6. The issue of charging for some treatments will need to be properly debated, but where should the line be drawn?
7. Should we pay a nominal charge for a GP visit?
8. We don’t have a truly NATIONAL NHS and we should stop pretending we do.
9. Primary Care Trusts were a brave effort to make things more local, but they were doomed by debts and lack of democratic accountability.
10. Community hospital and bed closures are too often driven by financial concerns, rather than clinical ones.
11. Drug licensing and provision needs to be looked at properly.
12. If people use their own money to pay for drugs the NHS is not providing, they should not be penalised for it.
13. The extra money put into the NHS has been eaten up by unwarranted pay rises for GPs and consultants, and NHS inflation.
14. NHS procurement methods need to be sharpened in order to reduce NHS inflation. Its buying power should be utilised more.
15. Standards of nursing care have fallen below what is acceptable in some hospitals.
16. Nursing training needs to be changed and improved, and nurses should not be required to have a degree level qualification.
17. The 48 hour week should be abolished in the NHS.
18. Nurses need to be able to work on the same ward in order for continuity of care to be maintained.
19. The word ‘care’ needs to be the first, second and third priority for nurses.
20. Doctors and nurses need to be made more accountable.
21. We need to be more careful about recruiting nurses and doctors from foreign countries. Those countries often have more need of them than we do.
22. Not enough planning is being done to prepare for an increase in the UK population of ten million.
23. We need to integrate primary and social care.
24. Have we planned to cope with the increase in the elderly population?
25. NICE has failed and needs drastic reform if the postcode lottery is to be ended.
26. We need a 7 day NHS, where more GP surgeries are open when people are free to visit.Operating theatres need to be used at weekend.
27. A&E departments should not be employing GPs.
28. Cuts in the mental health budget should be reversed.
29. GPs are often not equipped to deal with patients with mental health issues. Training must be improved.
30. Mental health facilities are provided by too many different bodies and few people understand what they are.
31. There should be more support for dementia carers, especially more Respite Care.
32. Preventative healthcare initiatives are too often expensive gimmicks.
33. We can’t have a rational debate about the future of the NHS until we accept that it can’t meet all the demands made on it.
34. If we were to set up a new NHS from scratch, would it bear much relation to the NHS we have today?
I don’t think I have ever given an Oration before! Thank you so much for asking me to be here today. Looking through your previous list of speakers I am afraid what I am about to say bears little relation to what you will have heard in previous years, mainly because I know nothing about neurosurgery. And I am not about to embark on a change in career!
Agreeing to give a lecture to an eminent group of people who inevitable know far more about the subject than you do is perhaps not the wisest thing for a political pundit and broadcaster to do. So in the next half an hour or so I don’t intend to tell you how to do your jobs.
What I am going to attempt to do is identify some issues which I think will dominate the health agenda over the next decade. I want to challenge orthodox NHS thinking and say a few things which I think need to be said, but don’t always seem to form part of the current debate.
In many ways, senior health professionals like yourselves and those in government and opposition have much in common – even if that thought might fill you with a degree of horror.
You’re all trying to wrestle with the demands of an empowered, knowledgeable twenty first century consumer base while you are all operating within a structure designed for a mid twentieth century command control system of healthcare provision.
There is another communality of interest – you all have a fair idea of what needs to be done but no one in politics is courageous enough to articulate either the problems or the solutions. And sadly I do not see that changing either under this coalition government or a government led by Ed Miliband. No one is prepared to think the unthinkable, say the unsayable, much less implement the do-able.
POLITICS & THE NHS
Politicians treat the NHS as a political football – insisting on initiative after initiative – to prove that there really is ACTION THIS DAY, and yet consistently fail to plan for the long term. They seem to think that structural reform and targets will yield results – and sometimes, in the short term they do, but who can really say that they can think of a single Health Secretary who has been able to plan for the long term – of either party? During the 13 years of the last Labour government there were six different Health Secretaries.
The Conservatives under Margaret Thatcher and John Major did a little better and managed only seven in 18 years. The coalition government has had two different health secretaries so far. So a Health Secretary serves for an average of a little over two years.
Of the fifteen holders of this post since 1979 very few had any direct experience of health policy before they took on the job. So they spend six months reading themselves into the job and the last six months trying to save themselves from being sacked. This gives them each just a year to make an impact. A few years ago, the Adam Smith Institute published a report which opened with these words.
Secretaries of State and their junior ministers come and go with sometimes breath-taking frequency. But the one thing they all have in common is the desire to make headline-grabbing changes to advance their careers. As a result the NHS is besieged by a bewildering array of initiatives from one minister, only for him or her to be replaced by another minister with their own (often conflicting) ideas. Politicians tend to think that they can improve the health service by simply giving orders, or setting targets. But such measures always have perverse effects, distorting clinical priorities and encouraging creative accounting. NHS policy should be determined by medical priorities and not by political ones.
Bearing in mind the NHS is one of the world’s largest organisations, this way of running it is utter madness. If IBM or Glaxo changed their chief executive every two years their share prices would plummet and within a short time the company would be considered a basket case.
And so we constantly hear pleas to take the politics out of the NHS. Liam Fox, when he was Shadow Health Secretary, said it. Various Labour Ministers said it. Andrew Lansley said it. Jeremy Hunt actually believes it. But surely none of them can be so naïve.
After all, the fact that the Health Service eats up £115 billion – a sixth (!) of public expenditure means that the way that money is spent has to be made accountable, and that has to be through the political system. The trouble is that half of this sum has, according to the Wanless Report, gone on price inflation and extra pay – 25% to consultants and 23% to GPs.
Was that the right thing to do? Voters will be judge and jury on that point. It had to be a political decision, not one made by a faceless independent board. So any politician who calls for politics to be taken out of the NHS is likely to be doing it to get a cheap round of applause of Question Time and can safely be ignored. It ain’t gonna happen, and nor should it.
That’s my view, but interestingly the think tank, the Adam Smith Institute begs to differ. Its briefing paper documents the bewildering and counter-productive range of political initiatives and interference which, it says, has wreaked havoc on our nation’s healthcare system.
The paper’s proposal is for a distinguished panel of health professionals to be appointed to run the NHS, to allocate its budget, determine its priorities, and operate it according to medical needs rather than political aims. A YouGov poll taken on the subject showed massive popular support for precisely such a proposal, with 69 percent in favour and only 12 percent against.
The NHS budget would be set by Parliament every five years, and up-rated each year in line with inflation. The ASI’s YouGov poll showed that this idea, too, enjoys widespread popular support, with 74 percent in favour. The suggestion that “the NHS has become a political football” receives 72 percent backing.
Whatever the merits of the Adam Smith Institute’s proposals or those of the Conservatives, an independent NHS it certainly isn’t going to happen when we consummate political brains in Number Ten. Think back to the Gordon Brown government.
I’m told that the Deep Clean initiative wasn’t thought up in the Department of Health. It came direct from the Number Ten Policy Unit, who gave the Department of Health a few hours in which to consider how to make it work. It was duly announced by the Prime Minister who made it sound as if this would be the only measure needed to eradicate MRSA and C.Difficile from our hospitals. Indeed, when I heard it I thought it sounded a deeply sensible measure.
That is until I switched on a 5 Live phone in and heard a succession of health service professionals slam it. Not a single one of them thought it would work. Not a single one of them was taken in by it. It was at that point I started to wonder if this gargantuan political brain was actually as formidable as we’d all been led to believe and that if his administration wasn’t just as driven by spin as the previous one.
Just as a Transport Secretary is judged on whether their tenure of office is free of a major rail crash or transport disaster, a Health Secretary is now judged on whether they can keep NHS stories off the front pages. That’s why Andrew Lansley had to go and was replaced by a politician with a far better bedside manner.
So that’s my first thing which needs to be said: You can’t take politics out of the NHS, and nor should you. In fact, as I shall explain later, I think we ought to be having a big debate about the NHS, but we are being denied that debate because whenever any politician on the right or left, but mainly the right has the temerity to criticise the NHS he or she is jumped on and warned about the consequences of having a go at a beloved institution.
If you point out that outcomes in the NHS are in most areas way below other comparable nations you are accused of denigrating people who work so hard in the NHS or advocating privatisation even when you’re not. If the NHS can’t stand up to robust critique, it says an awful lot about the arguments of its very vocal defenders.
PRIVATE SECTOR V PUBLIC SECTOR
Nowhere is this more apparent than in the private sector versus public sector debate which has bedevilled health policy for some time. In my view, this is at the very core of the failure of politicians to provide the leadership the NHS needs.
The public good, private bad mindset which bedevils politicians on the left is equally matched by the private good public bad attitudes often prevalent on the right. Only in this country could this happen. Even in these days of supposed consensus these attitudes still prevail.
Do any of these politicians think people care if people are treated privately or in an NHS hospital if they get the treatment they want, where they want, when they want it? Of course not. Yet people who use BUPA are made to feel as if they are somehow being elitist, rather than being praised for taking responsibility for their own healthcare and not burdening the NHS with their demands.
Beveridge and Bevan never meant for the NHS to have to meet every single demand ever made of it. Two systems can work happily together as long as each respects the other. For too long in this country Labour politicians have seen private medicine as a class enemy and Tory politicians have viewed the NHS as something for other people to use, not them.
David Cameron makes great play out of the fact that he is a regular user of the NHS. He had a disabled son whose fits made regular overnight stays in a local hospital a normal occurrence for him. His view was shaped by his experience. He put the NHS at the top of his agenda. He says his three priorities can be summed up in three letters. N. H. S.
One of Cameron’s first acts was to abolish the Tory policy of encouraging private sector healthcare. George Osborne said in opposition: “We are having no truck with ideas for some alternative funding mechanism like social insurance. Nor are we looking to help fund escape routes from public services for the few who can afford it, which is why we have moved away from the idea of the patients’ passport.”
All very well, but where are we going to get the capacity from if the private sector is not embraced in a way it hasn’t been before?
Let’s not pretend that private sector involvement in the provision of healthcare is anything new. Most people use private sector dentists. GPs are effectively in the private sector, as are most osteopaths and physiotherapists.
Drugs are provided by private sector suppliers. Chemists and dispensaries have never been in the public sector and no one has ever suggested they should be. It was recently reported with some horror in the Guardian that 70% of NHS contracts are with the private sector. They put this down to the Lansley reforms, omitting to say that the private sector has always played a major role in health provision.
Opponents of the private sector also raise the spectre of the NHS introducing charges, conveniently forgetting that patients already pay prescription charges. From time to time, the issues of charging for hospital food, or GP visits are floated, but quickly ditched once the howl of public outrage subsides. However, on radio phone-ins such as my own, the idea of charging for NHS services is quite popular in some areas. For example, people ask why the taxpayer should pay for the treatment of people who bring their own misfortune on themselves.
People who binge drink on a Friday night and end up in A&E. Why shouldn’t they be charged? People who regret getting a tattoo and can apparently have it removed courtesy of the NHS. But where do you draw the line? Charge smokers for lung cancer treatment? Charge obese people for diabetes drugs? Another one for the too difficult box, I suspect.
People questioned whether the Conservatives would also embrace the target driven culture which so obsessed the previous Labour government. It seemed to be the only way to increase throughput, although NHS managers continued to try to convince us that we can do with fewer and fewer beds and various management consultants still try to hypnotise us into really believing their reports that people prefer to be treated at home, no matter what their affliction.
The Conservatives professed to want to abolish the target culture yet have so far failed to explain how this can improve capacity. Because the truth is that weakening targets has led to capacity issues in many areas of the NHS.
This brings me on to structural issues. I was interested to see Chris Huhne say before the advent of the coalition, rather courageously, I thought, that the NHS needed to be broken up into local units. Quite what he meant by local, he didn’t say, but you and I know that turning round the NHS is like turning round an oil tanker.
It takes years, sometimes decades for structural and organisation changes to come into effect. And by the time you’ve worked out whether they were right in the first place, it is too late or we have different priorities.
So we’ve had various forms of local accountability over the past twenty years, none of which have proved satisfactory. In theory the smaller versions of Primary Care Trusts ought to have provided that, but were often so saddled with debt that they could not respond to local needs.
They therefore had to embark on a rationalisation process which local people just could not buy into. They felt they were being hoodwinked and that elaborate consultation exercises were generally a sham and that the decision had already been made. I saw this at first hand in North Norfolk, where I was a candidate at the 2005 election.
People kept being told that everything was done in their best interests but they just didn’t believe it. It even got to the point where people were even less likely to believe the words of a PCT official than those of a politician.
People just didn’t buy the argument that Community Hospitals had to close and that the same level of care could be provided in people’s own homes. They couldn’t see why a local alzheimers’s unit had to be shut, only ten years after it had been built specifically for that purpose. Local people weren’t convinced and local politicians weren’t convinced either. And even if they had been, could they, could I, as one of them, have had the courage to say so?
This culminated in Labour Party Chairman Hazel Blears joining a protest in her constituency against the closure of a maternity unit her own government wanted to shut.
What had brought this about? Was it really all about medical advances meaning that maternity care needed to be concentrated in one place, or that Community Hospitals were no longer relevant due to the level of care being provided at major hospitals?
Or was it more a question of funding, and the NHS was being forced to cut its cloth according to its funding? Most people suspect that many of the closures are being forced by the latter rather than the former – and this despite health funding having more than doubled since 1997.
People are rightly asking where the money has gone. They blame politicians, but they also blame so-called NHS bureaucrats who seem happy to accept a situation where a hospital has more managers than beds, more managers than nurses.
They see an organisation which is top heavy with middle management and a cadre of politicians who seem powerless or lack the will to do anything about it.
And the thing is, in this ever less deferential society people simply will not sit there and be told that others know what’s best for them.
On another level GPs see it every day in their surgeries. Patients engage in self diagnosis at a level undreamt of. They look at the internet and wonder why, if a drug is available in Texas, they can’t be prescribed it locally at their surgery. Some patients even turn up with their laptops to explain to their doctor how they have arrived at a particular conclusion. Now doctors realise what politicians have had to put up with for decades!
I want to return to the issue of funding, because it permeates all other concerns in the NHS. As I said before, a huge amount of money has been channelled into the NHS in recent years, but it’s not just politicians who are failing to see an outcome – its patients. Even though nearly half of it has gone on meeting inflation and pay increases, a doubling of financial input ought to have led to a double figure rise in productivity.
It has not and people want to know why. There will soon be a funding shortfall of £7-15 billion a year. How can this be? Is it a problem of acute financial mismanagement? Is Health Service inflation really so high? Why are efficiency savings so hard to make?
The Wanless report rightly highlighted a real fear that if the NHS does not prove it can use its money better taxpayers will no longer be willing to cough up for it.
Wanless said: “Such an expensive service could undermine the widespread political support for the NHS and raise questions about its long-term future.” This is perhaps unnecessarily apocalyptic, but it is something which politicians would do well to take note of.
We are already seeing in the area of constitutional issues, Europe and the devolution settlement, that if voters think they are being taken for granted they react accordingly.
CARE & THE PATIENT EXPERIENCE
We all make judgements on the NHS depending whether we work for it, we are patients ourselves or we have family or friends who use the NHS. All our judgements are based on our own experience or those of those close to us. Indeed, doctors, surgeons and nurses are not immune to this, with survey showing that in some hospitals 70% of those that work there wouldn’t want their family members to be treated in their own hospitals.
It’s all anecdotal evidence, but that’s the only evidence an individual has got. So when learned academic studies are published that are at variance with our own experience we tend to speak out. Clearly, people always tend to highlight the negative rather than the positive, which is why whenever I host a phone in on my radio show about a particular aspect of the NHS I am always careful to solicit positive as well as negative callers.
Ann Clwyd, the Labour MP, became a bit of a bête noir for some in the medical profession when she told of the terrible care her husband had received courtesy of a hospital in Cardiff. He died. She made a tearful speech telling of their experience and was later asked by David Cameron to head a review looking into complaints against the NHS.
Her report made very sad reading for all concerned with the standards of nursing care in this country. I regret to say it chimed with me, for my mother went through a terrible experience at Addenbrookes Hospital, after which she sadly died. It was a horrible experience for her, for my father, for my sisters and myself. Throughout it all, we felt powerless. It turns out that she was put on the Liverpool Care pathway. We were never told about it. No one seemed to be able to tell us what was happening to her.
She was put on the wrong drugs. She kept telling us “they’re trying to kill me”. We put it down to the effects of the drugs, but in the end perhaps she was trying to tell us something that we were too deaf to hear. We put our trust in the hospital and they let us down. More importantly they let her down.
The standard of nursing care was lamentable. Different nurses every day. I reckon she had 150 different nurses in the three weeks she was in that ward. I’d love anyone to tell me how there can be any continuity of care in such circumstances.
I queried why whenever I visited there was never a nurse that I recognised. Oh, it’s the 48 hour week that’s to blame, one said. And we get put on different wards each day.
Half of them seemed to be agency nurses, some with a variable grasp of English – never a good thing when dealing with older patients. They kept trying to feed her totally inappropriate food, when a cursory look at her notes would have told them it was wrong.
She was left sometimes for hours in soiled sheets. In the end my two sisters and I operated a shift system because we couldn’t let her be alone. We ignored the visiting hours, and the nurses allowed us to because it took work away from them.
And the thing is, it wasn’t because there weren’t enough of them. There was. When we eventually realised that my mother was going to die, we decided to take her home. The thought of her dying in that place was too awful for us to contemplate. But even then they were so incompetent that I was forced to book a private ambulance to take her home because the NHS ambulance consistently didn’t turn up.
She spent two weeks at home, and it was here that the NHS came up trumps with her wonderful GP visiting at least twice a day and providing just the support that she, and we, her carers needed. I shall never forget what that wonderful GP did that week. My mother died at home looking out on the garden she loved, surrounded by her family.
I should have made an official complaint about Addenbrookes. I should have raised merry hell with the hospital bosses, but you know what, I am ashamed that I didn’t.
I just couldn’t bear the thought of reliving it all. I let my mother down, and I let all those who followed her down.
While she was lying in there, unable to do anything for herself, I kept thinking about other patients who had no family to care for them. We were in a position to do things, but there are many older people whose families can’t or won’t support them in the way we could.
It was only when I read about Ann Clwyd’s experience, that I actually did something about it. She had thousands of letters and emails from people who had gone through the same thing. Blame is easy to ascribe, but it is often misplaced.
I have thought long and hard about how these things are allowed to happen. In truth there is no one single person or group of people who are to blame. And let’s face it, blame rarely gets us anywhere. But there are clearly questions to be asked about current standards of nursing care in some of our hospitals.
So when I heard Jeremy Hunt say, almost on his first day in the job as Health Secretary, that he was concerned about the fact that nursing care was becoming increasingly depersonalised, my ears pricked up.
But when he suggested that nurses should do a year’s on the job training before embarking on degrees he was met with a hailstorm of abuse from the usual vested interests.
“A really stupid idea” said the RCN. A truly pathetic response, which one might expect from a trade union but not from a Royal College. The very same Royal College which failed to spot any problems at the Mid Staffs hospital, or if it did, it kept them to itself with the consequences we know only too well.
It seems to me that aspects of nursing training is not fit for purpose. Just a fortnight ago Jeremy Hunt said this ‘culture of defensiveness’ must cease and doctors and nurses must ‘say sorry’ when things go wrong in the NHS. Administrators blanche at that saying “think of the legal consequences”, but surely he’s right.
Of course things will go wrong. In any organization the size of the NHS and with the risks involved in most medical procedures, there will always be mistakes and things will always go wrong on occasion. The challenge for the NHS is to find a way of acknowledging this in a way which doesn’t undermine the whole system.
I think we also need to look at who we are recruiting into the nursing profession. It seems to be ridiculous that all nurses are now expected to have degrees or the equivalent. Surely we need a mix of abilities and aptitudes. Where are the good working class girls who used to be the backbone of the nursing profession? They may not have had an ‘O’ Level between them, but they knew all about providing fantastic care. They weren’t too proud to do the dirtier jobs that some nurses seem to think it is isn’t their job to do nowadays. I don’t know what proportion of nurses in the NHS come from other countries, but how rigorously do we check their backgrounds and qualifications – or even linguistic abilities?
The NHS would collapse without foreign nurses and doctors, but I have always been slightly queasy about overtly recruiting them from countries which frankly are so poor that the best form of international aid we could offer them is not to steal their most capable medical staff.
CHALLENGES OF POPULATION GROWTH
One of the reasons the NHS has required an ever growing budget is to cope with the challenges of population growth. Over the next couple of decades the population will grow by 10 million, in large part to immigration but also due to a higher birthrate among many immigrant communities.
The planning for that should already be underway, but I wonder if it is. Coupled with the added burden of an ever growing older population it is no wonder that the NHS is already creaking at the seams. But how far can the taxpayer’s patience be stretched?
We already spend one sixth of our public spending on the NHS. If that proportion is to increase beyond a sixth, some incredibly difficult decisions will have to be taken elsewhere. But what should it rise to? It’s a question even the new NHS Action Party can’t or won’t answer.
Why not? A fifth? A quarter? At some point decisions will have to be made about a) scope of treatments b) restricting the scope of NHS functions and b) cutting ever burgeoning costs.
And it is here that I wonder whether the NHS can continue as a truly National Health Service. But let’s be honest. We’re deluding ourselves if we truly believe it is even now, a NATIONAL health service. Scotland and Wales run their own NHS’s. And the English NHS contains such wide variations that it can’t be said to be truly national. Treatments that are available in one area, are not in another. Outcomes vary so widely that the use of the word national becomes laughable, if not redundant.
So why don’t we ditch the sentiment and recognise that the costs of running a national institution may sometimes outweigh any benefits there are. The main benefit ought to be the massive purchasing power that such an organisation enjoys, but we all know that NHS procurement procedures are almost as much of a joke, and almost as inefficient and incompetent as those in the Ministry of Defence – and that’s saying something.
Suppliers and drugs companies run rings around NHS purchasing managers and get away with imposing what is laughably called ‘NHS inflation’. So let’s stop pretending. About the single benefit of primary care trusts was that they didn’t pretend at all. They were proof positive that everything is local.
With a growing elderly population, how will we cope with the mounting demands on geriatric care in hospitals and social care outside. The challenge for the government, and indeed NHS planners, is how to integrate the two. Otherwise we have to try to find bureaucratic ways of achieving a separation of health from social care in terms of costs and resources.
There are far too many geriatric patients who take up bed space in hospitals because there is nowhere for them to be discharged to.
Successive governments have failed to plan for the future and although the coalition has announced a plan of action in this area I wonder how many of us are convinced by it. Until politicians finally have the courage to tell people “yes, you’ll have to sell your home” to pay for social care, the debate will remain somewhat stagnant.
The state can’t be able to meet every demand that is made of it in the area of social care and people should not be misled into thinking it ever will. Just look at the statistics. The number of people aged 90 or over has trebled in the last 30 years. The number of people who live to 100 has gone up fivefold in the same period. Over the next 25 years the number of 80 year olds will double. The number of centenarians will rise from 13,000 at the moment to 111,000.
ONS projections say that increases in lifespans – attributed to improving medicine, growing wealth, healthier lifestyles and less physically demanding work – will lead to a society where more than one in five people is a pensioner. Think about that.
To the government’s credit, they are reforming the pensions system to take into account these demographic changes, but where is the forward planning in the health and social care systems?
Very few people have anything nice to say about NICE, the National Institute for Care Excellence. And let me be no exception. It was set up by the Labour Government with the best of intentions. Part of its mission was to to end the variation in medical treatment across the country and ensure that if a drug was found to be effective, patients should not have to fight to get it. Clearly there needs to be a body which licenses drugs but there is a huge suspicion that too many drugs are still licensed through budgetary consideration rather than clinical need.
And in turn, drugs which are available in some parts of the country are not in others – for much the same reason. And if a cancer patient should have the temerity to decide to use their life savings to fund their treatment using a drug which for budgetary reasons is not available via the NHS, what does the NHS do?
Instead of saying ‘thank you very much for helping us out and paying for your own drugs’, it refuses to continue any treatment for that patient. See? Public good, private bad. It’s the politics of socialist envy and basically says that just because everyone can’t have it, you can’t either. So people die. Is that really what should be happening? I don’t think so.
It’s an exemplification of the kind of dogma which has bedevilled our public sector thinking over many decades.
This is what happened to one of my listeners who emailed me this week.
“My 23 year old son, has just been turn down for a course of drugs, for his acute Vasculitis, which he has been waiting around 5 months for. Costs around �4,000 for the course. His consultant has stated that it’s one of the few drugs that would really make a difference. He had to go back into hospital in the early hours of Tuesday morning, and they have probably spent half that amount, running more tests, and keeping him in under observation, when he could have been back at work, earning a living, paying taxes, and with a reasonably pain free outcome, how short sighted can you be ?
Well it’s a good question, isn’t it? I am surprised that no one has yet taken the NHS, or NICE, to the European Court of Human Rights over issues like this. I suspect it is a matter of time. Perhaps then the postcode lottery may forcibly be brought to an end.
THE SEVEN DAY NHS
One thing I noticed when my mother spent those three awful weeks in hospital was that the place more or less shut down at weekends. As do GP surgeries in large part. How odd. Are people not supposed to get ill at weekends? Surely we should be moving towards a 7 day NHS, with equality of service provision throughout those seven days.
If we are to get better outcomes, surely that has to happen over time? It comes back to the point I made earlier about 21st century medicine operating within the straitjacket of a 1940s system. Why is it that GP surgeries offer appointments at times a majority of the population isn’t available to go to them?
Why isn’t there more evening and weekend opening? I run a publishing company and I reckon I lose hundreds of man hours of work a year as my employees say “Oh, I have got a doctor’s appointment”, as if that is a reason why they should be allowed time off to the detriment of the company. That may sound harsh, but multiply that all over the economy and we’re all losing out just because GPs have always worked that way and seem immune to the changes of a modern day economy.
I don’t blame them for negotiating the GP contract back in 2004 which allowed their pay to rocket for working fewer hours. Who wouldn’t? Quite what the then Health Secretary Alan Milburn was thinking of, God alone knows, and it is this government which has been left the legacy.
And that legacy, at least in part, is A&E departments which are bursting at the seams with patients who shouldn’t even be there.
We now have the frankly ludicrous scenario of A&E departments employing GPs to see all the people who visit A&Es because they have no way of seeing their GP at weekends – or at least, that is their perception.
These GPs are employed for one reason, and one reason only – to allow the A&Es to meet their waiting time targets.
The final area I want to cover this morning is one which is not an afterthought, but possibly one of the most important challenges the NHS faces. It’s become almost a cliché to describe mental health as a ‘cinderella service’. It’s a subject too few people take seriously and one that some still find difficult to discuss. While the stigma of mental health has been eroded it is still undoubtedly there.
When I started presenting on the radio three and a half years ago I never for one moment thought I would become known for my programmes on mental health, let alone be shortlisted for an award by the mental health charity MIND.
But I can remember the heartbreaking calls I took when I first did a phone in on depression. Frankly I could have devoted this whole speech to mental health and the problems associated with it, and after listening to me so far, you may wish I had.
Mental health covers a multitude of issues and when you look at the statistics on mental health you wonder why more resources are not devoted to this area of health provision. 1 in 4 of us will suffer from some sort of mental health condition – not just in our lifetimes, but each year.
But a quarter of those won’t visit their GP. But the real question is what happens if they do visit their GPs. Anecdotal evidence from my listeners suggest that not enough GPs are equipped to deal with mental health issues. Maybe older GPs didn’t have the same kind of mental health training which is available today, I don’t know, but time after time people tell me that their GPs seem out of their depth on these kind of issues. And perhaps this explains why the prescription of drugs seems to be the automatic default for so many GPs.
But part of the problem is that people suffering from mental health problems, or their families face a bewildering system which is so complex that even those who are familiar with it find it baffling.
OK, we have mental health trusts, but there are also actute trusts which provide liaison psychiatry services and some A&E services for mental health patients. Ambulance trusts may or may not be commissioned to provide mental health conveyancing services outside of emergencies, whatever they may be.
Clinical Commissioning Groups commission some services while specialist trusts commission others. And then of course there are GPs who provide primary mental health care to some 83% of mental health patients. And then finally you have local authorities who oversee and/or directly employ Approved Mental Health Professionals – or at least those who are not employed by or seconded to the NHS.
I can’t begin to cover all the aspects of mental health here, and I’m not going to try, but I do want to touch on dementia care. This is where the NHS and the social care system need to interact far better than they do at the moment. No one seems to have got to grips with the demands that the increasing number of people suffering from dementia are placing on both systems. Everyone has good intentions, but so far, it has to be said that not a lot has changed recently. The trouble is that to provide a proper care system for people with dementia will mean that huge amounts of extra money needs to be spent, but where is it going to come from?
Indeed, the mental health budget is experiencing a 2% cut. Beds continue to be closed and we are constantly told that it is far better to treat people in their homes. Really? The true heroes are the relatives who end up being carers for people with dementia.
What we really need to do, even as a short term fix, is to provide far better support for carers, especially more respite care. In effect family carers are saving the NHS or the social care system hundreds of millions if not several billion pounds each year.
The Mental Health Action plan which Nick Clegg announced a week ago was a welcome recognition that the current system isn’t working, but it was really a list of aspirations rather than firm commitments.
But things are moving in the right direction. It’s great to see professional sports people be open about their mental health problems. It’s great that politicians have confronted their own issues surrounding their own mental health. It’s great that programmes like mine discuss this issue openly and without hesitation. None of those things would have happened 10 years ago. If even just one person is helped by our discussions, and they realise they are not alone, I feel I have done something worthwhile.
So in conclusion, let me give you some predictions. First, that all politicians will tell you that the NHS is their number one priority. The NHS has achieved the same status as the Queen Mother in the nation’s affections.
But I do not see an appetite to change it fundamentally and as a consequence I think over time it will become a much hotter political potato than it may be at the moment, as expectations increase, performance will lag behind. The challenge facing all politicians will be how to square this unsquareable circle. The truth is that they will abdicate responsibility to health professionals and then blame them if it all goes wrong.
In future most government initiatives are likely to be centred around preventative measures rather than structural ones. Preventative healthcare has grown in visibility in recent times. An anti-obesity drive is always guaranteed to and provoke big headlines in the mid-market newspapers as well as intense discussion on radio phone-ins.
Such initiatives give the appearance of action, even if they can be incredibly expensive in PR costs. Politicians love them. They are great for photo opportunities, soundbites and gimmickry.
So expect a lot more of Anna Soubry exhorting us in her best nanny-like tones to eat less, drink less and exercise more. I think I need a lie down.
There needs to be a national and rational debate about the scope and extent of the NHS. Should it cover illness, injuries or both? Should people insure against injury – probably a small cost – as opposed to illness. But I pity the first politician to even suggest such heresy.
Can we afford to maintain the ‘cradle to grave’ scope that Beveridge established, although I doubt that he foresaw the range of treatments currently available and their cost. I doubt also he foresaw a health service where 2,600 people earn more than the prime minister, and 7,800 people earn more than £100,000 a year.
The bald truth is that until we accept that the NHS can’t and never will be able to meet all the demands made on it, we can’t actually have a proper and rational debate.
The pity is that no-one currently on the NHS scene seems to have much idea of the questions, let alone the answers. Parliaments drift by and the issues, questions remain the same: expensive reorganisations take place with little or no real benefit. And anyone who dares to criticize or critique the NHS gets their head bitten off by people who profess to LOVE the NHS.
So the real, overwhelming question is this: if we were in a position to set up a health service now, from scratch, what would it look like? Because I suspect one thing is certain – it would bear little relation to the NHS we have today.