Monday, 2 January 2017

"We need safe spaces..." - how the NHS ducks the big questions

I can't remember the precise moment or why the subject came up but some point in 2016, in a meeting with NHS folk, something along these lines was said: "we need safe spaces to discuss the real challenges facing the health and care system". What they really meant was that some subjects are just to difficult to discuss other than in a carefully protected space - protected, that is, from the public. This answer is a reminder that our populist, planned health system is facing something of a crisis.

Before we go on to talk about the challenges we can't discuss in public we have first to talk about money. I had a Twitter exchange with someone recently where I asked what she meant by 'adequately resourced' in the context of the NHS. The answer, as these things often are, was something of a cop out but was at least better than the more usual response to such questions - a response typified by this piece of populist cant from Tim Farron:
Farron said voters had reached the stage of not believing the NHS’s problems could be solved through efficiency savings and might be willing to pay more if they were convinced it would go to the health service.

He said he did not want to pre-empt the conclusions of an independent panel formed by the Lib Dems, which will look at possible taxes to help the NHS.
In varying forms this is the default response to concerns about our health system - more taxes, more resources. The problem is that, for all that sticking a ring-fenced penny on income tax sounds good, it goes nowhere to making the NHS more sustainable. Bear in mind that, despite the claims of its founders, the NHS has required above inflation increases in funding throughout its existence meaning that it now spends approaching £120 billion out of those taxes.

In one respect our health system needs that extra cash - as Jonathan Portes pointed out recently the proportion of GDP spent on health has fallen and we do spend less per capita than other places (significantly so than the USA). But when you open the NHS up, every single element within the system will tell you that with a little extra cash they can solve this or that problem. Indeed most of those individual bits of healthcare systems - the non-clinical as well as clinical - will tell you that right now they are starved of cash meaning that people might die.

So maybe we do need more cash. But first we need to huddle in that safe space and discuss some more fundamental things about the NHS. By way of example, West Yorkshire has eight or nine general hospitals (I forget the precise number but it doesn't matter for this discussion). All of them are seen by their local community as "their" hospital and the popular expectation is that the general means they do everything that community needs. The question we need to ask in that safe space isn't how do we get more cash for those hospitals or what services do we cut to stop them overspending. No the questions are more fundamental - does West Yorkshire need all those hospitals, are they in the right places, do the facilities meet modern needs or public expectations?

We might ask, for example, why Leeds has two huge general hospitals with real access issues right bang in the city centre? Should we be finding a greenfield site somewhere more convenient and building a new large hospital? And do all those hospitals need to have high support accident units, heart care centres and cancer wards or would it be a better service to have specialised units?

I don't know the answer to these questions - or indeed to thousands of other questions about health and care provision - but I do know (because I've been given a privileged peep inside the system) that the NHS simply isn't discussing these issues at all. Mostly for fear of adverse public reaction but also because the planners within the health system are driven by issues of sustaining what's already there rather than by more fundamental questions about structure and organisation.

There's a further problem, one stemming from the very top of the NHS (indeed from the World Health Organisation), which is the belief that the drivers of rising costs are lifestyle factors especially smoking and obesity. Even when the health systems own statisticians point out that longevity is the problem, we still get strategies founded on the idea that being fat and liking a fag is the problem. This is where the proposals for limiting access to surgery come from (like this one from York) - they don't really address the problem, they're usually overturned and they make it look like the Clinical Commissioning Group (CCG) is doing something.

It seems to me that the NHS, for all the "Our NHS" and "Save the NHS" rhetoric, isn't really all that good. OK, I'll grant that it's better than a system such as that in the USA which manages to be both very expensive and to leave out great chunks of the population from effective care, but there are other approaches - Sweden, France, Holland, Singapore - that might offer some ideas about how we might improve our health outcomes. The UK has a very centralised system that is painted to look like a dispersed and localised system. As the recent round of reorganisation - called Sustainability and Transformation Plans in that jargonistic NHS way - has shown, the idea of local control or direction is anathema to the system's bureaucracy.

The Tim Farron solution - whack up a few taxes - sticks a slightly bigger plaster over the wound but doesn't address the fundamental problems (just as allowing councils to stick up council tax a bit more does solve the care crisis) in the health system. We have a health estate that was mostly designed by Victorians (to which we've added a lot of prefabs) and a structure that would do the Soviet Union proud - right down to the endlessly revisited five-year plans. Until we actually use that safe space we mentioned to discuss the real problems of the health system the NHS will carry on lurching from self-generated crisis to self-generated crisis. And worse, populist politicians like Tim Farron will go on waving the NHS's problems about as a cheap source of votes.


No comments: