Hi Folks,

It’s probably fair to say, one of the most affectionately held institutions in the UK is the NHS.  But with almost daily crises being reported, I have to ask,  has the NHS had its day?

This may prove to be a controversial question. Attacking or even questioning the NHS is considered heretical in some quarters.  It’s certainly a political hot potato with both Labour and the Conservatives, not forgetting the SNP in Scotland, all claiming to be the best custodians of the service.  I believe it’s important to try and get beyond the political dogma and ideology to try to understand what is happening and why and if it can be improved.

NHS History

A state health service had been considered for many years prior to the 2nd world war.  In 1944, a white paper proposing a National Health Service was issued by the then Conservative government.  But it wasn’t until Clement Atlee’s Labour government won the 1945 General Election that Health Minister, Aneurin Bevan embarked upon its creation.  Widely considered the father of the NHS, Bevan succeeded and in 1948, the NHS came into being.

The NHS was founded on 3 simple core principles: That it meet the needs of everyone, that it be free at the point of delivery, and that it be based on clinical need, not ability to pay. For many years it succeeded and was considered the envy of the world. But these days, it seems that every day there is a new disaster facing the NHS and that it is failing. Waiting times are going up, vulnerable people are being left in pain as operations are cancelled and drug treatments withheld over cost. In short, every year, thousands of people are suffering unnecessarily.

 

 

Size of the NHS

Both my Mother in Law and my wife have worked in the NHS.  Two of my older offspring are currently employed or have been employed by the institution  as have many of our friends.    This isn’t surprising.  With over 1.5 million employees, its the biggest employer in the UK and one of the top 5 employers in the world. It’s up there with the likes of the Chinese People’s Army, The US Department of Defense and, believe it or not, Walmart and McDonalds.

Despite this, the NHS is chronically understaffed with over 100,000 unfilled vacancies.   Positions for both Doctors and Nurses are going unfilled which places existing staff under increased pressure. This, in turn, adds to the problem.

An NHS survey carried out earlier this year discovered that 40% of clinical staff had felt ill due to stress at some point during the last year.  Other key findings included:

Nearly 80% of staff thought they were under unrealistic time pressures some or all of the time.

Some 60% of staff did unpaid overtime every week.

Around 51% of staff were considering leaving their current role.

21% wanted to quit the NHS altogether.

Let’s consider that for a moment. At a time when it’s proving so difficult to recruit medical staff, the UK has a potential ‘army’ of thousands of trained and experienced staff, sitting at home, demoralised and disillusioned.   Many clinical staff are heading off to places such as Australia for the improved quality of life.  To help get around this, the NHS seems happy to recruit staff that have been struck off from other countries.  There may not be many of them,  but surely even one is too many?

NHS Funding

Currently, the NHS is funded from General Taxation and from the National Insurance scheme. A small part comes from patient contributions, such as prescription charges, although not in Scotland where prescriptions remain free, regardless of how well off the patient might be.  In total, the NHS was set to receive around 140 billion pounds in the 2019 budget.   That’s just under 10% GDP, which, whilst a huge sum of money is still one of the lowest figures in Europe for a system facing increasing demand.

It’s a fact that since its foundation in 1948, the number of old age pensioners has doubled. Life expectancy is rising. People are living longer and with that, the burden on the NHS is increasing.  With our modern sedentary habits, obesity and heart disease are also on the up, adding yet more pressure.  

Whether true or not, much was made in the 2016 Brexit referendum about the 350 million / week that could be spent on the health service.  BoJo has just announced an additional 1.8 billion spending for the NHS front line services.  In fact, politicians of every hue seem to think that throwing ever-larger amounts of cash at the NHS is the answer.

My wife has some very firm opinions on this. We agree on some aspects but are poles apart on others.  None the less, as she has first hand experience from working within the NHS, I trust what she says.

Management Focus

In her opinion, money alone isn’t the answer. She believes there needs to be a  refocusing of effort and resources away from reactive to more preventative care. It makes sense. Prevention is always better than cure.  She wrote a proposal for this once upon a time in her career. It was well received, but the general concensus was that it would never happen. Internal power struggles, empire building and a lack of will wouldn’t allow it.

I agree with her that throwing more funds alone is not the answer.  The way the system is structured, managed by a central government ministry, with tiers of often unfathomable bureaucracy issuing daily targets and initiatives making it inherently inefficient. Add to this dictates on everything from what drugs may be prescribed to what substandard meals can be served.  It all results in a baffling behemoth that we will never be able to spend enough on to make it work.

The Wanless Report

Interestingly, in 2002, Derek Wanless, the former NatWest bank chairman, published an interim report on improving public health and reducing health inequalities in England. His report, urged the government to develop a more coherent strategy to reduce preventable illness caused by unhealthy behaviour such as smoking and physical inactivity.  This was met with mixed reactions.  Wanless himself  admitted that the recommendations were unlikely to be implemented as it represented a long term 10 year plus program. As government cycles are 5 yrs in length and as it was unlikely to deliver tangible improvements in the short term, no government would be willing to take on the risk of becoming deeply unpopular. The final report was issued in 2008.

This is why wifey and I agree to disagree.  I do see the benefit in moving to a more focused preventative care regime. But, as long as the NHS is so politicised, it is never going to happen. And it is politicised. It’s used as a weapon and a means of virtue signalling at every election by every political party.

Also, I don’t believe that changing focus alone would solve all of the issues faced by the NHS.  My opinion is it would be too little too late.

NHS Performance

In almost every hospital in the country, it’s not unusual for elderly, vulnerable people to be left for hours, sometimes days,  on trolleys.  Bed blocking; a term used to describe keeping patients, most of them elderly, in a hospital bed that they don’t strictly need, is on the rise in Scotland. One in 60 of the British population is on a waiting list.  This sentences thousands of critically ill people to prolonged suffering and even death by keeping them on waiting lists for a year or more.  

This year has seen a fall in achievement against targets for cancer treatment waiting times.  These delays mean curable cancer can become incurable for thousands of people. Britain has the worst survival rates for almost all forms of cancer of any Western country.

An ongoing scandal involves dementia treatment. With an ageing population, the incidence of dementia is increasing. Currently, the NHS does not offer free dementia care. This forces people who have spent their lives paying tax to spend their life savings and even sell their houses to pay for private treatment for their loved ones.  

In nearly every area the NHS is failing. The envy of the world has become a basket case.   Bernard Kouchner, the health minister of France, widely thought of as having the best health system in the world, recognised this  when he condemned the NHS as ‘medieval’ and ‘intolerable’

Is there a Solution

So what can be done?  Perhaps a first step is to try and get past the sacred ideology of a Nationalised Health Service and accept that, no matter how noble it might be, it is no longer possible and it no longer works in its present form.  Implementing Wifey’s refocusing would undoubtedly be a big improvement. But more is required. Private health care should not be considered evil or the preserve of the wealthy. Around 12% of the UK population already have private health insurance.  These private hospitals tend to be run more like a business and as a business, they have to meet the requirements of the patients. That means having the staff to meet demand and ensuring the treatment can be delivered promptly. Isn’t that we need? So how do we achieve this?

Now I am no great fan of the French, but theirs is supposedly one of the best systems, certainly in Europe if not the world.  So can we learn from their example?

French Healthcare

Following their socialist principles,  the  French health care system is made up of a fully-integrated network of public hospitals, private hospitals, doctors and other medical service providers. It is a universal service and provides health care for everyone.  Health Insurance is compulsory. In 2006, the Protection Maladie Universelle (PUMA)  was introduced. The PUMA charge is about 8% of income, although this is covered for those on low income by the French state.  People often top up this with private health insurance, known as a ‘Mutuelle.’ Many employers operate a health insurance scheme and all employers contribute to the health care system.  The central government also contributes to health care. In fact, France’s spend on health care is one of the highest in Europe at nearly 11%GDP.

All of this sounds very similar to NI charges and the system in the UK.  The fundamental difference is, patients are expected to pay something towards every health care visit or treatment. Most of this charge can be recovered from the insurance schemes, but a percentage will be out an out of pocket cost.  Unlike the NHS, it does not in any way try to be a fully free system.

 

The benefit of this?  Well, it does provide freedom to the patient to pick and choose their doctor, their hospital and even their treatment on occasions. Compare this to the UK where, unless ‘going private’, the patient has absolutely no say in who or what happens to them.

An NHS for the future

Don’t get me wrong. The French system isn’t perfect. Under the recent economic downturn, it has creaked and spluttered, but it still outperforms the NHS.  This system that combines public and private payments and insurance operates not only in France but in Germany and the Netherlands quite successfully.  So why wouldn’t it work in the UK?

Well it could. The UK could have a wide social insurance scheme that repays in all or in part the cost of treatments to patients.  This would allow patients to choose which doctor they go to and which hospital they are treated at.  Doctors and hospitals could be made to publish figures on their success rates to woo patients.  We could even charge for GP visits, so people don’t abuse them and to give doctors an incentive to make it easier to see them.  And if people want enhanced treatment, why can’t they top up with cash payments, rather than be forced out of the system into a separate,  private system ?   Like elsewhere, (though possibly not in the US)  there absolutely should be a safety net for those on low incomes to ensure no-one is missed or loses out.

Is it Possible?

All of this is possible, but first, we have to rid ourselves of the ideology and get past the untouchable status of the NHS as a National Institution.

The left-leaning NHS fan club will no doubt cry foul and rally with their banners of “Hands off our NHS”.  But, others in the world, including our neighbours in Europe have shown such systems can work.  Meanwhile, the UK is demonstrating daily that the NHS simply doesn’t and cannot work in its current form.

I realise this is a very emotive subject. Please tell me what you think.   Am I way off mark?   What are your ideas?   Is the NHS done for as it currently is? How might it be improved?   I look forward to hearing from you.

Graham