We need to consider both the amount we pay for the NHS and also what we mean by the "culture" problem - the culture in question is commercial culture. Why then are we reorganising the whole NHS on commercial lines?
The report by Robert Francis QC into the Mid Staffordshire healthcare disaster gives a detailed account of the practical failures that led directly to inadequate care and, very probably, unnecessary deaths. Moreover, it does not shrink from pointing out failures in both management priorities and surveillance by a number of bodies that should have realised something was wrong. It even points towards a particular government policy that might have set the sad chain of events in motion – the invention of Foundation Trusts (the Wikipedia entry is worth checking) by Alan Milburn in 2002.
I am unconvinced, however, that it reaches the diagnosis. Why did Milburn feel the need to propose this policy, when it was obvious that it would lead to this sort of misery? And if his policy was not in fact critical, what general burden on the NHS needed only one more straw to break the system’s back in this unfortunate neighbourhood? It is not a Shipman story. Hundreds of people knew things were going wrong. It is another Winterbourne View story: nothing to do with a particular person or, I suspect, with particular public or private organizations. And judging by the recent story of a woman starving to death when the Border Agency closed down her private care company, we have got nowhere in solving the problem.
Not long ago I contributed to a book ‘Public Service on the Brink’. A reviewer commented that the book was good on problems but thin on solutions. Maybe I did not underline mine, or maybe it was unpalatable.
I think we have to pay more tax. Who should pay what is a more complex issue. Even before one considers the reasons why public provision works better than private in the health arena the basic problem is that you do not get a safe and effective health system unless you pay for it. We are not currently paying the minimum required to provide basic care. All sorts of tricks are in place to make it look as if the system works well but it doesn’t. In mental health care we are looking into the abyss.
Having read my suggestion the reader may prefer to turn to another article. However, I think it’s worth looking at the background arguments, because they are not what we are led to believe either by the politicians or the media. Unless the public faces up to this reality we will end up with a United States system (or worse), which is known to be even less successful in terms of health statistics, than ours, despite being more costly. There are two questions to answer. Firstly, is the NHS truly short of money? Secondly, can we afford it?
Is the NHS underfunded? What about all that waste? Was the focus on targets that led to staff being laid off at Mid Staffs just bad use of resources? This hardly seems likely since the targets were always reasonable and now, in 2013, the hit rate is slipping badly. The Mid Staffs management should have met these targets. A similar story has recently been told from Lincolnshire. A recent report on child mortality shows that our figures are not good and in about a quarter of deaths a significant error was identified. I suspect in another quarter the errors were just less clear cut. Hospitals are going bust because managers have unwittingly undercharged GPs for essential services, not because of any waste.
Moreover, if we look at a ‘well run flagship’ like UCH, where I used to work, even there, there isn’t enough money. UCH consultant staff have been receiving weekly and sometimes hourly reminders that the hospital is desperately short of beds and that routine work is being put on hold so that emergency cases can be coped with. (Emails from the Royal Free are a bit less frequent.) One email said ‘Please can you do everything you can with your teams to focus on discharge.’ Shouldn’t the focus be on optimum care? My own personal experience as a patient at UCH was that diagnostic services were excellent and everyone was very helpful but when it came to it no date could be fixed for my cancer surgery – I had to hope for a cancellation. So, despite being uninsured, I went to Harley Street. Even the very best places, and I do think UCH is the best, are running hand to mouth.
We used to think it dreadful that a significant minority of Americans had no effective health insurance. The British need to realize that they are now all in this situation. There is a pretence to provide a service but by delaying, and not quite referring on, people often never get the treatment or get it too late. Just make sure nobody in your family develops a mental illness (not easy).
There are indeed areas of waste, but most notably in the employment of people whose sole job it is to penny-pinch. The whole commissioning policy is based on the idea that if you divide the money up by region it is easier to penny-pinch because the decision is delegated. It can have no other function, since the level of service is stipulated centrally, as it should be. The cost is large, but still not large enough to alter the fact that there just is not enough money.
Nobody mentions the simple idea that the problem might be underfunding. I can find no reference to it in the executive summary of the Francis report. NHS policymakers on the media virtually never refer to it. Instead they talk of closing hospitals and accident departments, to ‘improve care’ despite there being no beds to put people in. It seems that it is better to close big units and have patients looked after in smaller community facilities. At the same time it is essential to stop treating patients in small non-specialist units and send them to big specialist centres.
Do I sense a paradox here? The reality is that we need to do everything better in more places with more money. This has nothing to do with big government or public sector ethos. It would apply just as much to a private system. The arguments about moving facilities from one place to another are just political infighting within the system: not just rearranging deck chairs, but throwing each others’ over the side. In my view there should be no distinction between GPs and hospitals. In most cities, at least, it is insane not to have the GPs working in hospitals so that they can get everything done for you in one day, including tests and referral to a specialist if needed, rather than taking so long to deal with things that quite often it is too late by the time you get to hospital. Why is a ‘health centre’ in Pond Street any more ‘in the community’ than a ‘hospital’ in Pond Street? Hospitals only cost more because they deal with the expensive tasks. Getting them done six weeks after a visit to a health centre (after five paper letters are sent by post for goodness sake!) costs even more.
But can we actually afford to pay more? Typical of what we are led to believe is a comment that cropped up in recent conversation ‘…but we need to live within our means’. The suggestion seems to be that there is not enough money. However, if we consider the Sterling-using community, i.e. people in the UK, as a whole, this is nonsense. The total amount of money held by British people is effectively zero, and always is. That is because money is just an I.O.U. – ‘I promise to pay the bearer…’ What I ‘have’, is just what others don’t have. Money is an agreement, not a substance. The current ‘crisis’ is a crisis of what people are prepared to agree to do for each other, not of missing money.
Perhaps the problem is that we do not have the real resources to provide safe health care for everyone. Maybe there is a world shortage of willow (aspirin) and cinchona (quinine) trees. Again, this is ridiculous. What we need most for our safe health care is staff: nurses to give old people a wash and to notice that their blood pressure is low or that there is blood on the sheet. Do we have enough people to do these jobs? We have hundreds of thousands of young people out of work desperate for something to do. We have an abundance of resources that we have not had since the 1920s. There is simply no problem of ‘living within our means’. Who suffers more, someone who cannot afford an iPhone or a young adult at home unable to find a life?
What is the problem then? As indicated in my contribution to Public Service on the Brink, I believe there is a specific problem with the structure of democratically elected government as we currently have it. Democracy is the least bad option but it is not free of flaws, which over time may build up to destructive levels. The US ‘fiscal cliff’ is a pantomime version of our problem. (The recent Italian general election takes it close to bedroom farce.) Elected full time career politicians are now incapable of suggesting that tax rates should be raised. There is no difference between parties, only a minor difference in ideas of who should pay. It is easier for right wing parties to justify tax reduction, in terms of ‘small government’, but left wing parties are forced to play the same game and so we have a new justification from Mr. Balls. Note that I am not necessarily making an argument here for the need to increase tax as a whole. I am sure we could save a bit getting fewer of our people killed in illegal wars in the east. I am simply pointing out the forces at work.
The new story is that increasing tax prevents growth by reducing spending power. Apart from the fact that growth is probably not something we want, since it has no direct relation to well-being, the economic argument is surely bogus. If the need for growth is to bring in tax then surely it is simpler just to increase tax rates? More importantly, whatever is paid in tax is redistributed to people as pay, with associated spending power, so none of it ‘goes out of the economy’. Public sector workers pay their own share of tax automatically via PAYE, rather than sending their earnings to the Cayman Islands. Paying off international debts might take money out of the economy but that is a separate issue. And there is no need to see public spending as ‘investment for future growth’. There is no harm at all (given the above) in just spending money on our most basic need – to feel that if we are desperately ill we will get safe and effective care. The arguments for spending on anything else seem fairly flimsy in comparison. The ultimate irony is that the biggest health problem currently facing us is poor people eating too much.
So I rest my case that we need to pay more tax to have the health system we need and not only can we afford it but paying for it would help out those we should have most sympathy for – the unemployed.
I have not said much about public versus private funding, partly because I see that as a secondary issue. Nevertheless there are a lot of pointers that indicate that there is no justification for privatising. Public sector workers will lose their livelihoods and for many that will mean a wrecked life. The paradigm private system in the USA is hugely inefficient. The Francis report makes reference to ‘corporate interests’ and an unhealthy ‘culture’. Corporate can just mean a united group, but the reality is that in this context it means ‘money-making’. The unhealthy culture is the profit culture.
What seems clear is that there is no option for ‘small government’ here. Subcontracting to private concerns has worked well in Europe only because of extremely stringent control and accountability at the top, ensuring that private hospitals train nurses and do not cherry pick work. What we seem to be heading for in the UK is a post-Soviet Russian or Bulgarian approach: sting the people for tax, hand it to your business cronies to pocket and look the other way. Francis implicitly criticizes the culture of looking the other way, further down, but this is something that comes from the top. Who allowed lavish backhanders to be paid to gag whistleblowers? Who did nothing about it on coming to power? Why in thirty-five years as a doctor did nobody independent ever ask me if there was anything I thought needed improving?
And in the present context, I think there is a deeper, if more intangible, reason for keeping private finance at arms length. The fact that neither Francis, nor government, nor media, nor even campaign groups, mention the lack of money relates to the fact that all those involved have a personal financial interest in not doing so. Nobody wants to be seen to even mouth two words on their own: ‘more taxes’. The longer the conspiracy of silence continues the further down the spiral we go.