Lord Darzi’s report on the state of the NHS, released today, is damning. His review found that waiting times have worsened, very little progress has been made on early cancer diagnoses and the health service has been starved of capital investment.
For a while, it looked like Wes Streeting was the man to come in and fix this. To many, the Labour Health Secretary feels like a breath of fresh air in his observations on the NHS. He basically thinks it’s broken, and had said as much. Many, many people agree, and all of us wish it weren’t.
Mr Streeting claims that throwing money at the NHS is not the answer, but when he then starts to talk about what he is going to do about it, he talks the language of control. He wants to tighten up use of resources; to encourage full seven day working, to pay doctors better, to raise standards of care, to get waiting lists down. Targets, targets, targets.
If he continues on this course, he will fail. I take no pleasure in saying this, but what he asks is impossible. If it were possible, it would already have been done. The party in government which manages to do all those things will guarantee themselves another term in power, and again, and again.
Why am I so sure that he will fail? It is because he is a poor people manager? Is it because he doesn’t surround himself with enough talented people? Is it because he doesn’t understand the enormous complexity of the NHS? Is it because he doesn’t care enough about the NHS? Is he too obsessed with his own career trajectory to take the health brief seriously? Although I don’t know the man, I will answer benignly to all of those charges – and so, ‘no’, none of these are the problem.
The problem is much, much deeper, and almost every developed country in the world has worked this out, except the UK.
It is simple. At the moment, money comes into the NHS from the top. For it to perform better, much, much better, money has to come in at the bottom. No ‘privatisation’ is needed (although it might be welcome in some areas); no more money is needed (at least not at the moment); no new ‘targets’ are needed. No new layers; no new ‘Trusts’ or confederations. All that has to happen is the money comes in at the bottom.
What do I mean by this? It really isn’t rocket science. Where does the money come into Tesco? Or Amazon? Or Netflix? Or indeed, any one of the millions of companies worldwide, large and small, that do the best they can with the resources they have, and which have over the last few decades, indeed the last century, enormously improved our lives in every possible way.
Their money comes in at the bottom, from the customer. This sends signals in with clarity and subtlety to the management of the business in the form of money. Where goods and services are needed or wanted, the resources are there to provide them. Where not, they are not. I’m not saying this is all sweetness and light – far from it. There is competition to improve and improve, so that someone else doesn’t take your job or your business away from you.
Can this work in health on a grand scale, like the NHS? Yes, not only can it, it already does in every developed country bar the UK. Take France, that well known hub of capitalism. In France, every person is a member of a state sponsored insurance system (the Sécurité Sociale), in which each layer of government plays a part and pays the claims. It is not a private system, it is government-insurance-funded, and any qualified (medically and professionally) healthcare supplier can join. Most hospitals or other institutional providers (about 70%) are owned by the state or local government; some by charities or not-for-profit firms; some by private companies. GPs, like in the UK, are private contractors to the state system. Patients choose which to go to on exactly the same grounds as they choose the brands or professional services they patronise – reputation; convenience; personal connection, efficiency, quality – and price.
The Sécurité Sociale typically pays 70% of health costs for non-recurring treatment, or 100% if the condition is determined to be chronic. The patient is obliged to pay the remaining 30%, and most people buy modestly-priced private insurance to cover most of this part. Individuals incapable of paying their share can qualify for 100% state-funded cover. The French state ensures that the system is solvent by raising the money needed in a national insurance contribution taken from employee and employer payrolls (just like NI in the UK, but more). As is common in insurance-based systems, the socialisation of the costs limits the downward pressure on costs, and combined with the bureaucratic instincts of the French state, the percentage demanded from pay packets has gone up and up. But overall, according to the BMA, France spends about 10.3% GDP on publicly-funded healthcare, the UK 9.3%. So there is perhaps a 10% higher spend on public healthcare in France, but unlike the UK, France is at the very top of the international comparative tables for quality of care and all of the mortality and morbidity indices. No waiting lists; clean, well-organised, well-funded hospitals; GPs available for everyone at short notice.
I chose France to compare the UK system with, but the same comparison, and indeed similar systems, would apply in Germany, the Netherlands, Australia, New Zealand and many other similar jurisdictions.
Why do we continue to produce Trabant-like healthcare, insisting that it is the envy of the world, when every other comparable country produces BMW-like healthcare – a little more expensive, but in a completely different league of quality, patient satisfaction, and ultimately, the nation’s health? We have, unusually for the UK, allowed ourselves to be duped into a sort of religious-type reverence for ‘Our NHS’.
If Streeting is really serious about improving the lives of the people of our country, he should embark on reform to turn off the tap of money from the top, and instead send to money to the system from the bottom. It can be done; it is not ‘privatisation’; it is being done everywhere else (including socialist-minded states); it works much better, and the only really knotty issue is the complicated transition. But now is the time – a new, enthused, large-majority government that can secure its party’s future in power. Go on, Wes Streeting, be brave!
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