11 April 2015

Will Britain ever get real about the NHS?


It was perhaps a certain naivety that gave Brits some optimism about the first – and only – election debate between the sitting Prime Minister David Cameron and the challengers for his job ahead of the General Election, which took place last week. After all, this was only the second election season that had featured them after they were introduced in 2010.

In the end, the date offered more heat than light, more about slogans than anything else. Never was that more true than when the debate turned to the National Health Service– and it was all too familiar.

Politics is, so we are constantly told, ever more about language and rhetoric. Spinners spend hours poring over public statements.

On the NHS, that has gone far beyond a joke. It is not enough to value the idea of universal healthcare free at the point of use as a concept – one must “love the NHS”. Doctors and nurses are not doing their job in difficult circumstances – they’re fighting on the front line. Nobody wants to reform the NHS – Labour leader Ed Miliband wants to “rescue” it. The debate is uncritical, nostalgic, what The Economist called “ideological, ahistorical bunkum” – and nothing short of cowardly.

Andy Burnham, Labour’s Shadow Health Secretary, has warned that there are “24 hours to save the NHS” so often over the past five years that people are beginning to doubt his grasp of Babylonian concepts of time.

Burnham may be right that the NHS needs saving – but scaremongering about its imminent downfall is thoroughly unhelpful. It is creaking in parts and fantastic in others – it delivers excellent care in some places, and shocking care in others. In almost every case, other than dentistry and prescriptions, it remains free at the point of use, paid for out of general taxation. It looks, in short, more or less like it did when it first emerged in 1948 – just a lot bigger, and a lot more complex.

But the easiest way to risk the NHS’ long-term future is to refuse to discuss even the possibility of reform. Instead, politicians compete to find more borrowed money to throw at it. As one wag put it on twitter, the NHS section of the debate would have been quicker and easier if all involved had simply turned over a card upon which they’d written how much more they’d spend on it.

If funding were to increase at the same level it did between 2000 and 2010, during which it nearly doubled in real terms, spending on the NHS would make up 100 per cent of the current level of state spending by around 2040. It is clear that that level of spending increase is fundamentally unsustainable. And yet, and yet – Labour have committed £2.5 billion, the Tories have pledged real-terms increases every year, the Liberal Democrats some £8 billion by 2020.

Even Nigel Farage, who before he was sat at the political top table suggested that the NHS was in dire need of serious reform and that we needed to look at alternative ways of funding it, has found £3 billion down the back of the national sofa to commit to it and has joined the communal choir.

Worse than these pledges, though, is the fact that more money doesn’t necessarily create better services. Despite an admirable push in every other area of the public sector to deliver more for less, the NHS remains seemingly immune from the same challenges. When the billions were being poured in during the last decade, the National Audit Office found that despite that “the evidence shows that productivity in the same period (went) down, particularly in hospitals.”

Even more troublingly, pumping extra cash into struggling hospitals can make the problems worse. Dame Julie Moore, the Chief Executive of the well-regarded Queen Elizabeth Hospital in Birmingham, suggests that “putting more money has sometimes actually led to… problems, in that you’ve artificially propped up some of the hospitals that really are not sustainable.” More money doesn’t necessarily lead to more problems, of course, but it doesn’t automatically solve them either.

The response to a report published earlier this week suggesting that efficiency in the NHS has fallen since 2012 was instructive. A private business would find ways to improve productivity; instead, Anita Charlesworth, the Chief Economist and report author, called for “an immediate injection cash.”

In a sense, the real problem is that the NHS is still measured by inputs rather than outputs. Success is judged by how much money is spent – not by what it delivers. A report from the TaxPayers’ Alliance in 2011 suggested that there were 11,749 more deaths in the UK than would have occurred if the UK had matched the average mortality amenable to healthcare rates of European peers. Research this year demonstrated that patients in Malaysia, Brazil and China had better survival rates for certain cancers than we do in the UK. Revelations of shocking care at Mid-Staffordshire Hospital Trust, replete with the unforgettable image of a patient drinking water from a vase, were followed by similar reports into poor care at the Medway Foundation Trust and – perhaps most gallingly of all – at Morecambe Bay NHS Trust, where a “lethal mix” of failings at “every level” contributed to the unnecessary deaths of one mother and eleven babies. For fans of particularly dark humour, even the one report most positive about the NHS, from the Commonwealth Fund in Washington DC, concluded that the only serious black mark against the NHS was its poor record on keeping people alive.

There are stories too of outstanding care that didn’t make the headlines – but we cannot brush these scandals under the carpet.

The answer, invariably, is hand-wringing, a public inquiry, and usually more money. Not reform, particularly after some fairly minor ones were dramatically botched earlier in this Parliament. Not placing accountability front and centre of care, or seriously challenging the culture of fear that gags whistle-blowers and those who variate from the envy-of-the-world hymn sheet. Not looking across the Channel to more successful, better funded health systems on the Continent. No wondering why Britain has fewer MRI scanners per head than Slovenia or Slovakia, fewer CT scanners per head than every OECD country, than Hungary and Mexico. Not pondering the fact that unless we decide to live out some dystopian real-life version of Logan’s Run, Britain’s aging population will leave more people needing long-term health care with ever fewer people to pay for it.

There is a debate to be had about how we fund the NHS, about its priorities, and whether we further pursue the market reforms begun in the last Parliament by the Labour Party. There is a debate about whether we look at successful insurance models, or whether we accelerate the so-called “tide of privatisation” that has seen the number of outsourced, private contracts in the NHS rocket from 4.4 per cent to, erm, 5.9 per cent between 2010 and 2015. Reports like the Institute of Economic Affairs’ What are we afraid of?, which suggests better outcomes tend to be found in market- or insurance-based healthcare, should be front and centre of that debate. Instead, they’re buried by politicians holding the NHS so tight they’re in danger of suffocating it.

It is in vogue in Britain to trash politicians – much of it unfair. But the sight of party leaders burying their heads in the sand, ignoring the failings of the NHS and the seemingly insurmountable challenges it will face in the coming decades, is thoroughly depressing. The public deserve better.