An insurance based system would be another way of rationing, and would be far preferable to the gradual degeneration of services, and altruism that we are suffering from now..
The untouchable status of the health service is at the heart of its moral and financial crisis
On Radio Four’s The Moral Maze last week, I had an illuminating encounter with the recently retired chief executive of NHS England, Sir David Nicholson.
I asked him how the NHS could claim it embodied caring, compassion and altruism when many elderly patients had been starved or dehydrated to death. The recent inquiries into Mid Staffordshire and 14 other hospital trusts laid bare a catalogue of neglect and cruelty. These problems are undoubtedly more widespread still.
Yet Sir David, who had overseen the Mid Staffs Trust for part of the period under review, waved this all away as “tabloid headlines”. Of course these founding principles still obtained, he declared. Why, in a survey NHS workers had said they all still supported them. It takes a truly bureaucratic mind to elevate a box-ticking exercise to the level of unchallengeable proof while dismissing the actual reality of observable human behaviour.
The NHS, permanently staggering from crisis to crisis, is currently staring at a £30 billion funding “black hole” by 2021. The Office for Budget Responsibility predicts that healthcare spending will rise from 6.4 per cent of GDP in 2018-19 not just to 8.5 per cent half a century from now, but to nearly 15 per cent once healthcare productivity rates are factored in. No wonder voices are sounding an alarm that something has to give. Even Simon Stevens, the new head of NHS England, has agreed that it must “reinvent” itself.
This is, however, not just a financial but a moral crisis. Callousness and cash are linked, undermining the NHS at its very core. Of course, it is not wholly to blame for the widespread erosion of the caring ethic — the decline of religion is arguably the principal cause. For Florence Nightingale, the most menial nursing tasks were invested with the highest of Christian spiritual and moral values. She would have smashed her lamp in fury when, in the 1990s, nursing leaders came to regard caring as demeaning to women since it made them inferior “handmaidens” to male doctors.
The NHS, though, has made this culture worse for two fundamental reasons. First, politicians are impelled to claim that the NHS is constantly improving. The whole service therefore has to dance to that tune. This sets up the second factor, the irresistible pressure to sustain a big lie.
Politicians know that while demand for healthcare is inexhaustible, the public’s willingness to pay for it is finite. So everything has to be massaged to sustain this Potemkin structure of universal, comprehensive coverage free at the point of use.
Hence the manipulation of targets such as waiting times. Hence the treatment of whistleblowers: silenced, threatened or sacked for exposing instances of appalling care. Hence also the absence of accountability, devolved on to regulators by politicians unwilling to take the flak when things go wrong.
The regulators, though, are themselves inadequate. The Care Quality Commission, which came under fire in 2012 for having failed to spot the serial abuse of patients, promptly hired 134 inspectors who failed basic competency tests. More than one in ten current inspectors are said to be not up to the job. Meanwhile, waiting lists are at a six-year high, up from 2.91 million in March to 3.1 million in May. The NHS bill for clinical negligence has now reached £25.6 billion. A further £20 billion has been wasted on a flawed computer system.
These disasters are not incidental. They are inescapable. Yet such is the sacralised status of the NHS, even those calling for fundamental reform cannot face the fact that it is bust beyond repair.
GPs and nurses have been discussing — although rejecting — the idea of charging patients for seeing their GP. Almost half of the NHS professionals surveyed by the Nuffield Trust predicted that within a decade, people would be forced to pay for some health services.
This cannot be a solution, as it really would penalise poor people. A far better idea is to change to a European-style social insurance system, in which people buy into insurance schemes that run medical services. These schemes protect the poor and, by giving patients the leverage of choice and competition, deliver a far higher basic standard of care than the NHS.
The health service is untouchable because, in a country that lost its global purpose at the same time as the NHS was founded, it is viewed as the one unambiguous moral good that furnishes pride in British national identity.
This is hypocrisy. It’s the principles that we should stick to, not the institutional structure that has eroded them — and which can and should be changed.
Update 25th July. Times letter from Sir David Nicholson. NHS needs Cash.
The former head of the NHS now says that it needs more money
Sir, No one, least of all me, would say the NHS is without serious problems, but in 2008, faced with a period of unprecedented austerity, we did not reduce the offer to patients or dramatically cut the pay of staff, like many European counterparts. Instead, we focused on efficiency and reform on behalf of patients.
This brings me to what Melanie Phillips (“Forget reform, the NHS is beyond repair”, July 14) describes as a “big lie”. She says one reason the NHS is in trouble is because politicians have to keep saying it’s improving. All I can say is: ask the hard-working GPs, nurses and other NHS staff as to whether it feels like they get support from politicians. It does not.
I also flatly reject the assertion that our NHS is inherently unsustainable and bound to fail. Delivery of a sustainable NHS will, however, require a modest amount of funding growth as the economy strengthens, modernisation of the way we deliver service, and better engagement with patients and staff.
It can be done. But we do need a calm and evidence-based public debate about the future.
Sir David Nicholson
Former chief executive, NHS England
Update 14th April
Sir, Melanie Phillips is right that the only solution to the NHS’s problems is a continental-style insurance scheme (Opinion, Apr 12). This has been indicated ever since 2005 in our annual Euro Health Consumer Index, which compares and ranks European national healthcare systems. Continental “Bismarck” health insurance systems outperform the British, Italian, Spanish and Nordic “Beveridge” systems. This is particularly true for accessibility — ie, the absence of waiting lists — where even oil-rich Norway has problems.
The continental systems have much less micro-management from on high, and rely more on responsibility and accountability being shown by the medical profession. Particularly in the Netherlands, this is boosted by a legal obligation for the profession to liaise with patient organisations. In other words: let the professionals run the show, and make sure they talk to their customers frequently.
The NHS’s problem is most likely not a lack of resources: it is inherently cheaper to run a healthcare system without waiting lists than to have them. Waiting lists create extra work, draining the healthcare organisation of resources. I know this from having been CEO of the University Hospital of Northern Sweden, where I was hired to cut costs. After three years of cutbacks, involving reducing the number of staff by 1,000, we ended up operating the first waiting list-free large hospital in the country since at least 1945.
Professor Dr Arne Björnberg