Nigel Hawkes in the BMJ 22nd September 2015 opines in “NHS truths that dare not speak their name”. BMJ 2015;351:h4983 The name is rationing.. Without it the health services are not safe in any hands..
Trying to make political capital out of the NHS is risky. If the effort fails—as it did for the Labour Party in this year’s general election—you are left opening and closing your mouth with nothing much to say.
Labour’s bid to “weaponise” the NHS was a dismal failure. Nobody seemed to care that much. The claim that the Conservatives were planning to privatise the service fell on even deafer ears. The NHS Action Party fielded a dozen candidates and polled fewer votes in total than the majority won by the health secretary for England in his South West Surrey seat. Opinion polls indicated not only that electors were tolerant of austerity, they actually welcomed it.
The result has been to close the book for the moment on the default position held by many in the NHS—and even more of its supporters outside—that more money is the answer to its problems. It doesn’t make this position wrong, but it makes it harder to voice. Hasn’t the government already promised £8bn (€11bn; $12.3bn)? Isn’t that enough? Not unless another £22bn can be saved by 2020 from budgets that are already bust, and nobody actually believes that this is likely. Likewise, very few people except those whose jobs depend on it believe that NHS vanguard projects1 will transform care in the present parliament (if ever) or that forming hospitals into chains will cut overheads and standardise services in a way that has eluded every previous effort. Or that NHS Improvement (the product of the enforced coupling of the regulator Monitor and the Trust Development Authority) will actually generate much improvement.
Politics of desperation
Like a drowning man grasping at a straw, the NHS in England is currently prey to the politics of desperation. The financial regulators apparently believe that the total deficit in acute care trusts—£2bn this year and rising—is the result of trusts not trying hard enough, while the trusts say that they can do no more without affecting services. Hunt has clamped down on agency staff spending, but if trusts cannot find enough permanent staff to fill the gaps, failures of care become more likely. Continuing restraint on pay, another Hunt demand, makes agency work more attractive: reliance on agency nurses doubled from 2012 to 2014. Many NHS workers get the best of both worlds by having a staff job and taking agency work on the side, sometimes in the very same hospital.
The peer Patrick Carter, who has been charged with finding efficiency savings in trusts,2 says (his fingers crossed behind his back) that there may be £5bn a year to be saved. It’s impossible to tell whether he is right, as this figure isn’t evidenced, and realising the savings is the hard part. The NHS has travelled this road before many times, most recently in Better Procurement, Better Value, Better Care, a strategy published as recently as August 2013.3 That aimed to save a more modest £1.5bn by 2015-16. Did it succeed? Apparently not, since we heard no more about it.
I could fill this column with hard to believe claims. They’re everywhere, and they mostly go unchallenged, because even the most determined nay-sayers eventually begin to tire. So I’ll leave you with one more. On 2 September, at the Health and Care Innovation Expo in Manchester, Simon Stevens, chief executive of NHS England, announced “a major drive” to improve health in the NHS workplace.
To pay for this he promised £5m. Since the NHS employs 1.3 million people, and a lot of them are overweight and unfit, this is a conceit of loaves and fishes dimensions. For £5m all we’ll get are action plans and frameworks, as if talking about it were a substitute for doing it, until the whole initiative dribbles away into the sand. Meanwhile the chancellor of the exchequer has cut £200m from local authorities’ spending on public health.
I can’t improve on a comment recently attached to an article in the Health Service Journal about the vanguard sites. It read, “Somewhere there ought to be an NHS Museum of Pointless Initiatives, where every centralising, witless progenitor of Another Damn Good Idea That Will Save Money After Costing Some should be forced to spend a week or two in silent contemplation before being allowed to proceed with their heroic pilots and their leaden roll-outs and their oddly (but invariably) much quieter windings-up.” I’d like to credit the author of this outburst, but, as is invariably the case with the more entertaining comments in the HSJ, it was anonymous.
Tigers of improvement
There are of course inefficiencies in the NHS against which the new tigers of NHS Improvement are soon to be unleashed. But international comparisons don’t indicate that the situation is hopeless. The service costs rather less than that in similar European countries and a whole pile less than in the United States, whose ideas we are increasingly importing.
The regular comparisons by the US think tank the Commonwealth Fund show that the NHS does well on access, equity, and efficiency, less well on outcomes.4 These reports have been a handy prop to health secretaries under fire—even Hunt has quoted from them—and while they don’t quite prove that the NHS is the best in the world (they record only one outcome measure, deaths amenable to healthcare, where the NHS comes nearly last) they do suggest that it’s decent value for money.
Will the current flurry of initiatives make it better value? Some of them, such as the new models of care being piloted in the vanguard sites, make sense only with a reformed payment system that ceases to reward the volume of activity in acute care. But, like money, nobody wants to talk about that, because large scale reform has got itself a bad name. We’re stuck in a world where the things that might make a difference are the truths that dare not speak their name.