The perverse incentives to deny the truth about the four UK Health Services is greater than the desire to be honest, have a long term view, and engage in the debate which Mr Stevens has asked for. But the pressures are getting bigger, and as more and more unnecessary deaths occur, and waiting lists become longer, and staff remain disengaged from the politics, but more and more angry, the penny may drop. We have to ration health care overtly. Only once this decision has been taken can we debate exactly how..
Is the NHS constitution still worth the paper it’s written on? It’s the nearest thing the health service has to tablets of stone. Its 15 pages enshrine the principles and values that should guide the conduct of the NHS in England. They say “the patient will be at the heart of everything the NHS does” and that, as a tax-funded service, decision-making should be transparent.
Sadly, on both counts, the deeds of a cash-strapped and understaffed service operating in a strange and volatile political environment are increasingly failing to match either the spirit or letter of those fine words.
That is closely linked to the document’s detailed description of key patients’ rights, including the NHS’s duty to treat those who need A&E care, an ambulance, non-urgent hospital treatment or cancer care within specified waiting times.
But the truth is that almost no part of the NHS can now cope with the demands on it. The decision to in effect shelve the referral to treatment (RTT) target – that 92% of patients should be treated in hospital within 18 weeks of referral, usually by their GP – tells us something profoundly worrying. The health service’s leaders such as NHS England boss Simon Stevens, ministers and the health secretary, Jeremy Hunt, know it can’t treat the required volume of patients within the agreed timeframes, but dare not say so in case their honesty triggers a media backlash or Theresa May’s displeasure.
Since the decision to relax the 18-week target in March, the total number of patients on the RTT waiting list has crept to more than 4 million people for the first time in a decade. But what really matters is the lack of honesty here. Neither NHS England nor the Department of Health has yet publicly acknowledged that a key target – unmet for 16 months – has now been downgraded or that patients are suffering pain, anxiety and distress as a result.
The same attempt to deny reality applies to the NHS budget. As NHS Providers, an organisation representing NHS trusts, says, hospitals face “mission impossible” trying to deliver the waiting time targets this year, the seventh of austerity funding. In a briefing last week on RTT, it said: “We should not maintain a fiction around what the NHS can deliver, given current demand increases, workforce shortages and sustained levels of funding increase that are well below historic averages. To do so carries several risks, including misleading the public.”
Faced with a government in denial on health and social care funding, the NHS is increasingly doing less for patients, despite rising demand – but again dare not admit that’s what’s happening. Jeremy Taylor, the chief executive of National Voices, a coalition of more than 100 health and care charities, is worried NHS England is increasingly making decisions that are bad for patients in a desperate attempt to make its sums add up. “We’ve seen a relaxation of the RTT target, a ‘budget impact test’ that could delay new drugs being available [for up to three years] if they cost more than a £20m threshold, an attempt to push the cost of pre-exposure prophylaxid drugs to local authorities, and a number of court cases where the NHS is seeking not to pay for certain treatments.” Taylor is also struck by the NHS’s “lack of meaningful engagement with the people who stand to gain or lose” from these decisions.
The NHS’s refusal to acknowledge that proposals to centralise many types of hospital care would inevitably generate controversy was judged a mistake by the King’s Fund, the British Medical Association and the Local Government Association – which is quite a feat. And NHS England has surrounded its bid to get 13 already cash-strapped areas to make £500m of extra savings this year, through the “capped expenditure process”, with almost total secrecy.
Such concealments, on all these difficult, politically charged issues, betray the service’s duty of transparency. But they also raise again a key question about Simon Stevens that won’t go away: is he the NHS’s voice in government or Whitehall’s man in the NHS?