In November 2009, I gave my inaugural professorial lecture at Nottingham Business School with the title "The future of UK public services". This was just at the start of the era we now term "austerity" and one of the points I emphasised was that we shouldn't see the situation pertaining, at that time, as a "blip" with normal service resuming shortly, once significant economic growth returned to the UK economy. As so it has proved to be. Austerity is still with us and seems likely to remain with us for the foreseeable future.
One of the things I emphasised in the lecture was that we should avoid what I termed "death by a thousand cuts" or "salami slicing". Instead, I said that we should recognise the current situation as a discontinuity from the past and one, which has led to what I termed a social and economic watershed in our history. I emphasised that we should address the problems of organising and funding public services by considering the questions shown below and having a vigorous public debate about the issues raised. It would also help if there could be some sort of political consensus among the major particular political parties on, at least, some of these issues. My questions were:
• What should be the future role of the state in the provision of public services
• What should be the limits of its involvement?
• What should be individual and collective responsibilities in relation to specific public services?
• How should public services be paid for in the future?
• How should public services be organised?
• What should be the balance between the private and public sectors of our economy?
• To what extent should the private sector be involved in public service delivery?
Not surprisingly, seven years on from my lecture, none of the above has taken place. We have had no public debate on these issues and we have had endless salami slicing coupled with a public relations exercise designed to give the public the idea that cuts were not taking place at all. I have lost track of the times I have heard something on the radio or TV whereby a particular vested interest is protesting against a cut in a service which they hold dear. Up pops, a Government Minister to explain that no such cut is actually taking place and indeed the government is providing more funding from some special funding pot it has established. What should be noted, however, is the heroic efforts of many public services (especially local government) to minimise the impact of the cuts in their funding base.
Oh, and we have had no political consensus on any of these issues. In fact, the main opposition parties still cleave to their Father Christmas policy whereby we should fund more public expenditure from more borrowing while forgetting that we have to pay interest on that borrowing and repay the debt at some future date.
At the start of 2017, it does look as if the chickens are now coming home to roost on public expenditure. In late 2016, we had the crisis in adult social care, which has been deferred for 18 months or so by some short term funding. Today, we see NHS services creaking under the strain especially in accident and emergency (A&E) services. In the new financial year, we can expect huge amounts of public and professional concern about the financial situation schools will find themselves in 2017/18. In addition, the Ministry of Defence will face its usual problem of too many commitments and too few personnel and assets to meet them.
However, something happened yesterday, which might give hope. Yesterday, the Secretary of State for Health made a speech in the context of the accident and emergency crisis whereby he stated that the four-hour waiting time target for A&E patients to be seen would exclude patients who turned up at A&E with minor ailments. In response, Jonathan Ashworth, the shadow health secretary, said: "Is he now really telling patients that rather than trying to hit the four-hour target, the government is now rewriting and downgrading it?" I would suggest that in making this change Hunt is explicitly recognising that the NHS cannot be all things to all people at the same time. Once we start looking at A&E we can start looking at other health services and start questioning whether other targets should be modified to recognise differences in priorities and importance of the services involved. Going on, we can look at other public services and start questioning whether they are all as important as one another or are some more important than others.
Where Hunt becomes disingenuous, however, is his attempt to pass the blame for patients with minor ailments presenting at A&E on the patients themselves. Last year, I was involved in some research looking at how the pressures on a major city A&E unit could be mitigated. It is quite clear to me that nobody in their right minds wants to be in A&E waiting for 4,5,6+ hours. They are there, either because they have no alternative access to treatment other than A&E units (where they will be seen eventually) or there is some alternative treatment they could access but nobody has told them about it. Indeed, after 35 years' experience of the NHS I found myself in something of a predicament in that I had a minor problem with a finger, which wasn't clearing up despite self-treatment. I showed it to a GP friend and asked her if I should go to A&E to have it looked at. Her response was "don't be so stupid, go and see your GP practice nurse". Now I didn't know that this was an option and indeed, until I try it, I am not sure it is an option. I suspect I will first have to see my GP on a non-urgent appointment, which could take three weeks and then wait another couple of weeks to see the practice nurse. Better to go and wait in A&E and get it done.
The morale here is that the A&E crisis can be easily be involved by re-designing services in such a way that patients can access services for minor problems reasonably quickly and that those patients are made aware of this.
If we don't change anything, nothing will change.