The Blog

The Three Problems at the Heart of the NHS

I have heard both Miliband and Cameron talk of stopping the day to day political meddling in the affairs of the health service, in Miliband's case this was shortly before he decided instead to 'weaponise' it, but neither of the main parties has ever taken a serious step towards this end.

It is with a familiar sense of dread that NHS staff await the coming general election, nervously anticipating how our NHS, our jobs and our lives will be bent to the political whims of the party leaders. Over the next few weeks there will be an escalating exchange of ever more improbable and unrealisable commitments made in an attempt to win votes, whether it is the promise of a legion of new doctors, nurses and carers to appear out of the ether, or whether it is the promise of cancer diagnosis while you wait.

Each party will produce sound bite upon sound bite proposing ways in which they would tinker around the fringes of this enormous institution. All will produce eye catching policies and none will tackle the three fundamental problems that lie at the heart of the health service.

The politicization of the NHS is the first and most glaring of these follies. In recent times I have heard both Miliband and Cameron talk of stopping the day to day political meddling in the affairs of the health service, in Miliband's case this was shortly before he decided instead to 'weaponise' it, but neither of the main parties has ever taken a serious step towards this end. Presumably the potential gain in votes that healthcare policies can achieve balances favourably against such risks as being blamed for the A&E winter crisis.

This is not a new idea and it is not an original idea. Healthcare professionals have been pleading for the NHS to be taken out of Westminster's hands for decades so, if Miliband and Cameron agree that this should be the case, then why will it not happen?

The organisations capable of running the NHS already exist, organisations such as NHS England and the National Institute for Health and Care Excellence that make decisions on the day to day running and funding of the system, so one would imagine the cost of transitioning control would be minimal. In any case the long term savings of having a healthcare system run according to a rational long term plan must be huge in comparison to making the NHS dance to the ever changing five year tune of the politicians.

Now, rather than rational planning, we have MPs trying to dictate health policy according twitter trends. Furthermore we have MPs such as David Treddinick, who sits on the most powerful health committee in the commons, suggesting that the NHS should offer astrology to its patients. How is it possible that, in the era of evidence based medicine, someone with such widely disparaged views and no experience of providing health care can be in a position to directly influence health policy?

The second major issue at the heart of the NHS is the internal market system. In the 1990s free market principles were introduced to the NHS on the assumption that they would drive efficiency and savings. They may have done had these principles been allowed to run to their natural conclusions. Competing services were set up with the view that poorly performing services would either have to improve or close shop. However, as anybody who bore witness to the attempted closure of Lewisham A&E in 2013 will have realised, closing services is not as easy as it sounds. It is almost impossible to shut services in a system that has no spare capacity.

Poorly performing services are not shut, instead they are propped up. This results in the taxpayer funding different and competing organisations to provide the same service. For example, if a man in Sutton presents to his GP with a prostate problem for which he needs to see a urologist, his GP has the option of referring him to the hospital or to the community urology service. If he is referred to the hospital the GP will pay a referral fee to the hospital. This cost accounts for the time of the consultant, the investigations he will have to perform and the overheads for the hospital facilities.

If he is referred to the community service he will be seen by the same consultant and he will have access to the same investigations and treatments but the referral cost to the GP will be halved. Patients like the service because it is provided in a local GP surgery and the waiting list is often shorter. The GPs like the service because it costs them less. The consultant likes the service because he has greater control over it and he gets paid based on the work he does rather than on a salaried basis.

However the hospital loses out because it is stuck with the same overheads as before but, with less incoming referrals, it has less revenue with which to pay for these overheads. The taxpayer also loses out because he is now paying for two services and two sets of overheads. The free market drive for efficiency, and the eternal game play it creates, wastes money in this manner throughout the NHS.

The third and final major problem at the heart of the NHS is the lack of a clear mission. The health service was founded on the principle of providing the greatest good for the greatest number of people. This utilitarian principle makes it inevitable that some patients, mostly those with rare conditions, will fall through the gaps. This is politically, and very often personally, unpalatable.

However it is disingenuous to try to paper over these gaps with headline grabbing initiatives such as the cancer drugs fund. Such a fund was never going to be sustainable and was set up for a fall from the outset. Medicine is ever evolving and ever advancing and the pharmaceutical companies are capable of producing as many expensive and unusual medications as there are pounds in our collective pockets. This means that an institution with finite resources has to make tough decisions on what it can afford to provide and short term plans to circumvent this fact are misleading and damaging.

The recent research by the health economists at the University of York has demonstrated definitively that the provision of rare and expensive medicines to patients with rare conditions is damaging to the health care received by the majority.

Sound bites announcing each new priority play well for a moment but with every new priority something must be de-prioritised. A new priority may be necessary but it is only right that we be honest and admit that this means making savings and cuts somewhere else.

Anyone who refuses to admit that the NHS offers a superb standard of care is willfully ignoring the evidence. The US Commonwealth Fund regularly surveys the healthcare provided in modern, western countries and the NHS routinely comes out on top but, as a nation, we have to decide what we want the NHS to provide. We can keep costs down and have a healthcare system that is a safety net, a healthcare system that will do the greatest good for the greatest number of people, or we can pay what is necessary to have a healthcare system that can provide everything for everybody. At the moment we are paying for the former and trying to provide the latter. We will never be able to have a reasoned and honest debate about how the NHS should be run until we decide what we want from it.

The NHS would benefit from a period of stability but if the politicians insist on making changes, as surely they will, these are the three issues they should address rather than engaging in the relentless and devastating meddling that the health service suffers from year after year.