Sunday, 16 October 2011

You are the NHS

Some aspects of Wednesday's post about the NHS have surprised me by the reaction they have generated amongst readers. Some were sceptical that the NHS bill is actually going to make much difference from the patient perspective. After all, care is care, right? And anyway, others said, news stories like the recent one about the CQC inspection of hospitals show us that maybe the NHS could do with some assistance from the private sector to help raise standards.

I have a lot of friends who work directly and indirectly for the NHS. They include nurses, commissioners, analysts, care staff and more. On the basis that these people from their various disciplines will have a greater understanding of the trials and challenges facing the service than I do, I have decided to thoughtfully reflect on some of the comments they have made to me since my previous entry. I will also try to look at a few of the central tenets of the pro-bill argument, and do my best to analyse them in greater detail.

The NHS is already costing the UK more, year-on-year, as the general population increases and the baby-boomer generation approaches retirement.

Put simply, it will cost more to provide healthcare to a bigger population with a high elderly contingent. As the population grows, greater taxation will offset the effect somewhat, provided there are jobs available for the population to do. This process will self-regulate to some degree in a well-managed economy, as businesses are more likely to hire staff when labour costs are low, and pressure of increasing unemployment lowers labour costs for unskilled workers.

General government expenditure on the NHS as a % of Gross Domestic Product (GDP) has risen year-on-year from 3% to nearly 9% since the early eighties. However, the figures shown here suggest that the bulk of that increase has ocurred since 2000 and thus part of the increase shown could be a reflection of the recent economic crisis on the UK's GDP.

The graphs also show that real-term % increases on NHS spending vary wildly and tend to be lower in years when growth is stagnant in the economy. This suggests that previous governments have reflected economic pressures in their spending decisions on healthcare.

Also, there are figures available that suggest that the US healthcare system we seem eager to emulate spends more per person on healthcare than practically anywhere else in the world, but continually ranks among the lowest in terms of quality care. The conclusion we can take from this is that how money is spent is as important as how much.

If a private provider can carry out NHS work for a lower price, doesn't it make sense to let them do so?

The question to ask is WHY a private provider can do this. If the reason is a genuine one - economies of scale, access to skills or equipment that the NHS does not have as standard, then all very well and I agree that this makes sense.

However, let us not forget that private companies also have to factor in profit margins, and therefore this is not a zero-sum equation. Private sector workers work longer hours for lower rewards, have worse working conditions, reduced access to pensions, collective bargaining and so on.

These conditions create low-skilled, low-motivation workforces where mistakes are commonplace, and we should not compromise on quality of service or workers' rights to deliver lower-cost procedures.

The choice agenda means that if people prefer to use in-house NHS services, they can stil do so.

I have to confess that I've never quite understood the choice agenda. In theory, care is free to all at the point of delivery, and assuming that every area shuld have equal access to the same healthcare, why would you even need a choice? We would all simply go to our nearest health centre and get treatment later the same day.

In practise, of course I realise that things are not this simple. If you needed heart surgery and had a choice of two hospitals, one of which had a 90% survival rate and one of which had a 10% survival rate, you wouldn't need to be Einstein to make the choice between the two.

The problem I have with this is that this decision requires us to apply rationalisations without ever exploring the underlying causes for the figures. To use the above (rather fatuous) example, rather than spending money on putting an infrastructure in place to allow me to make a decision informed by nothing more than a malleable statistic, why is the money not spent making the necessary improvements to the hospital with the 10% survival rate to increase it?

To sum up - I think it's a safe assumption that people will opt for quality of care as being more important than distance to travel and that while the patient isn't paying the cost, cost will therefore be an irrelevant factor. As long as the necessary standard of care can be provided, people will not care whether their provider is a private or a public sector organisation.

The NHS shouldn't be seen as sacred - it is a means by which the government dispenses healthcare responsibilities to UK residents, and nothing more.

Oh, danger. The NHS is a national institution and internationally renowned. There are some who see it as part of a greater national identity and that is why politicians talk of it as special.

There are an awful lot of people whose limited understanding of the proposals means that they will see any suggestion of changes to the NHS as a bad thing regardless of the rationale for doing so. Additionally, people will have seen on the television and in the media that the British Medical Association (BMA) is concerned about aspects of the changes. They will see stories about practises asking for money for procedures and start to fear that they will be asked to pay to see a doctor. They will worry, justifiably, about the over-reaching powers of the competition regulator, Monitor, and the unclarified role of the Secretary of State.

As a socialist, I am concerned by this government's frantic desire to push through NHS reform without clarifying or consulting with the electorate about what they want. They use terms like 'choice' and 'consultation' wihout giving anyone a choice about what happens or paying heed to consultation outcomes.

If there is scope for improving the NHS, this is something that can be debated on a national level and agreed changes can be phased in as appropriate. We are all aware of the supposed need for austerity. This could be used as a means to make people think about the economic realities of our situation and engage them in ways to make improvements. 'So Mrs Smith, do you want us to build more hospitals or to spend billions of pounds of public funds to bail out failing private banks?'

Finally, we are quick to criticise our healthcare staff but the thankless job they do in difficult circumstances is generally an excellent one. Politicians claim the headlines and put forward consultations, initiatives and more but it is dedicated NHS workers who make sense of the chaos imposed upon them on a daily basis. We should all be thankful that they do.

1 comment:

  1. As the spouse of an NHS worker, I've heard a lot about the government's plans for the NHS. The Tory government does want to privatise, but piecemeal like the railways, and have parts "bid" for contracts against other parts, with the state paying whichever is lower. With less income, the care will obviously reduce. Even now staff are being regraded downwards, with the knowledge that they will ethically do the best they can, not refuse some care options as it is above their current grade.