Tuesday, 7 June 2011

I care about Healthcare, not the NHS

Ok, so after the two month consultation into Andrew Lansley's 'controversial' NHS reforms, the bill now looks visibly different if taken at cosmetic face value. The 2013 deadline by which GP's were to take control of funding has been removed, with that management of budgets now set to also include doctors and nurses. Any switch will now take place "when GP's are good and ready" in Mr Cameron's own words, which of course offers the prospect of many being at that "almost there" stage on an ad infinitum basis in the coming years. Other changes include the creation of clinical senates to oversee patient care, confirmation that the 18 week waiting time guarantee would stay in place and a rather vague pledge only to allow wider competition for services "when it improves patient care and choice". I was under the impression that more competition increased choice by sheer definition, weren't you?

Unsurprisingly, the anything but Liberal Democrats are delighted with what one of their MPs, Andrew George, referred to triumphantly as "an effective U-Turn", while many backbench Tories are said to be spitting blood. From the outside looking in, I can't help but think that in practical terms they were fighting over what was a very small plot of land in the first place. "Privatisation by the back door" rolls off the tongue quite neatly as a line of attack, and is a convenient stick with which to hit Lansley, a distinctly mediocre political operator who should probably be locked in a cupboard for a while. However, the NHS would still have remained a taxpayer-funded organisation whose funding was protected from the fiscal realities that apply to most of us. The day's other promise from Number Ten, namely that of committing us taxpayers to further increases in NHS spending, was merely a regurgitation of a pledge from last year's highly depressing election campaign.

Apparently David Cameron 'loves the NHS' as much as anyone. I can't help but think that his need to state such open emotion towards a legal entity is a substantial part of the problem. While I support in principle any move such as that of the original proposal, which shifts decision-making power, funding and accountability to the most local possible level, surely in the grand scheme of things these are not the sort of earth-shattering questions that the Westminster Village would have you believe? In reality, this has been an argument over whether to apply one form of statism or another to the NHS, with fag paper differences wildly exaggerated for the benefit of tribal theatre. I have no idea whether or not Dave's affection for a state institution is kosher, but he either feels compelled to profess a false state of undying love for political means or he genuinely does love the National Health Service – either way we are in a sorry state of affairs..

Whenever politicians talk about the NHS, they first queue up like Goneril and Regan, King Lear's treacherous daughters, to indulgently espouse the warmth they feel from the bottom of their hearts for 'what we all regard as a national treasure'. It has gone way past nauseating and stopped turning my stomach a long time ago. Now the natural response is to either switch the channel over or at least cover my ears until the picture changes. Perhaps I'm committing an act of treason by saying this, but I genuinely do not 'care' one iota about the NHS. What matters to this bunny more than anything is the availability of quality healthcare to the general population at an affordable price - and if you subscribe to the view that people invariably get better value for their own money than the government ever could, it is virtually impossible to see where a taxpayer-funded monopoly with guaranteed funding becomes part of the solution.

For example, take the notion that competition will only be introduced "when it improves patient care and choice". As always, the critical question begs to be asked:- who exactly gets to make that judgement call as to whether or not it represents an upgrade or a more cost-effective solution? The best person to make that judgement is not a GP, or a nurse or god forbid, a politician but the patient himself. We now have the strange paradox in the public sector of a state which on the one hand promotes 'choice' for its customers but then reserves the right to dictate exactly what that 'choice' entails. Regardless of whichever wooly slogans the LibLabCon will drag out to worship at the altar of 'universal' healthcare, the true ethos of the NHS remains that of the state being in the driving seat, with the paying passenger having to settle for what he or she is given.

Real choice of course involves having the right to take your business elsewhere, as you would in almost any other walk of life. Were some of Britain's failing, MRSA-ridden hospitals private enterprises, not only would there be a national outcry about the cancerous effect of 'the profit motive' but the hospitals themselves would be closed, if not by the inspectorate then certainly as a result of a mass exodus of customers. The truth is that in terms of performance and outcomes, many NHS hospitals would have gone to the wall as standalone entities some time ago, and have only been kept alive by the insulation of their funding and the institution's undeserved status as one of Britain's 'sacred cows'.

Were they competing with private providers in a voucher system (my preferred solution as opposed to compulsory private care, as some may have presumed), then it would indeed be interesting to see what sort of choices the paying public would begin to make. The local NHS hospital would be competing for the value of your voucher while a private one may seek a small additional amount as a top-up. Many of the 'squeezed middle' who have found themselves penalised and inhibited for the best part of two decades would suddenly be presented with the opportunity to escape the state monopoly and spend their money where they saw fit. The good NHS hospitals would no doubt thrive while what passes for others would soon be driven out of business – surely this is a fair and meritocratic end result?. There is no point lying - state healthcare may well end up in this scenario as the second tier preserve of the unemployed and least well off, but only if it deserved to be.

Had the government returned from their two months out to 'pause and reflect' to put the proposal of a voucher system on the table, then despite the concept itself not being all that radical in reality (Malpoet will soon be on to confirm this), it would still have represented a shift in ethos and a significant talking point. As it is Nick Clegg and his friends have screamed their marginal differences with the original proposal to the rooftops and appear to have won a moral victory in the form of one or two aestethic 'concessions'. What we have ended up with is yet another restructuring, more edicts, targets and initiatives, with further tinkering around the margins, not that the bill put forward in the first instance was significantly better, it should be added. New Labour may have left office a year ago, but their modus operandi remains right at the heart of government.

Until we can shift the terms of the conversation to the point where it is about healthcare in general terms and not the 'sacred cow' of the NHS, then the real measures required to drive up standards and penalise failure will not be allowed to take place. Successive governments have constantly adjusted the shape, scope and structure of the health service while throwing unprecedented sums of taxpayers' money into the bottomless pit that it has become. All have failed to oversee a rapid climb up the European league table in terms of outcomes, which was of course the original stated aim. When we are able to engage in an adult conversation about healthcare, we might get the notion of a shift in culture (ie - the way we do health as a country) off the ground. Like comprehensive education, the NHS in its current form has long outlived its usefulness, and I make no apologies for failing to 'care' about it sufficiently.


  1. The NHS is a disaster. It is a monster bureaucracy which is incapable of meeting the real needs of patients because the providers have no reason to focus on patient needs. The people who work in the NHS are rational human beings. That means that they quite properly care about their security, their families and their prospects.

    Because patients are not paying for their treatment and they have no realistic ability to take their custom to another provider, NHS workers can only protect their own legitimate interests by sucking up to the target setters and pandering to jobsworth administrators and egofreak consultants.

    All the talk of shifting decision making from administrators to clinicians is meaningless bullshit that totally fails to address the real issues. Surgeons will be just as useless at managing the NHS as the bean counters have been. This is a deck chairs on the Titanic issue.

    The only thing that drives up quality and holds down costs is the millions of free choices made by people whose wealth and well being depends on the quality of the choices that they make. This brings me to the possibility of a voucher system.

    Vouchers can work in education because it is a very simple issue. You have a child of a given age and you allocate a voucher set at the value considered necessary to educate that child for a given period to a set standard. The parent then uses that voucher for the education they choose for the child and pays any additional cost if their choice is an expensive one. There is no parallel to this in health care.

    On what basis would any voucher be issued? At the very crudest level you could have a voucher of a given value for each person every year. You save up the vouchers until you need some form of treatment and then use them. I don't think I really need to explain why that wouldn't work, but at least some dreadfully vulnerable people could pay for some of their 'painkillers' by selling their vouchers while they drink and inject themselves to an earlier death. It could reduce crime a bit and be a mercy to those who are in too bad a state to steal their needs.

    Do you go to a doctor with an ailment and get a voucher to see a consultant to find out the appropriate treatment. Having seen the consultant you get a voucher for a specific procedure. Well that's the procedure that he uses, but there may be several alternative ways of correcting your condition. Does the voucher include the post operative support and dressings? Does it include the lifelong medication which follows transplant surgery? Of course there are a limitless number of questions of this kind.

    Vouchers might play some part in a transition from a no choice, no sense, no use system to full market provision, but it cannot be a solution in itself.

    The NHS has almost universal support because fear is universal. People cling to it for the same reason that they hang on to religion. It may always have let them down, but they are terrified of doing without it because they have no knowledge of what could fill its place.

  2. The truth of the NHS is that it consumes a huge amount of our national wealth and however much more money is put into it demand will never be met. Many thousands of people die unnecessarily every year in NHS care as a consequence of simple hygiene failures and yet all political and media focus is on imagined gaps in care or need for new treatments. We are continually threatened that smokers, heavy drinkers, the overweight, etc. might be denied treatment at the same time as new 'illnesses' of infertility, sexual dysfunction, body dysmorphia and much else is added to the range of publicly funded conditions to be addressed.

    There are constant squeals from the media about a postcode lottery if a treatment is introduced into one area. The only way of quieting this is for other places to introduce treatments that they do not think they need or to prevent a particular trust from innovating for fear of creating unaffordable demand.

    The welfare mentality is so deeply entrenched in this country that I don't see much prospect of weaning people from the universal care promise of the NHS. That is a shame because an alternative could be so much better.

    With competition the worst providers would cease to exist and avoidable deaths would fall. As private providers focussed on niche areas of care, their specialist skills would rise and success rates would improve the quality of life of patients.

    A safety net will always be necessary for the chronically sick and disabled. In the US this is provided by the medicare system, but it would be far better done by a combination of local charities and insurance financed funds. I don't have the time to detail it fully here, but it is fairly straightforward to establish a system in which those who are unable to obtain individual healthcare insurance will receive essential treatment from a common fund, then convalescence and continuing care is met by charities. Many professions already have benevolent schemes to support former employees who have fallen on hard times. These are supplemented by specialist organisations for specific illnesses, hospices for the terminally ill, religious and other belief based foundations. As the smothering inadequacy of the NHS is progressively removed, human scale care can emerge at a higher standard and lower cost.

    Although some will recoil at the prospect, some of the choices which will then be available to us will actually make us more complete human beings. Suppose, for example, that I am really confident of the health of myself and my family and that if something really bad happened I could manage to raise ten grand. I might then limit my health insurance to cover only claims for costs over £10,000. I might then be able to finance a grandchild's higher education on the saved premiums. Or I might get pissed a lot and wreck my liver. My choice.

  3. Comments too bloody long again. Had to split it in two.

  4. Mal - great comments as ever.
    To clarify, the voucher would be equal to a 'subscription' to the NHS for 12 months. You could then use it plus a little extra to get some sort of universal private cover if needed.
    Agreed though that it needs fleshing out and may only be part of a solution.