What’s going on with our NHS? Pt 5. The need to propose solutions.


It is useful to describe problems and to share personal experiences. They can help define what it is we are trying to improve. But….. we also need proposed solutions. There are no easy answers to the woes that beset the NHS. Here are my thoughts based upon my preceding four posts.

1. The need to propose solutions: Decide what we want.

Public opinion is clear – the people of the UK want a National Health Service, and they want it to be successful.

It is also clear that it should be above party politics, and its task clearly defined beyond fundamental principles.

To my mind, that suggests work for a non-aligned authoritative body. There are clear precedents.

A Liberal-led coalition government commissioned the 1920 Dawson report. The clarity of the concise, interim report (in fact the only report) of that working group still has much to offer those planning the future of the NHS.

Harold Wilson’s Labour government commissioned The Royal Commission on the NHS in 1975. But by the time it reported, in 1979, there had been a change of government, and it was the Conservatives who acted upon it.

There are other examples, but those two serve my purpose. They show how governments of any description can commission independent reports that are fruitful in developing UK health services. What should be noted here is that the Royal Commission took four years to report. The current NHS does not have anything like that long for effective, curative action.

2. The need to propose solutions:Construct a viable economic model:

All recent governments have pursued the idea of a local market economy for the NHS. They should apply that at the highest level as well, creating a clear distinction between the government as purchaser, negotiating with the NHS executive as the provider.

The government’s position would be mandated by, and based upon, the conclusions of the non-aligned authoritative body described above. That brief should include the services required and the principles underpinning the service.

The task of the NHS executive would be much as it is now. It would obtain the best value for the government’s public money regarding volume, quality, cost and the cohesion of the service.

As then, in any commercial situation, there would be a negotiation between purchaser and provider. It might be that the government could not afford the whole package and that it would want to negotiate on a lesser breadth of service or quality.

Of course, it would spell that out openly, perhaps inviting the public to express a view. Even a referendum, since the government is happy to hold one about a major, national issue, and take the result as a mandate for policy. More money for more services? Or not? The principle would be the same as that which I go through negotiating my car insurance. Do I want to pay more for additional services? Or even for the same service that I had last year? Alternatively, do I save money and accept a reduced service?

Two key matters remain. Firstly, such a model presents a conundrum concerning the NHS executive. It must be accountable to parliament, yet independent in its negotiations with the relevant government department.

Secondly, as now, the NHS executive body would be responsible for the overall management of the service.

At last, a negotiated balance between requirement and funding

For the first time, there would be a relationship between the service required and the funding provided for that service. Subsequently, the executive would also be responsible, as now, with ensuring effective management of the service.

Two further points are worth making. It is likely that providing services for large populations would be more economical than for small. Insurance and other commercial organisations merge and enlarge for a reason. In the case of insurance and the health service, there is the added advantage of risk sharing usually benefitting from large populations. But as noted in the previous post, large is not invariably good, and on occasion is exactly the opposite. We need the best of both ends of the spectrum.

The second point again touches on ideology. It is not possible to implement a crude, free market within a health service committed to equity, the provision of services according to relative need. A market is about producing winners, and therefore losers. But in the NHS, if amongst the losers there are people with greater need than some within the winners, then the crude market model falls over. The NHS requires something more sophisticated than that.

But equally, at the other end of what we might see as an ideological spectrum, it is likely that a centralised, bureaucratic, national behemoth would be inefficient, unresponsive to new ideas and wasteful of resources and money.

Neither is satisfactory.

The NHS needs more money. Far from providing that the government wants very substantial cuts in NHS expenditure. There are some signs that an increase in taxation is acceptable to a majority of the public if hypothecated for the NHS. Presumably, if the government is committed to an effective NHS, it is exploring that possibility.

3. The need to propose solutions: Produce an appropriate organisational structure:

In previous posts, I have tried to show how the present structure is failing. Our focus has been upon hospitals. We have poured resources into them, and to a lesser extent into general practices, to the exclusion of other opportunities for service provision.

The rubber band model in the previous post illustrates the deficiencies in this approach. I have no doubt that, if we continue in this way, the NHS will stagnate and implode. Many people may be thinking that we have already arrived at that point.

We should turn the emphasis on its head. That is not to say that we reduce our financial commitment to hospitals. They are already overstretched and in financial deficit. They need more money, rather than less.

Rather, we should find and invest the funding shortfall we currently make compared to other similar countries. And in large part that investment should be in preventive medicine, social care, public health and primary care – by which I mean community and home care, general practice and intermediate care centres.

4. The need to propose solutions: Doing the right things in the right place:

That would improve the quality and convenience of care for patients. For hospitals, it would reduce the torrent of admissions, and increase their ability to discharge patients. For primary care, it would allow a dramatic increase in procedures and care provided in the community.

The rubber band could then start pulling patients back, out of the expensive hospitals towards, and into, their homes. Home is not only where the heart is; it is where patients want to be.

And there is a further aspect to this. It seems at least possible that there is a benefit in devolving a total budget for the amalgamated work of social care, public health and health care at an appropriate level of population size. I know Manchester is already exploring this. Federalisation may indeed allow more effective management and also set a realistic population size for equitable service provision.

5. The need to propose solutions: Declare a schedule:

The NHS is in crisis. If it is to survive it needs urgent action. The public will not forgive politicians who let it wither and fail. Nor should it. The public wants and expects a successful NHS.As a matter of urgency, the government should disclose a clear plan of action, or be held accountable for that lack of action.

As a matter of urgency, the government should disclose a clear plan of action that will maintain and improve the NHS in ways consistent with high quality, equality and equity. Politicians who fail to support that should be held accountable for their lack of action. A referendum result of 52%:48% was taken as a solemn mandate for government action. A similar vote concerning the NHS would return an overwhelmingly greater result.

Half-hearted fire-fighting is not enough. The NHS requires an independent review along the lines of a Royal Commission, and then the necessary political action to enact its conclusions.

Such an exercise will take time, and that is something the NHS does not have. Within an initial stage, the government must agree with the NHS executive how to adequately sustain the service until introducing the longer term plan. Statements that more is being spent on specific areas than in previous years should be dismissed as delusion at best and at worst political obfuscation.