What’s going on with our NHS? Pt 4. What's gone wrong?
What’s Gone Wrong With The NHS?
This post moves on to consider what’s gone wrong with the NHS? Why are we where we are?
Fundamentals:
To most people its principles are beyond reproach: to be available to all; to be free at the point of delivery; and for provision to be according to relative need. Fine though they be, they contribute to the problem.
Its resources still follow the original, Bevanite principal. It is funded entirely from taxation. This is not a unique model, but most comparable countries have chosen a different one. Theirs usually combine some form of personal insurance with public funding.
These two, the underlying principles and the Bevanite funding arrangement, result in an unstable economic equation. Services are unlimited, yet the funding is – its level determined solely by the government.
As noted in earlier posts, the UK spends less on its health service than do other, comparable countries.
An unstable economic model:
One of the most important reasons things have gone wrong with the NHS is its economic framework. We might consider the NHS as a health insurance policy that is unique in its open-ended cover. No matter what is wrong with me, when I developed it, or how long it continues, the NHS will treat me. You can question how well it does that, but the point is that the legislative commitment is there.
The insurance is taken out for the entire population yet paid for by its only policyholder, the government and its treasury. It is true that the money for that premium comes from the taxpayer, but none the less, on our behalf it is the government that commissions and pays for the service.
But here is the rub. The government not only determines the nature of the cover but also decides the size of the premium.
No insurance company would allow you to take out a policy of unlimited cover for your entire family, regardless of existing conditions and risk factors, forever and with unlimited claims, while also accepting you will decide the premium you are going to pay. That is unthinkable; nonsense. Yet, in principle, this is the situation for the government and the NHS.
Politics:
Much as we might not want it to be so, politics affects the NHS. Its ideology and finance are clear examples, with powerful and persistent forces making opposing arguments. The previous post discussed how governments might well find it attractive to engineer a reduction in their perceived responsibility for the failings of the service. Also, the post acknowledged the lure to governments to consider ways in which they could reduce its financial burden on the exchequer.
Whatever our views about the NHS, it is naive and unhelpful to deny these influences could affect the thinking of any government.
If we are to maintain the NHS, let alone improve it, it must have more money. Of course, there are other problems, and in the next post, I discuss additional ways to improve it. But like all health services, it still needs more money in real terms, year on year. Health care costs accelerate faster than inflation. This is a particular problem in the UKbecause the NHS is funded entirely from taxation. And, crucially, governments do not want to increase taxes.
Organisational structure:
Every day we hear about patients being kept waiting for hours on trolleys, delays getting a GP appointment, cancelled operations and unwilling bed-blockers. There is clearly something dreadfully wrong concerning the service being able to meet demand. Of course, there are many reasons for this, and there is not space here to cover them all, even if I could. But a few stand out.
Doing things in the wrong place:
We use our acute hospitals (the ones we used to call district general hospitals), as containers into which we tip anything and everything for which we cannot find another place. That is absurd. They are the second most expensive element of the NHS. Only the regional, super – specialist hospitals are more expensive than acute hospitals.
Worse still, over the last few years, there has been a progressive reduction in the number of beds within our acute hospitals. We have fewer beds per head of population than almost any comparable country, and in some cases, such as Germany, dramatically so.
Once patients are in our hospitals all too many of them cannot leave, not least because over the years, we have reduced the number of intermediate care facilities, such as local cottage hospitals.
Anyone who doubts the need for hospitals to be able to discharge patients to appropriate facilities might care to consider the tertiary, super – specialist hospitals. They do not have bed-blockers. They manage occupancy of their very expensive beds with ruthless efficiency. As soon as a patient is ready for discharge they return to their local acute hospital. Accommodating them is simply not the tertiary hospital’s problem. Out! There is a clear pathway for tertiary hospitals to discharge patients.
Another example. Have you ever been in a private hospital, either as a patient or visitor? People are in and out as quickly as possible. Efficiency, they would call it. Maybe, but why? Why are there no “bed-blockers” in private hospitals? We should consider that question. Not to find the answers, which are pretty obvious, but to carefully consider the implications of those answers.
A final one. Why are there no bed-blockers, or chair-blockers perhaps, within a GP’s surgery of people who have already finished their appointment?
Always the same answers. Because they have somewhere else to go, and they want to go there. The rubber-band can turn tension into desirable movement.
The rubber-band model:
I liken this to a rubber-band attached to each patient at one end, and their home at the other. The band is loose at home. Should the medical need arise, the patient moves progressively through the health service to the required level of expertise. The rubber band stretches behind them. The tension always tries to pull them back, through the layers of the service and eventually to their home.
A diagram immediately demonstrates the problem. Tertiary care has a clear pathway, back to the acute hospitals in secondary care. But there the logjam occurs. We have completely inadequate intermediate care in the community, inadequate primary care and very little organised home care at all. Yet these are far cheaper facilities than hospitals, and commonly more appropriate.
The diagram is only figurative, So most care occurs in the home, the least in tertiary care.
Management:
We accuse the NHS of bureaucracy, but here it has made significant advances over the last few decades.
If we ask the management question “what is the NHS trying to do?” the answer is easy regarding its broad principles. But if we then ask the next one “but how, exactly, are you trying to do it?” the answer becomes very vague and bogged down in distracting minutiae.
That is hardly surprising. The NHS is one of the top five employers in the world – and I suggest the largest of all that has a nebulous, open brief. But it still infringes management principles understood by any corner shop, let alone major organisation.
There are advantages and disadvantages related to the size of an organisation. In many ways, the NHS benefits from being large. Examples include the quest for equity, the sharing of risk across large populations, and – at least in opportunity – economies of scale. But it also displays the worst features of large organisations. Examples here include inflexibility, slow reaction times and woolly management structures. Big is not always best, or more precisely – it is not best in every way. This is only too obvious with such a personal matter as that of healthcare.
Conclusion:
There are many reasons why we are where we are. I have tried to encapsulate what I see as the most important.
There is no clear relationship between funding and expectations.
There is, all too often, a lack of strategic management. Most notably, there is a lack of coherent investment in appropriate facilities. Treat patients with the right people, in the right place and at the right time. We need to grasp the nettle that, usually, this will not be within a hospital. And invest accordingly.
There is a difference in ideological thinking about the NHS across the spectrum of political leaning. That may affect commitment to the service.
Next time: What can we do about it? Go to Post 5 in series >