What Sort of NHS Do We Want?

I feel passionately about the NHS for  two main reasons.  One  is that it is efficient, and international comparisons show that it delivers good results in a very cost effective way compared to other countries. The other is that it embodies the sort of values which as a Christian Socialist I believe in.  It embodies in a practical way the concept of loving one’s neighbour as oneself.  It is something to which we all contribute, and use when we need to.  In that way it promotes solidarity or togetherness and holds us together as a society.

It looks at health as a social good, which we all have duty to promote.  I suppose the other way to look at it is as a commodity, which we buy and sell like any other. Under such a system we all look after ourselves and don’t worry about anyone else.  That is the way private insurance schemes would see it.  It worries me that the present reforms could take it in that direction.

We have lived in an era where private enterprise has carried all before it, and public bodies have been castigated as bureaucratic and inefficient.  I often think we couldn’t set up the NHS now.  Private interests would not let us.  Look at all the battles Obama has encountered in America trying to establish something which we would regard as falling short of what we have here.  So it is a treasure we must value.  The “NHS belongs to the people” is the first line of the NHS Constitution, and in my opinion the people must never let it go, or they will never get it back.

But I am a practical person, and I have been involved in politics in one way or another most of my life, so I know full well that it is no good having fine ideals if they cannot be put into practice.  That doesn’t mean we should not have ideals, but we have also got to think carefully how they can be realised in a practical way.  If we want to keep the NHS, as most of us do, we have to accept that it will have to change.  It is no good getting the banners out every time a change is suggested.  So I set out to think carefully want sort of NHS we want in the future.  The result is my book, “What sort of NHS do we want?”.

I started off standing in the Front Street of a village near where I live in East Durham. It has a population of just over 5000.  It was established as a colliery, but the pit closed in 1981.The signs of economic decline are rather obvious, but what strikes you most when you walk down the Front Street is the number of fast food outlets – six at the last count, with two shops which concentrate on cheap alcohol.  There are also two large care homes.

Here in microcosm are the problems facing our health service.  Economic decline has brought bad health and the resulting bad habits.  There is also a large, and growing, population of the elderly for whom care has to be provided. It seems to present an enormous challenge.

But things are not as bad as they appear at first. I found there are many good people in the village who are trying to do something about the situation. There is a lively health centre, with innovative and dedicated GPs and a go-ahead manager.  There is a thriving garden association which has 250 gardens and a waiting list.  It provides fresh vegetables which are sold at the community centre.

The community centre itself has been pro-active in attracting funding, and now runs a range of activities. Currently over 350 people of all ages use a wide variety of services at the Centre including healthy living activities such as skipping, indoor bowls, tea and line dancing; keyboard classes, IT classes, drama workshops, cake decorating, art classes plus a fitness suite and a Community Café. The latest addition is pilates.

What impressed me most about the community, however, is the Health Forum.  This was originally set up by the Primary Care Trust, but funding has now been cut.  They originally had professional help, but they now run it themselves and have managed to secure funding from various sources. It received a small grant which it used as leverage to attract additional funding, and then distributed it to projects which promoted good health.  In the past it has supported various schemes, including a project to install low level lighting to minimise the risk of falls in senior citizens’ bungalows, outdoor ventures for the cadets and other youth groups, and an allotment.  The actual spending of the money was properly monitored. All this was done by volunteers who cared about their community and its health.

So there is hope.  A community which has been on the sharp end of recession and economic decline, and has experienced their effects at first hand, is doing something about it.

It made me think.  What sort of role do we see for the NHS in the future?  We frequently hear about the health risks of bad lifestyles, and how conditions such as obesity are likely to increase.  We have managed to tame smoking, but alcohol abuse shows no sign of abating.  The NHS will be financially constrained whichever government is in power, and we cannot expect it to solve all our problems alone.  Communities must do something to help.

From here I set off to look at various examples of good practice here in the North East.  We tend to think of ourselves as poor relations to the rest of the country, and that is certainly what people in the South seem to think.  Our NHS is very good though.  Not only do we have world class hospitals here in the North East, but all our health organisations have become Foundation Trusts which means that they had to reach certain standards. One, Northumbria, is recognised as being good enough to take on Cumbria, which has experienced problems.  You probably do not know either that the North of England Commissioning Service (NECS) which is the organisation which grew out of the PCTs to commission health care for the new Commissioning groups is also highly regarded.  It too has taken on Cumbria, and manages NHS IT systems outside the region.

So as far as the NHS is concerned we have something to tell the rest of the country.  What struck me from my work was that the most successful health organisations were those which involved people, and took them with them.  If you think of what is going to happen in the future perhaps you can see why this is.

Many of our health problems result from bad choices and unhealthy lifestyles, whether it be bad diet, too much alcohol, lack of exercise or smoking.  We have made progress in reducing these problems, particularly the FRESH campaign to reduce smoking, but there is still a long way to go.  I believe that we will only really get to grips with these issues if the NHS works closely with local communities and everyone takes responsibility for doing something about it.  People are more likely to take notice of their friends, neighbours and relations than someone giving them a lecture. There are examples I have discovered where this approach is very effective.

The other challenge is the perverse  result of  a good thing – people living longer.  We are more likely to need medical care when we are ill, however healthy a life we have led.  Many of us will need long term care, and our aim should be to provide this in the community as far as possible so people only have to go to hospital for serious cases. This again means engaging with the community.

The other obvious fact is that the NHS and local government must work together, and this is starting to happen.  Both are organisations which must engage more in various ways with the community.

Whichever government is in power, resources will be limited, so we must make hard choices as to how money can be most effectively spent, and politicians are not always very good at this.  More resources will have to go into the community, and this will inevitably mean fewer, but better equipped hospitals.  It is no good running out to defend every closure, even of a service which is hardly used or is no longer effective.

It is a big challenge, but we have to rise to it, or we will no longer have an NHS as we know it.

Now I want to explain some of my conclusions.

I interviewed many people and looked at many organisations.  I was impressed, and somewhat humbled, by the dedication and enthusiasm of the people involved.  There definitely is an “NHS ethic” which motivates people to go the extra mile, and it is something we lose at our peril.  The debate about privatisation is not so black and white as many think it is.  The private sector makes a valuable contribution to the NHS.  There are some services it cannot provide, and it relies on the private sector.  Sometimes NHS services fail to deliver, and then the first priority is ensuring the public receive a good service, so in some cases the private sector is the only answer.

But most of the people I spoke to wanted the NHS to remain a largely publicly run service, accountable to the public.  They also wanted the various parts to continue to work together and were worried that extensive privatisation could undermine this, with various private contractors not cooperating with others.  Perhaps most importantly of all many, while valuing the contribution of the private sector when necessary, did not want that valuable “nhs ethici” destroyed, and they feared widespread privatisation would do that.  The threat of privatisation, which this Government seems intent on hanging over people’s heads, is very demoralising for staff.

My  book addresses two issues, which are interlinked.  One is that the pressure on the NHS will increase, but the resources to fund it are finite, and it is no use pretending they are not. The other is that it needs to be more closely linked with the wider public, and in particular local government.  The two are interlinked because the need to address the health problems we face, and use resources effectively, will mean the reorganisation of services, in many cases the transfer of resources from acute hospitals into the community, and this may involve the closure, or conversion, of some hospitals.  This is always a difficult issue, and can only really be addressed if the NHS is honest with the public, explains the issues to the them, and is willing to engage in a wide-ranging productive debate . Local politicians need to engage as well, and not simply try to gain short-term popularity by opposing every change of use or closure of a facility. If we are to be successful in dealing with the major challenges linked to unhealthy lifestyles such as cancer and diabetes, then we must have the public onside too. If we do not they will come back to bite us not only in terms of human misery, but crippling costs for the NHS as well.

We do not know what state the economy and the NHS will be in at the time of the next election, or what the complexion of the next government will be.  I sincerely hope that the NHS will be a major issue at that election, and the country can make a decision as to whether it wants to continue with a National Health Service, involving all of us, free at the point of use, but expecting obligations from us as well, or move towards some sort of insurance based privatised system, as some big vested interests seem to want.

I am optimistic.  Big business carried all before it in the last decade of the twentieth and first decade of this century, delivering wealth which was unequally distributed but still sufficient to pay for improvements in health and other social goods such as housing, schools and railways.  Now the system has proved to be unable to deliver in the long term, as thinkers as diverse as Adam Smith and Marx have pointed out in the past, and is being challenged all over the world.  Even the high priest of unfettered financial power, who thought he could ignore governments, Rupert Murdoch, has been called to account.  I do not think the British people will want to entrust such a precious commodity as health to the vagaries of big business. But it is not enough just to have an enthusiasm for the NHS.  Unless we have a clear way forward the system will not be able to deliver and people will become disillusioned.

Because it does express such deep moral values, political support is easy to mobilise to defend the NHS, so we must make it clear that although it may sometimes need to use the private sector, the system is not going to be privatised, and some form of individual health insurance established.  We will still have a collective national health system.

Demands on the NHS will increase.  The population is ageing, medicine and medical equipment will become more expensive, and the consequences of “lifestyle” diseases, such as diabetes, coronary heart disease and some cancers, unless they are addressed, will add further costs.

I return to that first sentence of the NHS constitution – “The NHS belongs to the people”.  How do we make this mean something, so people will want to support and defend their NHS?

Involving people in any organisation is not easy, and it is hard work.  I know, I have done it in the NHS for some time.  Involvement has to be meaningful.  People will soon find out if their involvement is purely tokenistic, so someone else can “tick a box”, they will get fed up, feel used, and drop out.  But it can be done.  Northumbria NHS Trust, which covers North Tyneside and Northumberland, has 70,000 members, and is a powerful force in the community.  This did not happen by accident. It took a lot of work and a strong personal commitment by the chair.  It means, however, that the Trust has been able to involve its members in carrying out some radical changes.

Compare that to other NHS trusts of similar size.  They usually have about 5000 members.  An official of one confided to me that they did not want too many members, because it was “too much work to look after them.”  Not an attitude we want  in a modern NHS.  One of the proposals in my book is that Trusts who do not involve people should be obliged to follow the good practice of those who do.

Having worked with volunteers, I know the problems.  Some have nothing else to do, and like going to meetings.  Others  like to hob-nob with doctors.  Some even turn up for the lunch!  A more common problem is very committed people who are obsessed with a single issue, often an illness which has touched their family.  But having said all that the majority are good people with something to contribute.

Volunteers must be treated in a professional way.  Many complain that they are not treated seriously by professionals, and this is often the case, and I can understand why.  Some volunteers are unreliable and do not take what they are doing seriously.  Others are concerned about promoting particular issues. Volunteers need to be properly recruited,(and vetted, following the horrific Jimmy Savile revelations) and understand their obligations.  In return they must be given proper expenses, and even possibly some sort of honorarium for their work. There also needs to be training. This does put some responsibility on the NHS or voluntary organisations.  If volunteers do not perform effectively there must also be a way of improving their performance, or if necessary, removing them. There needs to be a professional relationship.

The other big link with the people is democratically elected local government.  The new legislation gives local authorities a bigger role in planning health care.  There is a need for social care and health to work more closely together, particularly in the community.  It is not always easy, since the two services have different procedures and philosophies.  There is also the charging issue – NHS services are free, whereas social services are means tested.  But Northumberland has merged community health services and social care into a single trust, so it can be done.

Local authorities are now in the process of taking over public health from the old PCTs, and this means they can link up more easily with other services important to health, such as leisure services and housing.  They also have their mechanisms for involving the public.  Durham has its network of Area Action Partnerships. Local authority budgets are under pressure, both with the cuts and the increasing demands of care for the elderly, but they, like the NHS, will have to learn to work “smarter” and deliver more with tight budgets.

So that is a brief sketch of how a “people’s NHS” could develop.  There is much more in the book.  If you get a chance to read it please tell me what you think on one of the great issues of our time.

David Taylor-Gooby’s book, “What sort of NHS do we want? is published by Searching Finance, and is available from the publishers on Amazon.