The NHS Confederation has launched a two-part challenge; “to politicians to create the space for change essential for the NHS’s future and to the NHS to be ready to make the change, and do it well”. It is based on the oft repeated doomsday scenario that funding will be, at best, level in real terms whilst demand continues to rise, drugs cost more, and NHS inflation is higher than general inflation. Something must be done – and this is something.
Sadly and typically, it does not add that to the demand sided that social care is on its knees and mental health services are under funded. It’s an acute foundation trust’s perspective on the world. Apparently all is not yet lost; we may not need co-payments and user charges, if we can just reconfigure services.
Most of the justification stems from the supposed frustration that what may be beneficial changes are blocked by local (and sometimes national!) politics or politicians – who just do not see the case for change. The logic is highly convoluted and in fact illustrates why so much NHS change is opposed. It says we have a financial crisis so we have to centralise services (reconfigure) but then says the changes should be justified on clinical grounds and led by clinicians. Make up your mind which is it clinical or financial.
Most cases for change which are put out to support reconfiguration are poor. They try the same trick of arguing clinical improvements but everyone in fact knows the driver for change is to save money. The cases are invariably poorly argued in language that does not find any empathy with stakeholders. The assumptions come from the same people who did all the projections to support PFI or awarding FT status – ie assumptions about activity and quality and about income and expenditure which prove to be grossly wrong within a few short years. We are right to be sceptical. Even those of us who are in favour of major changes in hospital configuration despair at how poorly the NHS makes the case; how inept the consultations are and how confused the messages become.
The best case for reconfiguration and the one always touted is Stroke Care in London. There is evidence to show real clinical improvement – fewer deaths – but where is the evidence that it saved any money? There is none because almost certainly it didn’t.
If we suppose that someone else led the case for change and did it well and that we had some agreed framework overall for managing change then could we stop opportunistic local politicians from opposing what they would portray as cuts? Of course not. Big party politics is becoming less dominant and we have local politicians now who are aligned to parties but entirely free to campaign in any way they like – even if their national party is arguing the opposite.
We need a new governance model which removes the NHS from its 7 decades of isolation and special treatment and puts it where it belongs – within the rest of the public sector. It cannot be “freed up” to carry on making its own top down decisions like it has over so many bonkers schemes – effectively removed from proper accountability. Whilst national government sets out the “what” in terms of key frameworks, the entitlements and standards, the “how” that is delivered is for local determination – and that includes decisions about most of what we call reconfiguration. Rather than removing local politics and local politicians from the decisions about how our money is allocated and how priorities are set they must be central to it. NHS providers can have local autonomy if they have local stakeholder governance but only as much autonomy as is good for the care system as a whole.
If we wish to save money we can have less of a market and less fragmentation as that has added cost for no discernable benefit, and we could stop the waste caused by many top down imposed, well meaning but disastrous changes – like a £3bn system reorganisation.
I fear the challenge will not get much of a response and it shouldn’t. It assumes that the NHS has the capability to plan for change after 2015 when it palpably does not have that capacity now, if it ever did. There is no longer any strategic glue in the system – how can you plan anything which is being progressively marketised, privatised and fragmented? It requires a common perspective on the challenges but once again an analysis starts from the presumption that we have to accept the mantra that taxpayers will not pay to improve care. In just about every developed country the cost of care as a % of GPD is rising – so why not here too?
Why not pose the question differently? If we want a modern care system which is universal and comprehensive and free at the point of need then what might we be prepared to pay for it? If the case is well made then the answer should be very different to retrenchment and gloom. Why pre-empt that debate?
I like politics. It is better than violence at resolving differences. You cannot take the politics out of the care debate. The main parties are about as far apart as you can get on the NHS – one for a full market in health and care and the other for a predominantly public care service. It makes a huge difference in 2015 which of these is guiding policy.