What is the future for NHS reform?

What is the best we can hope for from the new Government – whoever is in charge? I have three hopes. First, greater commitment to the real purpose of the NHS – equity. Second, less structural reform, and more real innovation. Third, the emergence of alternative voices and perspectives – from communities, from the groups facing disadvantage and from the professions themselves. Overall I would like the NHS to see itself as a community – not as an organisation – a community that takes social justice seriously.
In A Better Plan for the NHS, Health and Care Ed Miliband and Andy Burnham say “The NHS is our country’s most precious institution and Labour’s proudest achievement.” This is strong stuff, but it is understandable that the NHS holds this place in the hearts of many. Before his death, my granddad wrote his memoirs – the memoirs of a working-class man from Manchester – he describes coming home from the war:
“We had a National Health Service by now. It was introduced by the Labour Government who swept to victory after the war was finished. This was a great innovation. Free medical attention, dental and ophthalmic treatment and free medicine, no more doctors’ bills to worry about… The British people like the system…”
This is surely at the heart of what makes the NHS great – free health care – no discrimination between the rich and the poor – equity. Yet, when we compare the principle of equity with the reality of the NHS – in its incarnated form – there are so many paradoxes:
  • The creeping return of charging, means-testing and privatisation.
  • The huge income inequalities – some have truly had their mouths stuffed with gold.
  • The institutionalisation imposed on disabled people and people with mental health problems.
  • The enormous centralised bureaucracy at the heart of the NHS.
  • The elitism and detachment from community and democratic accountability.
  • The exploitation of our wealth to draw medical expertise away from developing countries.
The real NHS is a little less loveable than the ideal NHS. So, of course, the temptation is to ‘reform’ the NHS; but this is so dangerous.
One of the most interesting consequences of the British healthcare system is its centralisation in Whitehall with political control handed each term to one (or usually more) Secretaries of State. Each one then discovers that almost everything good about the NHS is far too complex and detailed for them to do anything about. So politicians find there is next to nothing of meaning that they can do – so in order to be appearing to be doing something they must do big things without meaning – hence structural reform.
Over the life of the NHS we have seen two waves of meaningless structural reform. The first wave from 1945-1990 was bureaucratic reform – dividing and re-dividing the NHS into districts, regions, units etc. The second wave began in 1990, and we are still in it now, and it is market reform – creating phony market mechanisms, commissioning systems, contracts and increasing privatisation. If we cannot end this wave then we may eventually see the collapse of the NHS.
When I think of this process the image that always comes to mind is of a child playing with an expensive and complex toy, and a tired parent saying, “Now, stop fiddling with that – or you’ll break it!” However I do not blame politicians for this problem. In a sense we are the parents, but we keep giving control of the NHS to one individual because that’s the way we think democratic control must work. This goes back to the founding story of the NHS – we treat it as if it was founded by politicians and we hope that it is safe in their hands (or we fear that it isn’t). We forget the decades of work to create the NHS done by communities, campaigners and activists, work which the Socialist Health Association documents so well.
So, the big question, going forward is whether we can turn away from meaningless bureaucratic controls, and phony market systems, and instead find our way onto a better path. There is nothing inevitable about this – we have just lived through the worst Government in over 75 years – who seem to have set about destroying the welfare state – and there is  good chance they will get in again. Alternatively the Labour Party is trying to position itself as close to the Conservatives as it can get away with, in the hope of winning back power.
It is a dispiriting scene; but there are some rays of hope, and with hard work these could be magnified into something stronger.
1. We could take the principle of equity more seriously
As it stands champions of the NHS stand upon the highest peak of the welfare state and watch as the rising waters of injustice swallow up the social security system and social care. It is hard to be optimistic. But, we could wake up and realise that it is not the NHS that matters – but justice itself. We could recognise that the principle of equity both needs better protection and a wider scope. For instance, I’d like to see a movement to unite behind a constitution – not for the NHS – but for the welfare state as a whole; and not some meaningless policy document – but fundamental legislation to underpin the whole system.
One emerging opportunity is the renewed effort to ‘integrate’ of health and social care. Eventually we will find (again) that integration is the wrong way to frame the challenge. However we will find that there is a much more important distinction to be made, between circumstances where individual budgeting is useful, and where it is not. It will turn out that the line between these two circumstances will be drawn quite deeply within the NHS. Figuring out where personalisation should begin and where it should end will turn out to be one of the key policy questions.
Now this could be a disaster. For it could allow the excessive means-testing of social care to creep into the NHS by the back door. Hence, many resist the extension of ‘personalisation’ into the NHS. However, what if, instead of resisting individual budgets – advocates of justice attacked the root problem – means-testing itself. If the NHS is good – why do we allow severe means-testing of social care? There is no moral case for social care means-testing. Society only needs one system of means-testing – it’s called taxation. There is nothing fair about taxing disabled people and older people and calling it a ‘community care contribution’. This is just an extra tax that targets disabled people. Instead of resisting personalisation advocates of justice within the NHS could make common cause with those of us opposed to social care means-testing.
We could go even further and ask questions about the benefit system, income distribution in health care, the pharmacy industry or regional injustices. Equity is a powerful and positive concept – and if we really care about it then we should be prepared to ask tough questions about where it applies and how to make it work.
2. We could declare commissioning dead and look for real innovation instead
I don’t know whether anyone will be brave enough to declare commissioning dead, but there remains no evidence that it has created any significant improvements and perhaps it would be useful to challenge the whole concept. Certainly, the last set of structural reforms, despite the rhetoric, have largely moved more power and control to Whitehall – leaving a rather complex structure of local Well-being Boards and Clinical Commissioning Groups (CCGs) with only minimal influence over the real system.
However, while this may not be ideal in the long-run, I think it may be best to leave these structures alone, for they contain within them some positive possibilities. While power has not shifted to local clinicians or to local government, they are both at least now able to be part of a real conversation about local health services. This is real progress and it opens the door to further innovation.
Real innovation does’t come from Whitehall and it doesn’t come from commissioners. It comes from communities and it comes from practitioners themselves. The NHS will truly flourish when people can find room to develop new ways of working. Innovation – which must be essential to the on-going health of the NHS – is a creative people-led process and it needs a permissive environment which is not frightened by local differences, experimentation and the odd failure.
One area where much more innovation is possible is in mental health services. Today the mental health system is coming under increased scrutiny for good reason – not just because it has been severely cut – but also because it is fundamentally flawed. It has invested in the very things that don’t promote good mental health. Increasingly self-advocates and families are finding ways to develop better forms of support. For instance, the People Focused Group in Doncaster has demonstrated that mental health is advanced more by peer support than professional services. Such groups are finding allies within CCGs precisely because clinicians understand the frailties of the current system better than anyone. These kinds of people-professional alliances will be essential to restoring the NHS to health.
3. We could welcome more diversity and greater connection to local communities
Increasingly the NHS needs to look beyond the confines of services and of organisations. We need to identify and build upon the capacities of our communities and we need to be able to build new alliances. For instance, WomenCentre in Calderdale and Kirklees had generated multiple benefits for local women and families – health benefits and other social benefits – in ways that are much more efficient than typical models of public service. However the organisation is not a ‘service’ to be commissioned; it is a community – women supporting women. If the NHS is to thrive it needs to be able to listen to and respect this kind of perspective.
The NHS needs to learn that its commitment to justice can’t just be a matter of organisational form or the repeated use of the formula ‘free at the point of use’. A real commitment to justice means taking seriously how you work as an individual, how you work with others and how you work to improve things in the wider community.
Perhaps the most important challenge – however crazy it might seem – is to stop looking to politicians for the answers. Politicians are not the answer, and they are not the problem. They are mostly good people trying to do the right thing. (Sorry – I know that will be heresy for some.) However, they work within the confines of the feasible – and it is we who define what is feasible.
If professionals, advocates and local leaders come together to define better solutions then politicians will open the doors to let change happen. But, if we sit in our silos and complain then we will find that policy is dictated by the assumptions of the powerful, the wealthy and by commercial interests. The NHS is in our hands – but if we choose not to think, not to act, not to get organised – then we will find ourselves… well we will find ourselves precisely where we are: in trouble.
The NHS can be a community. It can be a place where people take justice seriously. If, as individuals, we begin to act as if we can make a difference, as if we are not just cogs in a system, then we may be astounded at what we can achieve.
These are only some weak rays of hope. Whether they turn into anything more depends on us.