Recently the Guardian ran a long article: How to save the NHS – by the people who work for it. It makes sobering reading for those of us who follow the politics of the NHS. It is compiled by a series of people working in different branches of the English NHS. The coalition government’s reforms get a predictable roasting. A colossal distraction dumped on an organisation that wasn’t ready. Outsourcing contracts that make things worse, not better.
But something else comes through very clearly. The mounting stress that the NHS is under, and the frustration that its workers feel that problems are not being dealt with at root. Prime amongst the causes is the increasing number of elderly patients with multiple conditions. This was no surprise; it has been predicted for years. And yet almost nothing was done to prepare for it. Smart new hospitals were built on the assumption that patients were younger, fitter people who would pass through them quickly. And the management culture that prevents anybody from looking at problems in the round, and that tries to reduce problems into mindless targets – well that goes back to age-old institutional divisions, and aggravated by more recent managerialism. In some ways there are too many managers, enforcing mindless targets; in others there are not enough – facilitating the kind of re-engineering and reallocation of resources that would reduce waste and solve real problems.
What lesson do I draw from this? The NHS has to change. It needs to find new ways of working, and adapt its facilities accordingly. Simply sacking the managers and letting the patient-facing workers get on with it would solve nothing. It doubtless needs more taxpayer funding in the mix – but waste is rife and there are limits to extra taxpayer funding. None of the political parties (not even the minor ones) suggest raising any of the three main taxes: Income Tax, NIC or VAT, unless rises can be targeted to a small minority of wealthier taxpayers. There are clear limits to how far this kind of somebody-else’s-money approach is feasible, but no political appetite to raise general taxation. The NHS must either reform itself or collapse under the weight of extra demand, with the better-off turning to the private sector, and becoming even less willing to see their taxes used for free healthcare. This has already happened in dentistry.
It’s quite easy to see elements of the reform process. Integration of social care; more emphasis on mental health and geriatrics; better public health; continued heat on the drug companies. Others will be less obvious, but will emerge from analysing problems with an open mind. But all large organisations have heavily inbuilt inertia. Reform will involve pain. Some services will be cut; many people will have their jobs changed. Such change requires strong leadership, who can persuade the persuadable, and override the suspicious. And here we must confront some awkward facts. First leadership is not going to come from politicians; they simply don’t have the knowledge or credibility. Second that leadership is going to come mostly at a local level. What needs to be done is to rework the tangled elements of many services by dealing with the people involved directly, face-to-face, and finding what works in each local context. What will not work is to call in an expensive set of management consultants to put together an over-engineered but nevertheless superficial national plan under a grand-sounding name (“World Class Integration” anybody?). Or arbitrary ideas, like pushing people out of hospitals and into the community, which may work as theoretical propositions, but are beset by a million practical problems locally. And yet this is the typical approach of initiatives originating from the Department of Health. Too many grand know-it-all experts; and too much use of management consultants.
But if politicians can’t lead reform directly, they still have to give political cover for reform programmes that might take 10 years or more to work through properly. To do that the management of the NHS must be depoliticised. The politicians should set the broad strategic direction, supply the funding, and be part of a process of local scrutiny. But otherwise they should step back and defend the system. This sort of consensus building is not impossible. It has been achieved for old-age pensions, for example.
And yet many campaigners who want to “Save” the NHS seem to want to do the opposite – to politicise the NHS so far that reform becomes a practical impossibility. They create alarm about cuts to local services, privatization, postcode lotteries and TTIP. They seem more motivated by anger, and fixated on political totems, than on trying to promote progress within the NHS.
Two wrongs don’t make a right. The coalition was wrong to dump such an ambitious a top-down reform on the NHS. It was wrong to pursue its reforms in such a politically arrogant way. The government should have taken Labour’s imperfect structures and evolved them; piloting different reforms locally to reduce bureaucracy, engage clinicians and achieve better integration. Progress would have been slow at first, but surer. And it would have lowered the political temperature. But it would be wrong again to tear all these reforms up. Surely some changes are needed – especially over the competition and outsourcing. What is worth keeping about the reform is the way it places a distance between the politicians and the people running the service. This framework may not be perfect, but surely it is best to move forward through evolution, not another reorganisation.
The problem with Labour’s campaign to “weaponize” the NHS and turn it into a key political battleground, and its politically motivated and gimmicky manifesto pledges, is that it distracts from the real work that is needed: devolved reforms led by clinicians. We could have yet another 2 year hiatus. The NHS can ill-afford that.
Matthew Green is a member of the London Liberal Democrats executive, and has been part of Liberal Democrat policy panels on wellbeing and the economy. The views expressed above are his own. He blogs at thinkingliberal.co.uk