Prospects for the NHS: Transformational incrementalism

NHS Funding NHS reorganisation

Our basic model of universal free health care is affordable and desirable for sound economic reasons as well as for social justice. It is a model supported by the public. Currently it is in the headlines because by general consensus it is unable to meet expectations given current levels of funding.

Cuts in funding over two parliaments and the chaos from an unnecessary redisorganisation have halted the improvement trend established up to 2010. Cuts in social care have caused hardship for hundreds of thousands and piled even greater pressure on the NHS. Bad stories about the NHS will lead to the better off opting for private care, weakening further the NHS in a damaging downward spiral to a two tier health system and a residual grudging provision of social care only for the poorest.

The government says, with some justification, that it has put in more money and given the NHS the funding it requested. It will not be easy to persuade the public that more is necessary and taxes must rise. Many sceptics will say that however much money is given to the NHS it is always just a few days from the next crisis. And even if extra funding suddenly became available it might be hard to spend as there is no easy way to step out and buy lots more nurses or doctors. New capacity takes time to develop.

To persuade the public that we must adequately fund our care system we need to articulate what it could be like in 2030 from the viewpoint of those using it. That viewpoint has to be compelling and credible. We need to be able to show how it could be paid for and then win the political argument about whether we want and more importantly will pay for a modern care system or just let the old one wither and die.

If we are to talk about more funding and sustainability then we need to be clear about what is being sustained. Nobody surely wants to sustain the current social care arrangements. We can have an NHS within current funding it just would not be very good! Sustainability means not just keeping the basic model it also means having a modern, world class system.

We need a care system bringing all care together and pooling the major budgets for health and social care; and in time most care will be free at point of need. We have to end all forms of tribalism and organisational competition. We need to end the view of an NHS as some remote island separated from the rest of the public services. We need to design systems around the needs of people and patients. We need devolution (after some trials with delegation) and to think about what is actually “national” and what isn’t. We need to think again about all the relationships which define the system especially as between patients and professionals. We need to honestly embrace the reality of rationing and accept some democratic control over resource allocation as the best solution. We need the kind of genuine openness and transparency the NHS loathes and which local government has learned to accept.

There is a lot of consensus on most of that analysis but at the two political extremes are very different views; which largely ignore any evidence. The far right do not believe in any kind of socialist health system and would opt for a totally different, market based model which they think would be much cheaper for the taxpayer.

The far left share the idea that there are major savings to be made but their change would be to remove all private provision and undertake a huge reorganisation to reinstate organisation structures from 30 years ago.

In the real world the dominant current issues facing the care system are that the funding is insufficient; social care is a disgrace and the system is fragmented and incoherent from a user’s perspective. It is a mess as the H&SC Act removed any proper ability to control and plan the system – there is no strategic glue anywhere just legions of semi-autonomous bodies all with their own aims and objectives. Add to this long standing issues of the lack of accountability; a medical not a social model (fixing more than preventing); unwarranted variation and systems that are not designed around the recipients of care – we have a system and training regime designed for the passive grateful generation not for the iPhone one.

We are unsure about efficiency and effectiveness as we don’t have the data or methodologies to examine it. There are good grounds to suspect that there are more technical efficiencies to be made. Changes which will improve the experience of care through integration may also reduce costs. Unfortunately for the efficiency evangelists evidence suggests these changes do not produce “savings” they are far more likely to be a contributor to slowing the rate of growth in expenditure. We know less about allocative efficiency (they know far more in Wales) and the concept of allocating resources to where and what gives the greatest return is alien to the NHS.

So as well as more funding, both to plug current gaps but also to fund transformation, there is a greater need for clarity about the purpose of the care system, leading to its design then to how it can be funded and how we get there from where we are today.

The consensus is that the best route to improvement is to make better use of what you already have. Reorganisation and huge national initiatives don’t work. It is also obvious that the care system, especially the NHS has neither the capability nor capacity to take on major programmes and projects with any realistic hope of success.

What we need is injection of greater revenue funding to plug the current gap and then a couple of years of stability with no new announcement and no new initiatives, whilst all the various providers did their very best to make best use of that funding in delivering care. All the various vanguards and pilots and pathfinders should continue but with an enhanced and more independent evaluation. During the two years the longer term planning would be done with the full and proper engagement of staff patients and public, both locally and nationally.

In that time some consensus can be reached on the longer terms aspirations and on developing plans to get there; 10 year plans. Transformational incrementalism.