SCOPING THE ISSUES
I’ve been asked to talk about what is needed to address the failings of current policy as described during the day. I’m going to organise this around the principles and values which underpinned the original NHS. I have limited time so these will be examples.
This principle is about covering all kinds of care. Refers to physical health care, mental health care, public health care; and preventive, curative, palliative; cradle to grave – from care of expectant mothers and new-born babies to care for the dying.
The principle doesn’t guide us as to the limits of what should be provided: there will always be more services possible than we can provide given the finite nature of our resources and this applies even in a time of plenty and certainly applied in 1948.
But staying faithful to the principle will require:
(1)Adequate funding which at least mirrors the per capita spending (and purchasing power) of comparable countries, the abandonment of ever more destructive and unrealistic ‘efficiency’ targets and a move away from private provision which often represents poor value for money and can undermine training
(2)Building up the capacity of the NHS in primary care, community services and hospital services: the service is just not big enough to provide care for a pop of 68m as it has been allowed to shrink relative to need. This would include:
- restoring major aspects of health care which have fallen into disrepair: for example, NHS dentistry which has been described as close to collapse
- developing an annually reviewed workforce plan and expansion of fully funded training places and training capacity to ensure adequate numbers of staff are employed in future years
- Discrimination and inequalities in the treatment and working experiences of staff be combatted; this includes tackling racism and brining privatised staff back in-house
- better retention of staff through improved pay and working conditions, including adhering to nationally agreed terms and conditions for staff currently employed by ICSs; more consistently compassionate and supportive management, involvement in decision-making and respect for professional judgement, elimination of discrimination and racism and a staff-in-all-policies approach
- a reduction in our, by comparative standards, very heavy and to come extent unethical reliance on foreign trained workers
(3)Greater capital investment in
- undertaking necessary repairs
- replacing out of date equipment and buildings; expanding the primary care estate to make ensure as many services as possible can be provided locally; and expanding diagnostic equipment and hospital theatres and beds to drive down waiting times
(4) Establishing pari
- ty among different fields of and ensuring connectedness with an expanded publicly funded, publicly provided social care sector.
Universalism is about including everyone. We need explicit underpinning in law for the provision of free health care to all who are resident in the UK, including migrants, regardless of where in the UK they need that care. We don’t have this in the 2022 Health and Care Act.
Universalism is made possible through the use of general taxation as the funding mechanism – divorcing access to the service from payment for it so it is essential to retain taxation, rather than insurance or charges, as the mode of NHS funding.
We need to end charges for NHS care such as prescriptions, dentistry and so forth which block access for some.
And cherry picking by private companies suggests universalism also requires common ownership.
This is to do with fair
- ness; with individuals paying for the health service through taxation according to their ability to pay and receiving health services according to their need for them. It is also to do with fair treatment for employees.
The principle of equity requires the solidarity implicit in collective funding and common ownership. It requires that:
- We understand and tackle discriminatory and inequitable provision of services for patients
- We move away from reliance on private companies which cherry pick patients needing routine and straightforward – patients who tend to be more affluent – leaving patients with co-morbidities and more complex conditions – patients who tend to be poorer – with longer waiting times. Replacing private provision with expanded NHS care will drive down waiting times for affluent and less affluent patients more equitably.
Economy is to do with cheapness: the service should be economic in its use of resources; in Bevan’s phrase, “the language of priorities is the religion of socialism”.
Health care organisations which are guaranteed predictable levels of taxation based funding can allocate scarce health care resources according to need and not waste them through funding models or consumerist approaches which incentivise unnecessary diagnostic procedures or treatments or involve wasteful transaction costs which add little value to health care.
(1)So we need funding models which incentivise economic approaches to health care provision and which don’t encourage unnecessary activity. At the same time we need to resist forms of protocol driven decisions which don’t allow for sufficient professional judgement and discretion and which result in unfair denial of care.
(2) We need funding models which incentivise economic approaches but without undermining quality and we need to resist ICS moves to use ‘integration’ and collaboration to pursue cheaper but also poorer quality models of care
(3)We need to see good administration and good governance but moves away from the competitive bidding processes we see in a marketised NHS.
(4) New and cheaper workforce roles involving less training and lower levels of skills than traditional roles have a place – with the proviso that the quality of care is not reduced and that these staff are not expected to undertake work which requires skills and training beyond what they have been given.
(5)The principle of economy, as well as the principle of human wellbeing, also requires us to reduce to the greatest extent we can avoidable and preventable illness and avoidable need for health care. This entails a huge investment in public health and tackling the wider social determinants of health:
- through reducing poverty and inequality via a higher national minimum wage, greater trade union rights, reforms to the tax and social security systems (e.g. raising benefit levels and reducing conditionality) and more generous spending on public services, for example those around early years.
- through improving the conditions in which we live via better access to good quality affordable housing, a reduction in precarious employment, and air quality and other environmental protections.
- through focusing on wellbeing as well as economic growth or efficiency, for instance through emphasise on inclusive growth and social value.
- through building a coherent and comprehensive public health service able to analyse and respond to ongoing community needs
- through providing high quality information, equipment and other resources to support appropriate self-care
- So we need good partnerships across agencies dealing with – for example – health care, social care, housing, transport, public health, training, early years services – so that the wider determinants of health can be more effectively addressed. Local authorities are in a good position to lead on much of this but they need funding levels which reflect the cost of doing this work well.
The original NHS was founded on the principle of public planning. The NHS was the jewel in the crown of a welfare state which itself presupposed that we can use rational planning to meet social need through a more collectively organised society.
Market competition introduced greater unpredictability and uncertainty into the system as individual NHS organisations could not be certain what their income would be, or what services they would be providing from one contract to the next.
PFI distorted our planning, with planning decisions being taken at too local a level and the high costs of the model resulting in hospitals which were too small.
- as much as possible certainty and predictability of medium term funding for NHS organisations and avoidance of restructures which tie the NHS into reliance on private companies
- abandonment of competitive market processes which undermine coherent planning
- regional planning for hospital and community developments and whole area/system reconfigurations rather than hospital focused reconfigurations so that we can effect a shift of services into community settings while ensuring enough capacity across all parts of the system
- effective panning for future needs including workforce needs and surges in demand and public health planning for emergencies and pandemics
- Professor Sir John Bell recently said we should think of pandemics not as one event in a hundred years but one event in 15 years)
- decision-making on the future provision of services which is undertaken by public bodies and not shaped by private and third sector organisations
- effective democratic scrutiny and accountability around health service planning especially at a local level; higher levels of transparency and greater provision for the involvement of the public in scrutiny and accountability process
Another way of framing this is to say we need to:
Reverse forms of privatisation set in motion in the past 30 or 40 years, restoring the public character of the NHS, and strengthen its democratic accountability
Fund the service properly
Increase its capacity, in particular by caring for and investing in staff as its most precious asset
Address both the rising costs of health services and health inequities through addressing wider determinants of health and expanding public health.