At the beginning of 2000, the health service received just over a quarter of public spending. Now it is approaching half but resources are not infinite.
Soaring demand for services, crippling legacy contracts with the private sector, mismanagement and waste means the NHS is always in financial trouble. In 2018/19, just under half of all NHS trusts were in deficit, of which nine were in financial special measures. Things improved in 2019/20 with 27% of trusts in deficit and seven in special measures.
What do other countries do?
Refunding fees. Some countries opt for specific healthcare costs to be paid initially, which are then reclaimed by specific patient types (e.g. elderly, retired, low income). In France there is a fee to see a GP; the fee is refunded to those less able to pay. This can discourage time-wasters with trivial complaints, reduce pressure on doctors and free up more appointments for those who are ill. Some people feel that upfront fees to see a doctor would impact on early diagnosis of conditions and therefore early treatment and more successful outcomes. But figures show cancer outcomes in France are better than in the UK, even with charging a fee to see a doctor
Fee exemptions: The UK charges for prescriptions and NHS dentistry. With prescriptions a number of categories are exempt (e.g. pregnant women, children under 16, and those over 60), such that only 10% of people need to pay for medication.
France and Germany have a better level of acute hospital beds than we do. But Scandinavian countries don't - and their healthcare is often regarded as the best in the world. They have superb social care services which enable them to prevent many problems before the need for hospital admission is needed. But they pay far higher taxes than we do.
'Hotel' charges, where patients pay a nominal fee (about £8 per night) for a bed, to cover meals and bed-linen laundry. (France and Germany)
Old buildings, new buildings Many hospital buildings are old, and were built to different standards and for different ways of treating people. Almost a third were built before 1974, and another ten per cent dates back to the 1980s. Many trusts have both old and new buildings, but pay so much on the mortgage for new builds that they cannot afford to maintain older premises. So collapsing ceilings, leaking roofs, burst pipes, broken boilers, malfunctioning air-conditioning systems and many other issues are a challenge to hospital management and often a danger to patients. But there is no incentive for trusts to tell the truth about dilapidated buildings.
Buildings constructed and maintained via Private Finance Initiatives (PFI), were almost all set up during New Labour years. Without these deals there would be far fewer modern hospital, well-kept and looking good, nice environments in which to be treated. But PFI builds come at a crippling price in ongoing quarterly payments on contracts, whose average length is 31 years. Latest estimates suggest the final bill will exceed £80 billion for buildings which would have cost about £13 billion to construct if paid for upfront.
Healthcare management. While the image of the incompetent NHS manager persists, inspectors rate 70% of NHS Trusts as being well led. However, there are no specific qualifications or experience needed to be a hospital boss, responsible for the welfare of thousands of patients and managing huge teams of staff and vast sums of taxpayers money. And rarely any consequence for those who screw up.
The Care Quality Commission is the independent regulator of health and social care services. Failing trusts have insufficient staff, inadequate medical care and 'dire' end of life care. Specific issues include overcrowding, breaching A&E waiting-time targets, shortage of doctors, use of agency nurses, poor staff communication and medical record keeping, inexperienced doctors, clinical staff shortages and inadequate IT systems, failing to inform the coroner of serious incident investigations before the bodies were cremated, meaning the truth about how someone died and the hospital's role in the death, could not be uncovered. Combined, these issues indicate an organisation that lacks basic systems and structures to guarantee a decent standard of care.
Those in positions of responsibility have a legal 'duty of candour'. In reality, a deeply disturbing culture permeates the health service, especially hospital trusts, meaning errors, abuses and failings are routinely covered up, and staff are fearful of speaking out, making it more difficult to improve matters. Professor Sir Brian Jarman developed a way of measuring whether hospitals have higher or lower death rates than expected in order to create a reasonable measure of quality of care. His methodology adjusts patient data such as age, gender, deprivations levels and whether it was an emergency admission. Depressingly, managers worked out that by giving more patients a 'palliative care code' (in hospital for end of life care), the hospital could not be criticised for failing to save them, thus dramatically reducing official death rates. Other hospitals reduced death rates by discharging dying patients to hospices. Jarman claims the Department of Health did not want to receive the alert system, effectively saying 'Please don't tell is what's wrong'.
Problems also occur with the split between clinicians and managers. Hospital consultants exert huge power and influence in the NHS and the vast majority are decent, hard-working and honest. But some routinely capitalise on poor management by taking money for hospital sessions they did not carry out, fiddling rotas and boosting private practice by deliberately slow productivity in NHS time. Private hospitals have efficient operating lists because they are paid per patient by an insurer, by the private hospital or are self-paid by the patient. As a business, a private hospital will ensure its resources are being used for the most profit.
Basic NHS salaries for consultants are modest relative to earnings in private practice. If consultants could earn significantly more from the NHS, it would reduce or even eliminate the tension between public and private work. Encouraging consultants to work full-time for the NHS is needed to sustain the health service. Until that happens, managers need to ensure hospitals get what they pay for.
Data systems Hospitals are still working with patchy, unreliable and outdated computer systems, leaving doctors and nurses making critical decisions in the dark. Parts of the NHS remain in the digital Dark Age, especially with patient records.
And early 2000s efforts to modernise the patient record system ended in an expensive contracting fiasco. Today across the NHS, huge sums are still squandered procuring software that is unfit for purpose and must then be upgraded, repaired or changed, usually by the same company that failed to provide what was needed in the first place. Failure to train staff in new systems results in chaos and potentially puts patients at risk.
However the pandemic showed that the NHS can change swiftly on occasion, when (for better or worse) online consultations became mainstream.
Inefficiency It has been estimated that hundreds of millions of pounds are lost every year due to time-wasting and operating theatres being under-used. (a) Surgery starting so late in the morning that patients at the bottom of the list were sent home without having had their operation or were delayed until the following day. (b) Operations cancelled to suit staff, e.g. a member of staff thought the list would not finish on time, causing them to stay over their scheduled work time. NHS workers have little or no incentive to maximise output. They are paid the same amount however many patients they see and slow work is rarely reprimanded. It is a testament to the dedication of the depleted workforce that the NHS gets as much done as it does.
Acknowledging mistakes is the only way to improve a service. Datix is the most widely used patient safety database in the NHS. It relies on staff inputting information about safety incidents, so reveals the blunders and oversights, accidents and abuses, communication failures and confusions that take place every day in NHS trusts. Examples are errors with anaesthetics, late cancer diagnoses, drug dosage mistakes, medicines given to the wrong patients, botched gynaecological operations and injuries to mothers during childbirth, blunders with blood transfusions and lapses in infection control. But some adverse incidents are not recorded in the first place as there is widespread reluctance to flag up problems. Datix is there to highlight risk and learning from mistakes, but people don't like using it because they are afraid of how it will impact on themselves.
Medical negligence lawsuits. The number of compensation claims is soaring and settling disputes takes a big chunk out of the already stretched NHS budget. NHS Resolution, the quango that handles medical negligence lawsuits, paid out £2.4 billion in damages and costs for claims in 2018/19.
When to stop treating people. Charlie Gard, patients in long term comas, etc
Patients must use the NHS more appropriately and take more responsibility for looking after themselves. The single biggest issue is the national struggle with obesity. A third of children leaving primary school are overweight or obese, as are almost two-thirds of adults in England. The body positivity movement has been hijacked by some fashion brands and social-media influencers claiming it as an acceptable lifestyle choice. There is a growing recognition that drugs are not always the answer to patients' problems. Those who complain of loneliness, stress, depression or anxiety may get more out of group activities such as singing in a choir.
The time has come for zero-tolerance for those who fail to turn up to GP and specialist appointments. With privilege comes responsibility, and as attempts to educate patients about the cost of such behaviour has not worked, some system of sanctions is needed. Sticking-plaster solutions will only accelerate the decline, fuelling the market for private-health insurance for those who can afford it, and bringing in the two-tier systems the NHS was designed to avoid.
How to get things changed? The NHS is generally held in high regard, and people were impressed by the way the service responded to the coronavirus pandemic so any debate over how it is run and funded is sensitive. But most believe that the NHS is now in a worse state than before the crisis, which exacerbated existing problems (chiefly waiting times and differing standards of care nationwide) and that things are unlikely to improve soon.
Surgeries and hospitals are places where people receive treatment when things have already gone wrong. Globally and in the UK, the key issues are: high blood pressure, smoking, household air pollution, low fruit intake, alcohol use and high Body Mass Index. Other contributory factors are: low childhood weight, excessive salt intake, insufficient nuts and seeds, iron deficiency, sub-optimal breast feeding, high total cholesterol, low intake of whole grains, vegetables and omega-3, drug use, occupational injury, too much processed meat, intimate partner violence, low fibre intake, poor sanitation, vitamin A deficiency, zinc deficiency and dirty water. It is not lack of medical care that causes illness in the first place.
The NHS can encourage people to take part in health screening, to have vaccines, give up smoking, lower alcohol intake and eat their 'five a day' but the Dept. of Health cannot create the conditions that enable the population to make health lifestyle choices. Politicians over-estimate the impact of health spending, when attention would be better directed at addressing the factors that make people unwell in the first place. The need is to boost public spending on education, housing, welfare, and so on, to improve health outcomes. But while good healthcare does not equate to good health, poor healthcare equals worse death.
How do we reform? The founding principles of the service - available to everyone and free at the point of use - means ideas for reform are met with suspicion. Those who have identified the failings and problems do not believe there is any case for diverging from the founding principles, and no political party would do so. But change is necessary and in order to identify the right changes, we need to know where we are now.
With politicians unlikely to set aside traditional differences, the need to take on vested interests requires cross-party co-operation, so there is a case for establishing a Royal Commission to explore the most fruitful ideas for reform.
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