Advocating change in the NHS is tricky surgery

Advocating change in the NHS is tricky surgery

by Jonathan Stanley
article from Thursday 18, January, 2018

THREE THINGS are sure in life: death, taxes – and fury at taxes that delay death. No one likes paying tax and no one likes the idea of paying for their healthcare. Such is Britain. Not England, but the whole UK as a whole.

First past the post means large majorities are quite common, giving the government of the day both power and inertia in enacting radical change. This has led to a near constant sub-optimal performance through the so-called valley of despair. This is where resources delivering real time productivity are diverted to manage change. This is why for the first two parliaments under the SNP the NHS did not seem too bad... precisely because largely it was left alone.

No radical restructuring beyond pithy soundbites means no real change has happened. What has happened is we have not had a strategy for a decade, which is why staff shortages, skill-mix and social care provision are all suffering.

You need sound long-term strategies and the need to react to the pressures for change when they arise. Famously, the UK does the opposite, by and large. 

Few like change, yet we all want low taxes, nice houses and a health service everyone afford. This is not centrism. This is two-faced greed that does a fantastic PR job by calling itself progressive and centrist. It is neither. To effect such change you need, as a BT advert popularised, an ology. You need a study and a philosophical direction to buttress against the mammoth criticism that will come inevitably from public service workers.

We have been conditioned through 70 years of profound cycling of rhetoric. One large party believes in low tax and expensive property. The other believes in a generous, Beveridge-type health care system that rejects risk stratification and funds it through income taxation.

The level of demand on the NHS is growing. So too however is the nature of that demand. The demographic has changed. Their socioeconomic condition has changed. Their complexity has changed. Their non-clinical needs essential to good health have changed. Our political attitudes have not. 

We have had a public musing now that we must "be more like Norway". Its EEA membership no doubt is purely coincidental. An MP from here has today explained why we should be more politically like Sweden. Are you ready for Doc-Thor?

The Norse God of Thunder will see you now

Uh oh!!!  A meme is becoming a theme within a few days. The policy coffee table has been busy. Another electoral cycle, another cuddly theme. But this is no constitutional matter.  This is a preamble to an ideological assault of some kind on the status quo. Exciting yes, but extraordinarily dangerous.

To attack the status quo from opposition is very risky and it is unquestionably divisive. It certainly cannot possibly work alongside being unionist for a simple reason: it puts too much water between Labour and the Tories. Far too much to ever cooperate on domestic issues that dominate devolved administrations like Holyrood. The result will be a weak SNP government, or worse, a solid Labour-SNP government able to pin down the Tories on being anti-independence and against the Scottish model of public service.

People vote against ideas more than they do for them. It risks a pincer and here is why.

There is no Norwegian model. There is a Norwegian health service that has developed organically for Norway.  Its ology or osophy is simple. It spends a lot and some of this is raised through user fees. Hotel fees (you pay towards using a hospital bed) are normal. In fact out-of-pocket expenses fund about 12 per cent of the system’s costs. In England the prescription charge raises 6 per cent of the drug budget, or 0.6 per cent of the total NHS cost. Peanuts. Migrant health tourism? About 1 to 1.5 per cent again, depending on definitions. 

Without an ology or osophy this can be spun easily as the Tories pushing through top-up fees, co-payments on patients while keeping tax on higher income down and rejecting council tax revaluation that has left us with an increasingly regressive formula. Sticking coo horns on its head and calling it Scandinavian won't cut it.     

It is clear that increasing healthcare spending above the tax-yielding GDP share acceptable to voters is a challenge. The Tories have already been aggressive in ensuring higher income taxes don't fund this in Scotland. So we must lay off the ideological attacks on private healthcare and promote it. 

Otherwise we are talking about hotel fees, prescription charges and working out who on Earth will pay and who will be exempt. England's charging of working poor for pills and exempting elderly property millionaires is an iniquitous as it is unfair. 

Twelve per cent of spending funded by fees is a bombshell and would amount to about £1.5 billion in fees raised somehow from the patient base of 5.5 million people based on a budget of £12 billion for NHS Scotland. This is the total fees including any private insurance but here is the rub. Private insurance is quite popular among the corporate sector and takes a burden off the NHS. In Norway it barely exists. The UK has out-of-pocket expenses at 57 per cent of total private spend and in Norway it is 95 per cent! As I have previously published, we could use our powers here to make private insurance somewhat tax deductible and in Westminster make it a business cost instead of a benefit in kind, as it is now. 

This would use tax breaks as seed funding to pull more cash into the system and offload the NHS of those who can pay for a more convenient service. 

We cannot follow the SNP trope of "going Nordic". It is just about distancing us from the rest of the UK. Ulster has a different "model" to Scotland. So too does New Zealand but only just. It is a very interesting place for Scottish planners. Most Kiwis are Scottish descended and have similar values. They have an NHS based on regional health boards that are part elected and they have extended their emergency services to be free even for tourists. This alone makes for an attractive option to replace EHIC once we Brexit.

Its share of health spending is a little higher than ours and they have small, means-adjusted fees for GPs or for going directly to a hospital clinic but swap the GP fee for a prescription charge and we are almost there. The vast bulk of GP visits generate a prescription anyway and unlike the New Zealand service does, cap fees after a certain number of visits.

New Zealand has brought back the enrolled nurse to increase staffing levels and this not only offers a non-university route into healthcare it offers Scotland the REALLY radical step of making all clinical training and recruitment postgraduate in the sense everyone would have to be trained for 18 months as an enrolled nurse first. Imagine what that could do long term for camaraderie and instilling common NHS values. And by the Tories!

Attacking the status quo on public services on multiple fronts using superficial tropes about greener grass elsewhere will have us shredded fast. I tried it in UKIP and had a lot of initial support ­– but enough senior members buckled in the light of inevitable lefty opposition. I defended my position and still do and have not suffered, the party however was caught with mixed messages from people with no healthcare experience and trust evaporated. Rightly so.

We do not have 150,000 constitutional experts to take on Adam Tomkins. We do have 150,000 healthcare workers who eat drink and breathe their area of expertise everyday. That's a different kind of audience. Tropes and memes are torn apart quickly. Lord Warner of the Labour party should serve as a warning. He ventured into this arena with neither ology nor party support and was burned up for it.

My humble advice is that the Tories get themselves an ology and fast. Whatever way we do this we have to have a hymn sheet and that means values.

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