Accepting what's wrong with the NHS must come before planning its reform

Accepting what's wrong with the NHS must come before planning its reform

by Jonathan Stanley
article from Wednesday 7, June, 2017

PARTS OF SCOTLAND have had tax funded, free at the point of use, health care for a century. The idea is firmly embedded in the national psyche. Much has changed since the Highland and Island Medical Service was founded and now the whole nation today is barely recognisable.

We are ageing as a population with more and more of our later years are spent in poor health and disability. We have a centralised politicised health care system and the share of the national economy devoted to it has risen to about 9 per cent. As far as the UK is concerned Scotland’s NHS is not so remarkably different to the rest of the country and that is because much like Wales and England it remains essentially in a Blairite, centrist mould. Moreover, the Holyrood-centred approach to planning suggests we have not moved too far from the pre-devolution Scottish Office in the way we think of management.

Scotland has a high use of Public Finance Initiatives that leaves us with both a high volume of relatively new infrastructure but saps annual budgets with high interest charges and service fees. This is higher than anywhere outside of London.

In England there is a kind of formalised internal market, in Scotland managed clinical networks determine resource allocation to a greater extent. The true degree of operational independence of health boards and foundation trusts is arguably quite similar and England appears to be returning to the mean here with the single market slowly waning.

There is nothing particularly bad or good about our health service, despite many protests otherwise, but there is clearly scope for improvement. Gimmicks such as free prescriptions and eye tests have essentially no real impact on the service, they are purely of political significance as are free car parking and sun cream. To have any chance of serious reform we have to accept some home truths. 

Not a single Secretary of State for health in England or Scotland has been scientifically or clinically qualified. Not a single Scottish Minister has any science credentials higher than, well, Highers.

The career politician is the meek and limp solicitor, a professionally encaustic journalist, or a prissy juvenile ex-bag carrier. Insipid, maladroit on policy, and childless by and large, the narrowing of repertoire of skills and personae is striking in a bland sort of way.

The source of ill health today is within the individual, not contracted from others. It is one of the modern lifestyle, where injuries from hard drinking outweigh those from hard work – and where prevention is almost entirely within one's own ability. This is harsh to note, but it is true and the answer lies in motivation. Why do so many discount their future health for short-term choices and how is society preventing them seeing a brighter future?

More than any other area the dominance of state planners is most evident in staff training and urgent care. One could not seriously consider the judiciary independent if the state governed every exam meticulously and set a limit on how many lawyers there would be. This is, sadly, the state of affairs in the NHS and the result is staff shortage and job insecurity that suppresses reporting of adverse events. It leaves us dependent on imported labour in way that Finland, Japan and South Korea would balk at.

Urgent care remains fragmented, serving the needs of politicians who set baseless targets, driving people to use the most expensive services first – such as A&E – where a GP appointment would do.

The single most crucial innovation in healthcare is data. Information exchange and storage are essential in modern medicine. The ability of the state managed NHS to handle this task is disastrous. Beyond all else this is a gross failure of the state monopoly.

So where do we start?

We start with a blank canvas. If we were to build a new service today what would we do differently?

We could start with operational independence of every health board, with each employer having a small say in the formation of policy, and with private equity to develop capacity: The John Lewis model. 

Reform the Highland and Island Medical Service as one single board for the north.

We could have all urgent care, from out of hours GPs to A&Es all under one body to better plan services.

We could bring back vocationally-led enrolled nurses and have the private sector train our workforce, from university onwards. Private chambers and pupillage work for the legal profession, and there is no apparent shortage of them.

We could recruit people directly from clinical services to stand as councilors, MSPs, MPs and into the civil service. Fatal conceit leads our planners to plan in total absence of awareness of what they are planning for.

We could use Scotland's share of the Bank of England's Asset Purchase Facility to compulsory purchase all outstanding PFI contracts and cancel the service contracts accordingly.

We could start to think. In right-of-centre politics policymaking is dead in Scotland. There is a near absence of anyone championing free market, heterodox solutions to complex problems. Instead the right, if it can be called that, is part of the consensus. Sentimental, statist, social democratic policies that ignore the most vulnerable for fear of missing out anyone else.

It isn't working. Our healthcare is falling behind England's and is miles from Denmark or the Netherlands. For a supposedly internationalist nation we seem to strive to shun any other system even when it clearly outperforms our own. 

That isn't pride, it is arrogance and conceit. We are denied even the luxury of self awareness, we are forbidden from asking why a health board lied 50 times about waiting times and struck patients off the list for political gain.

Why do we fund diversity officers and free personal care for the wealthy elderly – and then underspend on heart disease? Why do we argue over whether school meals should be free, instead of developing a Nutritional Curriculum to integrate healthy eating and home economics into the education system so children learn what is healthy and how to prepare it? Imagine if children made their own salads, stews or if young vulnerable mums were taught the same?

There has been a considerable loss of intergenerational capacity within families that needs rebuilt to promote good health and wellbeing.

This article can only be the start – and admits the reality of where Scotland now is – before we plan to deliver better health for all.

Dr Jonathan Stanley, a regular contributor to ThinkScotland, is a Locum in the NHS. This article was commissioned by the Scottish Research Society as part of its policy development programme, which can be found on its website here.





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