Nick de Bois is the Member of Parliament for Enfield North and a Secretary of the 1922 Committee. Follow Nick on Twitter.
Stephen Dorrell, Chairman of the Health Select Committee and a former Health Secretary, made a remarkable point during a debate on A&E recently. Commenting on the then pressures on acute care services he remarked, "We see that it is not the differences between the Government and the Opposition that are striking, but the fact that there is a shared analysis. However, there is an apparent unwillingness to apply that analysis and work it through".
Notwithstanding the inevitable clash over the last few days, isn’t it possible to put the instinct for party politics to one side in order to meet the challenges facing the NHS? Well, with Labour weak in the polls on just about every issue compared to the Conservatives except for the NHS (and even here they are now vulnerable), they have little incentive to co-operate. The Conservatives, on the other hand, have everything to gain by such a move. More compellingly, however, it is patients themselves who would see the most benefit – which Jeremy Hunt is repeatedly demonstrating his commitment to deliver.
However, notwithstanding the row over the Keogh report, the status quo is preferable because, at present, there is a great deception underway. Politicians of all parties, as well as health chiefs, trade unions, professional bodies, medical professionals and even local GPs are all prepared to think the unthinkable – but are not prepared to tell the public what that thinking is. Namely, that we will, unless things change dramatically, end up with roughly a £50 billion deficit between funding and demand to meet our healthcare needs by the end of the next parliament (according to the Nuffield Trust). Demand for healthcare, over the last 30 years, has on average increased by four per cent a year, and there is every reason to believe it will do roughly the same for the next 30. The requirement to change our practices and expectations of healthcare, established and little changed since the inception of the NHS, is frankly unavoidable.
No government will fund an extra £50 billion a year (about 12p extra on income tax within two Parliaments). And no government wants to break the principle of free at the point of delivery, funded by general taxation. To do the former would require a massive hike in taxation. To do the latter would be a "brave decision, minister", and undermine something that almost all Britons are proud of – access to healthcare regardless of income. That's pretty much what the three political parties would privately agree on, whatever may be said publicly. (To his credit, at least Stephen Dorrell is saying it.) So why, whenever I have a discussion about the health service, are so many people unaware of the stark choice facing politicians, and more importantly, the implications for safe, effective healthcare? It's not as if we haven't been warned.
Over ten years ago, Derek Wanless spelt out in his report the stark truth that unless we change both the way we supply healthcare needs; move the patient to a more engaged process of self- care; make better use of cheaper and more accessible primary care, and embrace new innovative practices, then a sustainable funding model for the NHS will not be achievable. To achieve high-quality efficient care to enable people to live longer, healthier and fuller lives and avoid going to hospital unnecessarily is the core challenge that needs to be put at the door of policy-makers in the Department of Health and in NHS England.
Despite this, progress since Wanless has been relatively slow, amounting to little more than tinkering around the edges though poorly judged re-configuration plans, minimal engagement with allied professionals and limited trials in telehealth – to name but a few of the NHS initiatives over the last decade. Some pilots have proved their value and potential but then have not been adopted more widely, while others have faced institutional resistance. The result is the public is often left confused and the professionals on the ground frustrated. For the public, the purpose and the strategy behind some of the changes are just not communicated, and are therefore met (unsurprisingly) with suspicion, often failing to be successfully and widely implemented where appropriate. Policy makers forget how important it is to bring the public with you.
These past measures and any future measures have never been set in a context. To date the politicians and the medical and allied professions have, in effect, been having a conversation with themselves, and have not trusted the public to understand and accept the challenge facing this country’s future healthcare needs. Crucially, this then also excludes the public from sharing the responsibility for dealing with that challenge. There has been no national conversation, but simply trumped-up dodgy local consultations or trials that, rather than involve the public, leave them feeling like the opposite has in fact occurred.
Isn't it time, for example, that we all levelled with the public that, unless the 60 per cent of the population that need to change their lifestyle habits do so, they may not just harm their own quality of life but unnecessarily cost the taxpayer some £8 billion – and stress the health service further? Public health has over the last hundred years faced major challenges, such as woeful housing, appalling sanitation and no education. Today, it faces the challenge of very poor lifestyle, and it's time people faced up to their responsibilities rather than accept the health consequences as inevitable, fuelled in part by the knowledge that the state will look after you regardless of how you look after yourself.
Surely we should encourage medical professionals, teachers and even health and wellbeing boards, with the full support of politicians, to challenge poor lifestyle habits; not just the stereotypical but ever-present “couch potato”, armed with beer can and cigarette, but also the parents who are presiding over the 25 per cent of our under 5s being medically obese.
Ministers, think-tanks and medical professionals all talk about this, but when do we put it out there to the public? Wouldn't you just love to hear a Public Health Minister ask why the taxpayer should pay for the weekend A&E costs of the yobs injured after nights fuelled by alcohol? Why do we fight shy of highlighting the case for self-care? Probably because when a Minister did discuss it, the tabloids screamed "outrage" at the audacity to suggest if you have a headache, don't in the first instance rush to a GP or nurse. And when you think in 2011 we issued over 20 million (yes, 20 million) prescriptions for paracetamol and 6.6 million for Ibuprofen, isn't the "outrage" missing the target? The cost to the Treasury was a staggering £82 million.
Furthermore, few people would go and buy a service from somewhere that costs two and a half times the cost that it does somewhere else. Yet that’s what the NHS is currently doing by funnelling people to A&E, rather than putting in place primary care services that would be more appropriate. Attempts at reconfiguring services to change this system have been controversial not least because, yet again, no-one at a national level is providing the context for these changes.
There is no silver bullet for solving the inevitable financial crisis facing the NHS. However, prevention of ill health, keeping people out of hospital where appropriate, accessible primary and allied care, telehealth programmes and eliminating the waste provide a lot of ammunition. Whatever is proposed, it is crucial we bring the public with us on this journey, so that they can recognise the challenge and better still, be part of the solution. The case for greater urgency about integration between the different parts of the health and social care system needs to be made to the public by both politicians and more importantly across the medical community.
The public should be trusted, and a coalition beyond the political parties that takes the debate out of the hallowed halls of the medical, professional and political elite is required. Otherwise, the stark choice will present itself after the next election – to raise taxes by up to another £50 billion to fund an inadequate, system or end up introducing charges alongside an inefficient service. Is anyone brave enough to lead this national conversation and by doing so set a course for a national consensus on healthcare and the NHS for this country.