Dr Tony Hockley is Visiting Senior Fellow in the Department of Social Policy at the LSE, where he teaches public policy. He is Director of the Policy Analysis Centre and a former Special Adviser in the Department of Health.
You can always spot the kick-off for the run-up to the Chancellor’s Autumn Statement by the declaration of the demise of the NHS by its service providers. This year, it has happened two months ahead of the Statement. The tactic often works, and even more cash is diverted from other more innovative public services into bailing out health service providers that that defies reform. The repeated success of these lobbying tactics has consistently held back the improvement of the UK’s health system since its current model was created nearly 70 years ago. The new Chancellor has raised expectations of loosened purse strings with his suggestion that fiscal policy will be “reset” when the statement comes in November.
It is just two years since the last cry of “wolf”. Each time, the providers use the spectre of charging for patient care to scare the Chancellor into further relaxing the purse strings. The tactic is always dressed up in the language of wanting “an honest debate” and, only days later,the lobbyists concede that they oppose any consideration of charging and support a “free” health service. Far from wishing for an honest debate, it is a simple, straightforward demand for more cash.
Even the head of NHS England has warned that any further injection of cash should go into social care. Whilst inefficient hospitals are bailed out, the services that work to keep people healthy and out of hospital are being starved of resources. It is this imbalance that threatens the NHS, not the resistance of the hospital sector to rise to the challenge of beginning to focus on innovation and efficiency. It is now seven years since the Nicholson Challenge on efficiency was set out . It is also two years into the NHS’ own Five Year Forward View, which won consensual support for radical change for a much more efficient system, with its focus diverted from treatment to prevention.
The Government responded to the Forward View with extra funding; going well beyond the fiscal “ring-fence” of the NHS which protected it from the cuts imposed on other important areas of public spending. It also conceded to demands for the extra funding to be front-loaded in or to assist NHS reforms from 2015. This placed a huge responsibility on the NHS. Cuts and freezes elsewhere in the public spending could easily lead to worse levels of health status in the population. The duty is on the NHS to reach out beyond the traditional hospital and ensure that this does not happen.
The opposite seems to be true. Hospitals continue to invent games to pass the parcel of patient care to community providers, which include unnecessary requirements for GPs to repeatedly refer the same patient for hospital care, and slow the flow of patients by sending test results to GPs rather than directly to the patient. This has been happening whilst the share of NHS funding that goes to primary care has continued to fall.
The outrageous handling of the problems at Southern Health provided the latest demonstration of how the entrenched culture of the NHS continues to thrive. For all the cries of an allegedly bankrupt system, the Board of a discredited provider shifted its Chief Executive sideways into a specially created job in an expensive and cynical ploy to divert public attention.
The arguments over the Junior Doctors Contract and ambitions for a “7-Day Service’ have once again focused public debate on the hospital sector and doctors’ pay. It is easy to lose sight of the fact that this is a small part of what the NHS does, and an even smaller part of what it should do. The majority of health workers are not hospital doctors, work at least as hard, and are much worse paid. Health delivery is a team effort, but the team is unable to innovate, and cannot afford to do so, if new models of care must pay homage to protecting the medical status quo.
It seems that the hope of head of the NHS England that providers will begin to “Think like a patient, and act like a taxpayer” is in vain.
To provide more hospital bail-outs will sustain this culture, not reform it. Taxpayer support must begin to reward those who change, not protect those who do not. Around the country there are great examples of providers delivering better care without bailouts. The reformers deserve more recognition and reward, not those who have spent the seven years since the Nicholson Challenge hoping that something will turn up.
The Chancellor needs to stand up to the cries of “wolf”, and see through the radical plan that has been agreed for the English health system. To do otherwise will simply maintain the status quo for another year or two, until the next alarm is raised. The economic crisis of the 1970s led directly to the NHS management reforms of the NHS in the 1980s, and it is imperative that the 2008 crash once again makes substantive reform a political possibility. Once again the politicians need the confidence to see it through.