So says a Conservative minister in admitting that Andrew Lansley’s NHS reorganisation was the ‘biggest blunder of the Coalition government.’ I never thought I would admit it, but I think he is right. The Health Service is facing massive, and apparently intractable, problems, and many believe that the ‘reforms’ just made them all worse. Unsurprisingly, this view is prevalent within the medical profession:
Mark Porter, chairman of the British Medical Association’s governing council, said: “Rather than listening to the concerns of patients, the public and frontline staff who vigorously opposed the top-down reorganisation, politicians shamefully chose to stick their head in the sand and plough on regardless.
“The damage done to the NHS has been profound and intense, so this road to Damascus moment is too little too late and will be of no comfort to patients whose care has suffered.”
But, perhaps more surprisingly, this view is also found within the Government itself:
One insider said the plans, which were drawn up by Mr Lansley, were “unintelligible gobbledygook” and an ally of Chancellor George Osborne said: “George kicks himself for not having spotted it and stopped it. He had the opportunity then and he didn’t take it.”
A former No 10 adviser also told The Times: “No one apart from Lansley had a clue what he was really embarking on, certainly not the Prime Minister. He [Lansley] kept saying his grand plans had the backing of the medical establishment and we trusted him. In retrospect it was a mistake.”
Despite this widespread opinion, the current Health Secretary, Jeremy Hunt, still defends the changes, and says they will deliver savings. In the discussion on Radio 4 yesterday morning, an external health analyst described the Government’s figures as being made up to get the answer that they were looking for, and just not reliable. You can see this when comparing past and future costs. Whereas past costs have risen relentlessly, somehow or other future costs are expected miraculously to fall.
The most controversial part of the financial equation is the extension of PFI, the private finance initiative introduced by the Conservatives under John Major in 1992, but significantly expanded by Labour under Tony Blair. It is either the mechanism which is saving money, or a hidden financial drain on the NHS, depending on how you view it. In an open letter to politicians, Richard Laing, the General Surgical Registrar, highlights some alarming statistics about PFI.
The NHS will end up spending 80 billion pounds on hospitals that cost 11 billion to build (I believe one PFI hospital for example, will end up paying 4 billion pounds for their 380 million pound building). Most trusts that reside in a PFI building end up spending over 6% of their annual budget on PFI repayments and this can include extortionate maintenance costs.
The largest single player in the UK PFI market currently owns or co-owns 19 UK hospitals (and remarkably it only has 25 employees in stark contrast to the 1.7 million employed by the NHS). Their profit margin was 53 per cent in 2010 (apparently most successful FTSE 100 companies make margins of around 6 per cent). The founder and chief executive of this company, in 2010, owned almost three-quarters of the company (or 14 UK hospitals) and collected pay and dividends of £8.6 million, a significant proportion of which is essentially tax-payers’ money (I suppose that’s not very much when you consider it would only pay for the treatment of diabetes for just over five and a half hours, but still, it’s all relative).
One thing is not in dispute; as a result of the reforms, the acute care trusts within most of the healthcare regions are massively in debt, and there is a serious risk that organisations will start to fail.
It seems to me that there are three moral issues hidden amongst all these figures, one of which is rarely mentioned, and the other two never feature at all in the debate.
The first is the question of goodwill and the morale of health service employees. Laing points out that, contrary to most impressions, the NHS is remarkably efficient, in that it delivers a very good service at a much lower cost than comparable developed health care systems.
Health expenditure in the UK was 9% of GDP (USA 17%, Netherlands 12%, France 12%, Germany, Denmark and Canada 11%).
The UK had 2.8 physicians per 1000 population (4.0 in Germany, 3.9 in Italy, 3.8 in Spain, 3.3 in France, 3.3 in Australia).
The UK had 2.8 hospital beds per 1000 population (8.3 in Germany, 6.3 in France, 3.4 in Italy, 3.0 in Spain).
Average length of stay in the UK was 7 days (9.2 in Germany, 8.2 in New Zealand, 7.7 in Italy, 7.4 in Canada).
In comparison with the healthcare systems of ten other countries (USA, Canada, Australia, France, Germany, Netherlands, New Zealand, Norway, Sweden, and Switzerland) this year the NHS was found to be the most impressive overall by the Commonwealth Fund. It was rated as the best healthcare system in terms of efficiency, effective care, safe care, coordinated care, patient-centered care and cost-related problems.
And how does Laing account for this remarkable delivery? ‘It is because of the remarkable individuals who work for the NHS.’ All the more strange then that Lansley’s reforms were not based on the experience of those actually working in the system.
The second issue is the NHS’s use of foreign medical expertise. Without drawing people to the UK to work in the healthcare system, the whole organisation would have collapsed long ago. Overall, 11% of NHS and community care employees were foreign nationals. But the figures climb steeply the more qualified you get. 14% of professionally qualified clinical staff are not British—and a staggering 26% of doctors. Nearly 10% of doctors come from a single country, India—and you do not need to think hard to work out which country (India or the UK) needs qualified doctors the most.
This information rarely features in debates about immigration—but there is a further question to ask. How is it moral to suck this kind of professional expertise from other countries, simply because, for year upon year upon year, we have failed to train enough doctors and other trained staff for our own needs? This year the Midlands region has only been able to fill 63% of its training places for doctors.
The third moral question touches on the founding principle, and perhaps the most distinctive feature, of the NHS. ‘Free at the point of delivery’ is the untouchable mantra of all political comments about the health service. Woe betide any politician who suggests that this should change. But what is often forgotten is that this commitment was predicated on three assumptions about health and healthcare:
1. With the establishment of a free, national service, overall levels of health would improve.
2. The delivery of healthcare, after an initial step-change up, would not continue to become more expensive.
3. People would take more and more responsibility for their own health, so that in the long term, demand for care would fall.
In one sense, the first has come true, in that the overall health of the nation has improved drastically, with life expectancy continuing to rise. But the problem is that something like 80% of NHS costs relate to the last 10 years of life, and extending old age is just going to push costs up. The second is clearly false; one of the dilemmas in Western medicine is the availability of ever-more expensive forms of treatment, as shown by the controversy when cancer treatments are judged to be too expensive to make available through a ‘free at point of use’ system.
But the most challenging is the third. The two biggest strains on the NHS are obesity and alcohol misuse—entirely preventable issues under the control of patients. It is claimed today that 10 million hospital visits a year are due to alcohol misuse, leading to both acute and chronic illness. And obesity is increasing at alarming rates which will push up health costs and the demand on services. The moral dilemma comes from both sides. On the one hand, why should I proactively take care of my health when any problems that arise will be dealt with at no cost to myself? On the other, why should I continue to contribute to the healthcare of people who do not take responsibility for themselves when I do for myself?
The issue here is a mismatch between a socialist, communitarian model of behaviour assumed in the ‘free at point of delivery’ commitment, and an individualist, free-market model of behaviour in the language of customers and service. The two cannot co-exist in a sustainable health service.
And yet this conflict is built into the basic processes of the NHS. The capitation system, where GPs are paid per patient regardless of how many times they visit, is based on the assumption that patients take responsibility for their own health. It creates incentives for doctors to encourage patients to do this—but it completely contradicts the idea that patients are ‘customers’ expecting to get a ‘service’, an idea made explicit by John Major with the ‘Patient’s Charter.’ Imagine customers in any other service context demanding a certain level of service when they have paid a fixed fee to get unlimited access to the product whenever they demand it. The system has created large disparities between wealthy areas, where patients visit less, and poorer areas with much higher levels of patient attendance. In the former, practices can take on more patients; the doctors there earn more; so jobs are easy to fill as there are many applicants per vacancy. In the latter, work is more demanding, doctors earn less, and practices find it hard to recruit.
Given these underlying problems, any political party trying to make the NHS work within budgetary constraints is attempting to square a circle. Even Lansley’s reforms are using private money to rearrange the deck chairs—though of course we might now enjoy a better quality of deck chair. We either need to abandon the individualist, market-led consumer model of patient behaviour—or start charging for the service at its point of use. There is no middle way.
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