A frontline view

Stephen Bradley

If we want a world-class health service, we need to pay for it. Labour must make that case

The plight of the NHS consistently ranks high on the list of voters’ concerns – and in media column inches. But from inside the health service, both the media’s interpretations of the problems the health service faces and the remedies offered by politicians often seem ill-conceived.

The word ‘crisis’ has become a cliché, but, in the NHS, it is in no way an overstatement. While the government can claim, in crude terms, that NHS spending has increased, when this funding is set against an ageing population, increased attendances overall and inflationary technological costs, we have seen an unprecedented squeeze on resources since 2010. The results of this are clear to anyone involved in healthcare. As of March this year, four-hour accident and emergency targets had been unmet for 17 months and ‘winter’ pressures now extend deep into the summer. A&E waits matter, not only because of the misery and indignity they cause to patients, but because disrupted flow through the hospital at the ‘front door’, is a barometer for the functioning of the wider system. Devastating cuts to social care mean a bottleneck at the ‘back door’ with vulnerable and frail patients facing long waits for suitable placements. The extraordinarily high levels of bed occupancy leave doctors and bed managers juggling risk, often discharging patients they would not have dared to a few years ago. For intensive care beds and some specialties the situation is particularly precarious; we regularly have periods with no available psychiatry beds in England.

This squeeze has taken place following a prodigiously wasteful and fragmentary reorganisation, which has set in motion a rapid portioning off of services to private providers who resort to litigation if they are not awarded contracts.

Meanwhile, the harrowing working conditions for clinical staff are probably unmatched in any other industry. This should be of great concern, not just for the wellbeing of staff, but because of the outrageous waste of scarce clinical staff leaving the profession.

One overarching narrative is that the NHS is a wasteful behemoth, in urgent need of ‘reform’. The assumption driving the break-up of the NHS seems to be that it is inherently antiquated, resistant to change and lumbered with unimaginative public sector staff. The NHS, we are frequently told, is ‘unsustainable’.

Yet the truth is that the NHS is remarkably efficient and that a centralised tax-payer funded health system is the most affordable way to deliver healthcare. Although we dedicate a small proportion of GDP per capita to health by international standards, we achieve outcomes that are impressive and remarkably cost-effective. The dogged culture of constant learning and improvement is one of the most inspiring aspects of working for the NHS. A commitment to the ideals of the health service inspires NHS staff to donate vast quantities of unpaid overtime, without which the system wouldn’t function. It is heartbreaking to see this idealism being sacrificed to a faith-based ideology that idolises ‘competition’ and ‘choice’.

Undeterred by colossal deficits caused by underfunding, health secretaries have promised expensive impossibilities such as seven-day routine appointments. It is possible that some innovative ‘new models of care’ will deliver marginal cost savings. The sustainability and transformation plans might deliver modest efficiencies, although almost all plans are heavy on aspiration and light on detail. Worthy, if not entirely evidence-based plans, such as integrating health and social care, may well improve quality, but are unlikely to save money. The brutal, if obvious, truth is that if we want to continue delivering comprehensive health care, we will have to pay for it.

Although most NHS staff are loath to endure further reorganisation, the survival of the NHS probably requires renationalisation and repeal of the 2010 Health and Social Care Act. Public opinion, which has remained stubbornly opposed to privatisation, would likely support a purposeful resuscitation undertaken alongside leaders within healthcare.

Following the trauma imposed by Lansley and Hunt, we need to think seriously about ministers. We need expert-led governance that can facilitate long-term planning. Health is of course necessarily political, but the highly partial policy interventions in recent years have been corrosive to morale, contrary to evidence and have meant unethical allocation of scare resources. An electoral cycle which lasts a fraction of the time required for public health measures to pay off mean that egregious false economies are now widespread.

Institutions such as NICE, which evaluates drugs, have proved remarkably successful in making contentious decisions less arbitrary and suggest that improving the evidence base for, and the quality of, health policy are achievable.

Labour should lead the way by making a frank case for investment. While Labour benefited from public concerns around the health service in the election campaign, the uncomfortable truth is that its funding plans would still leave a significant deficit. We need to abandon the fantasy that a few service refinements can be a substitute for adequate funding. While our opponents insinuate that publicly funded and delivered healthcare is unaffordable, we should be clear that any other system will be costlier, less effective and more inequitable.

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