3 problems with the NHS

A few weeks ago, it was our 10 year medical school reunion. Many of us have gone our separate ways: to alternative careers or alternative counties. The majority, though, have remained in the NHS.

To many of us, the NHS is like a cantankerous relative that always gets drunk at weddings. However difficult they might be, for all their faults, you love them and would miss them if they weren’t there. But what are the faults with the National Health Service, and is there anything we could do about them?

1. It’s not National

Over the years, the NHS has gone through more “responsible bodies” than Dr. Who. To get an idea of the current structure, imagine the most complicated Powerpoint slide you’ve ever seen, and then ask MC Esher to paint it. The picture below might help, but don’t spend too long on it, as it will have changed some more before you get to the end.

Every few years someone comes up with more corporate doublespeak – be it “Vanguards”, “Clinical Senates” or “Forward Views”. All names that would resonate with David Brent-style consultants on management training days at Travelodges next to A-roads, where you curse the fact the white-board markers will run out before you can. I feel uncomfortable accepting “5 year forward views” from governments that couldn’t predict a recession even when you’re in the middle of one. 

There’s been plenty written about the numerous top down re-organisations and the impact of various legislation on the NHS (in particular the Health and Social Care Act 2012). Essentially the overall effect of it has been to divide a national system into a number of fiercely protective little fiefdoms. While I accept that the service should be responsive to particular local needs, the current model produces significant variation between regions and creates the very thing the NHS was set up to stop: health inequality.

Another important effect of this breakup is that the line between what is an NHS service and what is a commercial enterprise has been significantly blurred. Commissioned providers are now able to use the NHS like some sort of Blue-Peter badge and gain the best of both worlds – profit to shareholders, criticism absorbed by the NHS.

2. It’s not a Health Service

With devastating cuts to Public Health and a whole host of health improvement initiatives, we don’t really have a Health service. What we do have is a reasonably effective Acute Illness Service, although it’s debateable whether you could say that about Chronic Illness too.

Our local kid’s hospital is probably going to change its name from the “Royal Hospital For Sick Children” to the “Royal Hospital For Children”. While I understand the motivation, I don’t think it’ll result in a massive upsurge of parents who were previously wary of bringing their kids in case they met too many sick people. I’ve been around hospitals quite a while now, and I can confirm that they tend to have a lot of unwell people in them - I’d wager statistically significantly higher percentages than in the community for instance. There has been a recent drive for a more community rather than hospital-centred approach to health service delivery, but that may be driven by the sudden realisation than all new hospitals are too small and we don't technically own them.

Cuts to Public Health will be devastating but they are not surprising. Unfortunately politicians favour short-term solutions to long-term problems, and investment now for a healthier future does not tend to resonate with ministers not looking beyond the next election cycle.

Another possible factor is people’s preference for tangible things. In the last few years I’ve been involved with a number of charities who have very generously donated funds. This has been invaluable, but it’s much easier to get charity funding for physical ‘things’ (eg. medical equipment) than for staff training etc. 

People like to see they’re getting something for their money - whether it’s a new dialysis unit, operating theatre equipment or magic beans. In the end though, it’s a catalogue of opportunities missed, and we’ll all pay the price in years to come.

3. It’s massively underfunded

Notorious B.I.G. famously declared that “Mo’ money” means “Mo’ problems”. I think he'd been to the same statistics and critical appraisal course as Jeremy Hunt. Association doesn’t necessarily mean causation B.I.G. To be honest, I’m starting to question B.I.G’s research as it was never properly peer reviewed and others have been unable to replicate his results. In fact it seems that when it comes to Health Service funding, the exact opposite is true.

Underfunding is any NHS Manager’s “Elephant in the room”. But it’s that elephant off of Blue Peter and it’s shitting everywhere. And I mean everywhere. There isn’t a single service not under the stranglehold of underfunding, and everyone who works in the NHS can see its direct effects every day. But managers are afraid to speak up for fear of losing their jobs. They are struggling with the mutually exclusive goals of cutting staff costs and maintaining safe staffing levels (although for all his rhetoric about patient safety, Jeremy Hunt has absolutely no plans to release NICE safe staffing level guidance).

The government have been quite clever in their narrative of underfunding, with statements and media reports frequently referring to Trust “overspends”. For future reference, here’s a handy translation guide: “Overspend = Underfund”, “Efficiency savings = Crippling cuts” and “Ringfencing = Failure to keep up with increasing demand”.

Ringfencing has always been an interesting concept to me, and I think reflects the government’s inability to grasp that things change over time. I could have “ringfenced” my pocket money back in the 80s, but although that was sufficient to fund my ‘sitting around watching He-man and drinking Um-Bongo’ lifestyle back then, demands on my finances have increased and it would no longer fund my ‘large mortgage, wife, two kids and despair at humanity’ lifestyle I lead today.  Or perhaps the Government really do understand the concept of Health Inflation and just don’t care. Either way, it doesn’t make it easier to stomach these “The NHS is getting more money now than it ever has” claims the Government keeps making.

The government has been successful in pretending they aren’t underfunding the system, and blaming Trusts for poor financial planning, but it’s difficult to escape reality. Which is we are spending a decreasing amount of GDP on Health Care, significantly less than most of our European neighbours and of similar levels to countries which Americans would struggle to find on a map.

And don’t get me wrong, I know there’s a limited amount of resources available. I just would prefer to fund a system designed to treat and support kids with cancer than say a multi-billion pound nuclear missile system designed to vaporize hundreds of thousands of people in a fraction of a second