- The Times reported that Aneurin Bevan, architect of the UK’s NHS, summed up its founding principle by saying:
- “Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community”
- But what Bevan did not foresee was that the health service would be absorbing an ever-increasing share of public resources – he expected less as the population became healthier
- As a result, several attempts have been made over the years to find ways to reduce demand and/ or supply costs but both have continued to rise significantly and remorsely
- Hence The Times set up ‘The Times Health Commission’, a group of some 30 experts with a wide range of skills and experience in health provision, seeking their recommendations for radical changes which would address this problem
- They have just reported, and our understanding of them follows
- Current NHS position:
- Overall:
- National healthcare costs are now some £180bn per annum
- The NHS employs some 1.6 million staff – some £3bn is spent on agency staff in England alone (the latter should be the exception, not the rule)
- The NHS has become a reactive sickness service – it needs to be a more proactive health service – its focus should be on keeping people healthy rather than just treating them when they are sick – in other words, it should be on healthy life expectancy rather than just overall life expectancy
- The NHS has a serious productivity problem, particularly in secondary care
- Supply – Staff:
- The NHS employs more doctors and nurses than ever but this was not translating into more care, offering substantially fewer appointments and operations
- Training a doctor costs taxpayers some £175,000 – a nurse £64,000 – but more of them than ever are leaving these shores:
- Under 60% are still here in the NHS or community services 8 years after training
- Half of them leave in the first two years after
- Australia offers them sunnier climes and higher salaries
- In a recent staff survey, 30% said they felt burnt out, 40% found their work frustrating or emotionally exhausting – only 25% said they had enough staff to do their jobs properly
- Bullying and sexual assault are rife – one third of female surgeons sexually assaulted by a colleague over the last five years
- A poor working environment exists e.g. non-availability of free parking, making a cup of tea or having a hot meal during shifts
- Supply – Process:
- Commissioners repeatedly expressed frustration with NHS system inefficiencies – whilst praising the care offered by individual staff
- Patients are shunted between uncomprehending constituent parts of the service
- There is a culture of box-ticking and risk aversion
- The health service is a series of fragmented and competing fiefdoms, encircled by an alphabet soup of quangos and regulators
- There are better ways to drive efficiency using technology, data analytics and AI
- Overall:
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- The Commission also noted that Jeremy Hunt, now UK chancellor and a former health secretary, had claimed: “The NHS was being micromanaged to death, it was dreadfully inefficient because of excessive central control, and an average hospital had 100 targets, a GP 78”
The Commission’s Recommendations:
- Overall:
- A greater emphasis on prevention and community care
- A need for a national health service, not a national sickness service
- A need to diagnose disease more quickly and treat people closer to home
- Supply – Staff:
- A new GP contract
- Student loans to be written off for doctors, nurses and midwives who stay in the NHS – a tie-in formula to keep trained doctors in the NHS – their debt cut by:
- 30% if stay in NHS for 3 years
- 70% after 7 years
- 100% after 10 years
- A boost to research by giving senior clinicians protected time to do more
- Supply – Process:
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- A digital health account for all, covering all their health records – i.e. patient passports
- Weekend high intensity theatre lists to tackle waiting lists
- A no-blame compensation scheme – so staff don’t hide errors but instead learn from mistakes
- A National Care System, equal but different to the NHS – to improve a local right to care support
- Mental health support for children guaranteed within four weeks
- People to be treated in individual rooms so no cross infections and better recovery times
- Large ‘Specialist centres’ and ‘Surgical hubs’ to be set up for such as cataract operations
- An improvement in the productivity of theatres
- A reduction in the time people spend in hospital after surgery
- Reforming social care capacity to avoid overcrowded hospitals and help the millions who cannot get the support they need
- Unifying data platforms/ software systems in use
- Letting the public see hospital performances, and choose where to be treated
- Employing data analytics, AI, robotics and genomics to provide more personalised and predictive new age of treatment
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- Demand:
- An expanded sugar tax and curbs on marketing of unhealthy food to children – to tackle obesity
- A ‘Heathy Lives Committee’ (another?) to improve healthy life expectancy by five years
Our first reactions are that we agree, or cannot argue, with the above recommendations but believe there are important gaps, including the following:
- Supply – Staff:
- The ‘tie-in’ formula for keeping trained doctors in the NHS for longer seems an excellent idea – we wonder why it was not installed long ago
- An apparent conflict arises when NHS doctors work part-time for the private sector where they are able to offer their same services but with the USP of much less waiting times, sometimes even using NHS facilities – this seems unfair to those reliant on the NHS, so this ‘right’ should be reconsidered at least
- It’s morally wrong to find that one third of NHS doctors and nurses have been recruited from abroad – many from countries which have more need for them than the UK
- Supply – Process:
- The NHS should dispense with most if not all current performance measures and targets that serve no useful purpose (and question the value and so need for the number of inspectorates, regulators and quangos) – and replace them with no more than 10 measures for each unit manager – these different sets should not only focus on inputs, output volumes and outcomes (quality and service levels achieved) but the availability, utilisation and efficiency of all costly resources under their control
- There should be one body controlling workflows through all parts of local NHS services, from GP gatekeepers, through hospitals and on to social care
- When one waits for treatment and notes the earnest efforts of staff, it’s clear that a review is needed of current working practices that staff have to follow – one which minimises major areas of waste and changes job descriptions so that staff make good use of their skills and work more with patients (which they want to do) rather than on paperwork or computers
- An ‘NHS Best Practice Database’ is needed – one which overcomes all objections claiming ‘incompatibility’ – one which prompts improvement ideas and ‘catch-up’ action, or at least answers ‘why not?’
- Demand:
- At least consider the political dynamite question: Must we scrap the ‘free-at-the-point-of-delivery’ promise and at least charge for all appointments, as with NHS dentists, to decimate numbers of hypocondriacs and time-wasters seeking appointments
- Establish an OfNHS, a la OfWat, to conduct detailed performance surveys of all NHS units and publish the detailed (not one word) results so that the public who pay for the service know what they’re getting for their tax-money
- Dare to openly debate ‘rationing of services’ and reach a consensus on what the public at large is prepared to pay for, not just leave it to NICE
Overall, the NHS is a great national asset, a major credit to our society and political system, a major success for a vast number of UK citizens and more – average life spans have greatly increased, average healthy life spans also – but that success has brought attendant supply and demand problems which now need urgent attention
We can only hope the NHS paymasters, HMG, will note what the Commission say, take their blinkers off and focus not just on more numbers of doctors, nurses, and hospitals but realise it’s the current mix of all costly resources, how they’re used and how motivated NHS staff are that determines the productivity levels needed