Does the NHS expand to absorb the funding available?

The cost of the NHS has risen faster than inflation for good reasons and not so good. Innovation has brought shorter hospital stays, local in place of total anaesthesia, less intrusive  surgery and more effective medication.  Shouldn’t the total cost be going down rather than up?

Part of the increase has been at the expense of adult social care, whose funding via local authorities has been cut in real terms. Even so, The King’s Fund reported that: “the number of general and acute beds has fallen by 43 percent since 1987/8, the bulk of this fall due to closures of beds for the long-term care of older people.”  It is amazing the local authorities have been able to cope thus far. 

The Adult Social Care Green Paper will be delivered over a year late, coming out finally this Autumn. Of course, no explanation has yet been given. Cure and care need to be considered together but there is no sign they will be.

This blog has been prompted in particular by a letter from the Rev. Roy Allison who won the 1995 Adam Smith Institute competition the “Economy in Government.” It attempted to quantify the savings available from unblocking NHS beds. Eamonn Butler (the ASI’s Director and Co-Founder) is quoted as having said: “I have no doubt that the Rev. Allison’s proposal will be adopted.” Turns out, fat chance.

The Office of Health Economics celebrated the NHS’ 60th birthday by debunking a couple of myths:

Firstly, it shows that the UK is not a low spender on public health. Of the top 21 OECD countries only France and Germany spend more as a percentage of their GDP.

Secondly, up to 35% of the cost of the NHS does not go into primary (GPs) or secondary (hospitals) at all: “In 2006/07, the latest data available, Hospital services gross expenditure accounted for 43% of NHS cost, while the Family Health Services (FHS) accounted for 22%. This compares to 52% and 36% respectively in 1949/50, equating to a 5-fold rise in hospital expenditure per capita and 4-fold rise (in real terms) in NHS expenditure per capita over the same period.” (p.22).

The figures change from decade to decade but a large proportion of NHS England’s funding does go to the free individual health treatment for which it was set up. Supervisory boards and consultants alone cost £139m. The NHS should be streamlined to deal only with treatment and cure, leaving care, and better funding, in the hands of the specialists. At the same time, the variety of adult care services, mainly the elderly, mentally ill and those with learning difficulties, need some sort of framework to promote best practice and efficiencies. This is why we need a Royal Commission, which would be only the second in 70 years, or equivalent. For both cure and adult care.

This blog has thus far omitted the third big spender: public health. This too has a complex web of goals and management. Some lie within hospitals, others in County Councils, NHS Regions and Public Health England which answers directly to the DHSC. Norfolk’s approach, and other local authorities are similar, in that they ludicrously dabbling in every aspect of life: healthy food, drinking, smoking, driving, diseases, sex, home and school visiting, and “integration, prevention and reduced inequalities and priorities of mental health, dementia, early years and obesity.”

Government should indeed make us at least aware of the consequences of taking detrimental life choices. And government needs to prepare for, and deal with, epidemics. But that needs one small department, not armies of bureaucrats supposedly “working with” each other. For a start, public health responsibility should be withdrawn from the NHS.

In addition, with the declining number of beds to attend, one would expect the number of nurses have declined pro rata. In the past thirty years, bed numbers shrank by 43 percent while the number of nurses, visitors and midwives has grown by 14 percent (280k to 319k) – and that is ignoring the 30k primary care and district nurses where numbers have been stable. At the same time, some hospitals have failed to take proper care of patients due to a shortage of nurses and/or their supervision and training. The Commission needs to take a hard look at this anomaly along with other areas where efficiencies have been promised but not delivered.

The most fundamental instinct of any organisation is to grow. The NHS is no exception. With 1.7m employees in the UK (1.2m in England alone) unbounded growth will prove too much for the economy to sustain. On the one hand, justified demand for treatment and cure must be met. The NHS has a fine record on that. On the other hand, we cannot expect it to make the savings that would undermine its claims for more funding.  Only an external review can do both.

A start can be made by shedding non-core NHS responsibilities: namely adult care, public health and top-heavy supervision. A streamlined NHS focused only on treatment and cure would be in a stronger position to cross-fertilise best practice and improve productivity.  And continue to deliver what it was created to do.