Making Sense of the NHS

Much of the last election, and many elections before, centred on the claimed inadequacy of the NHS. The same arguments have circled for decades creating heat rather than light and, importantly, social disaffection without progress. Adversarial political mudslinging and ill-advised interference have damaged NHS cost effectiveness and capacity, and will continue to do so until politicians leave it to the professionals.  The cross-party convention proposed by Norman Lamb, or the Royal Commission proposed by Lord Saatchi, could help bring that about.

Making sense of the NHS boils, ultimately, down to two issues.  The relatively easy one is how much HM Treasury should provide, be that from a hypothecated tax or the general pot.  That political decision should be based on the state of the UK economy, the plentiful international comparatives, the coherence of the NHS corporate plan and competing demands.  The allocation of those resources, and the rest of NHS management, should be taken out of politics. 

The convention/Commission should review the governance and scope of NHS England and the extent to which pricing should be used to cool demand:

  • NHS England is too big and overloaded with policy makers rather than policy doers – doctors, nurses and technicians. If NHS Scotland and Wales are roughly right-sized, as their separation implies, then NHS England should become six autonomous NHS Regions, i.e. public corporations like the Bank of England or BBC. The public corporation may be only the least bad governance structure but imagine how much worse the BBC would be as part of a Whitehall department.  Since adult social care is already devolved to local authorities, regionalising the NHS would allow the DH and NHS England to be downsized to just a few staff dealing with the overall allocation of resources. 
  • The NHS should be streamlined to be more manageable. The boundary of its responsibility should be narrowed to curing what can be cured and providing medical treatment.  It should not attempt to care for the incurable. Caring and curing need to be closely linked, and cooperate better, but integration would be unmanageable.  The NHS should provide individual treatment and not tackle public health as a whole.
  • Pricing, prescriptions for example, is already used by the NHS to restrain demand. Co-pricing, i.e. patients picking up some of the cost where they can afford to do so, is used elsewhere in Europe and New Zealand, and would be no more counter to the NHS original constitution than charging for dentistry.  What does not strictly need to be cured, or medically treated, could be subject to co-charging, if resources are available, for optional matters such as IVF. One way or another, demand needs to be cooled.

    The number of GPs and geriatricians needs to be increased. An aging population grows the need for geriatricians but supply has been reducing.  GPs do their best but few of them are trained in geriatrics and their interaction with geriatricians has reduced.  It is not the most attractive branch of medicine and the pay and prospects are poor. People aged 65+ now absorb about half of the total cost of the NHS. The number of general physicians is, per 1,000 potential patients, eight times greater than the number of geriatricians: the very people who need doctors most are the least well served. The British Geriatrics Society is outgunned by competing medical professional bodies.

    Mental disorders have also dramatically increased. Drawing the boundary of NHS responsibility between treatment and cure (NHS) and care (other services) for treating geriatric issues is difficult and the boundary for mental health is more difficult still.  Today, surveys indicate that about 12% of the UK population have mental health disorders and more than double that proportion of doctors – mostly due to stress. Clearly some sort of tiered approach is required to focus professional help on those with the greatest need. 

    The potential benefits from these proposals fall into four groups:
  • Improved morale, recruitment and retention of nurses, doctors and technical staff.  The continuous political fault finding, interference and reorganisation of the NHS damages staff motivation and patient satisfaction. The professionals need empowerment and clearer lines of authority. Local and national lobby groups press their vested interests to the detriment of the whole. The contribution of politics to the NHS is, in sum, counter-productive. Unfortunately, even if politicians back off, the NHS will continue to be subject to sniping by the media. Smaller organisational units would bring staff and patients closer to top management.
  • Better management of the demand for NHS services which will always, and increasingly, outstrip supply capability, not least because they are free. Ways have to be found to cut unnecessary calls on A&E and GPs. Falls by the elderly are now treated by ambulance paramedics in the patients’ homes rather than carting them into A&E.  Better for everyone. 
  • Balancing the books by continuing to streamline working methods and bureaucracy to release more patient time for doctors and nurses, simplify the allocation of resources and better interface with, and learn from, the private sector. The NHS could make much better use of IT.  GPs in England use at least four IT systems, for example, which do not communicate adequately with each other or with hospitals. Acute hospitals should move more patients (sooner) into the less expensive cottage hospitals and convalescence homes.
  •  Focusing the NHS on curing the sick, surgery, mending limbs, medical treatment and maternity. At present, only 80.5% of the NHS England funding is devoted to its core role: primary and secondary healthcare.  That streamlining would not reduce the quantity or quality of patient care and enable the adult social care budget to be doubled at no cost to the Exchequer. 

The full paper, to which this is the introduction, will be released in September this year.

A 1988 paper on the NHS published by the Adam Smith Institute, Too Big to Manage can be found here