This article is a revised and expanded version of written evidence submitted by Albert Persaud to the All Party Parliamentary Group on Primary Care & Public Health – of the United Kingdom Parliament – in 2013 for its inquiry into ‘The sustainability of the National Health Service (NHS): Is Bevan’s NHS under threat?’
Preamble
For many people there may be three important pillars of British society: the weather, the monarchy and the NHS. Politicians can do little about the weather and even less concerning the monarchy, so the NHS has become a politicians’ playground. One of us (AP) joined 25 years after the creation of the NHS by the Welsh politician Aneurin Bevan. AP recalls similar questions being asked then as are now. Since that era, there have been numerous top-down reforms, policy announcements, policy changes, all politically driven with one distinctive feature; which is, all the pronouncements have been largely aimed at the length of the particular political party’s life in government (about four to five years). Very few of these changes have been evidence-based, or properly costed, but more importantly, have been deficient of seriously thought through implementation plans to bring about real changes.
At any given time a busy NHS hospital ward in England may have over ten kilograms of documents, policies, guidelines, ‘good practice’ guidelines from its NHS trust, hospital policies, and so on, all on shelves covered in dust (with due account taken of infection control policies, no doubt).
Interestingly, the Temperature, Pulse and Respiration (TPR) chart used today is basically the same one that was introduced in 1948. Also of significance, the people – NHS workers – who are meant to use or observe the advice or edicts of these documents, have for the most part since 1948, hardly ever been involved in their drafting let alone assessed them for their relevance to them, their work and the patients they care for.
With every new policy change or pronouncement, what seems to have invariably emerged has been a plethora of NHS experts in England in particular (where most of the recent changes have been occurring) – some self-appointed critics, jargon inventors who always give the impression of wisdom – they know what is right and what is wrong with the NHS and to those who work in it. What tends to follow is a series of ‘word salads’ – a group of words, phrases and sentences put together, that do not, however, make a lot of sense. (Note: such behaviour is similar to symptoms sometimes found in people with a serious mental illness like schizophrenia that sometimes requires medication). There is now an industry of such people and consultants (of the non-clinical variety, usually) whose voice and ability to lobby may become the story; instead of that of the patients, their families and NHS workers.
The NHS is unique and a precious pillar of UK life. What is never discussed or indeed recognised is how it has moved and progressed since its inception; this is sadly very often true of politicians including prime ministers, experts, economists, vested interests, patient groups and others. The UK’s NHS has long depended on overseas people and nations, however, what is and has never been adequately recognised, is the contribution made by migrants. People came to the UK in the 1950s and 1960s and in subsequent years, to build the backbone of the NHS. They came from the Caribbean, India, Pakistan, Malaysia, and Mauritius and elsewhere to add to those from England, Scotland, Wales and Northern Ireland. It is time that this fact be truly taken into account and openly acknowledged.
Is ‘Bevan’s NHS’ under threat?
- The All Party Parliamentary Group (APPG) on Primary Care & Public Health posed a number of relevant questions: on how the NHS was delivered, its scope, costs, current structures and the future of the NHS. In what is written here we attempt to go to the centre of the crossroads at which the NHS finds itself. In a way it moves away from a certain mindset in parts of the NHS that cuts (or ‘efficiency savings’, if you care to adopt a particular politically driven management term) means fewer ‘tea bags and papers clips’. (There is at least one, and probably more than one, large NHS trust in England at which the staff have been told that they had to provide much of their own stationery, including pens. That sort of management and leadership seems entirely arbitrary and unlikely to contribute much towards the ‘efficiency’ savings averaging millions of pounds per trust being demanded of the NHS in England by the UK Government.) The same thinking continues that those with ‘vested interests’ [doctors, nurses, royal colleges, the British Medical Association (BMA), NHS trusts, chief executive officers (CEOs), some patient groups and organisations and increasingly the voluntary sector now supposedly wearing the mantle of the Big Society] must be obeyed and venerated; and that, if you make ‘cheap shots’ at the frontline staff – those who provide the care – that they must ‘work smarter’ – a concept that seems to presuppose that these same workers have to accept that they are deficient in intellect (stupid) in the first place! Similarly a good case could be made that the current problems of the NHS are inherently caused by politics and politicians where ideology often gets confused with common sense, choice gets confused with preference and evidence, facts and reality get confused with opinion, folklore and myths.
As far as England is concerned, the NHS should sit alongside the Home Office and HM Treasury as primary functions of the UK Government rather than as it stands number nine or so in the list of Government relevance and importance. In England the Secretary of State for Health needs to be a person who commands the respect of NHS staff, professionals and the public; capable of putting the NHS first rather than purely party politics, respect the NHS and maybe performing the role of an advocate rather than, in some cases, giving the impression that the NHS is some sort of backwater of the former British Empire.
New NHS Model
The most important aspect of the APPG’s inquiry was the notion of the survival of the NHS.
Here we propose a model for the next 50 years that should be built on these three pillars: creating a modern NHS, safeguarding Bevan’s values and founding principles.
(1) NHS Statute Board
The Government should establish in statute a board to direct the NHS; similar to the Bank of England’s Monetary Policy Committee but not the current commissioning board [which has, to be sure, gone through two changes of name, having been born as the NHS Commissioning Board Authority, shortened its title to the NHS Commissioning Board and now lives its life under the title of NHS England – which one of the authors (GD) noticed recently may abbreviate to NHSE – like that for the former NHS Executive, which was abolished in the year 2000, not having reached its teenage years].
This board would oversee and direct the NHS in England – looking at the NHS as a long-term national investment, evidence based, focused on outcomes and the patient, staff and public experiences.
The board would set the policies, cost its effects and set out clear implementation actions and timescales. It could perhaps be chaired by a judge and have strong legal powers. Although other options could of course be possible.
The board could set out in clear language what it is that the NHS in England would be responsible for and would treat – for example:
- Category A (must do): for example dealing with strokes, myocardial infarctions (MIs), coronary heart disease (CHD) and the results of road traffic accidents, maternity services, immunisations, depression, organ donation and transplants, and blood transfusion, etc.
- Category B (would do after serious considerations given to judicious and equitable application of a new social or health insurance policy) – long term and residential care, and rehabilitation, etc.
- Category C (not delivered through the NHS but done through social or health Insurance): including in-vitro fertilization (IVF), tattoo removal, circumcision, hair transplants, etc.
The board would produce policies that join up health alongside physical health policies (for instance around CHD and diabetes) with mental health policies (covering self-harm, depression and so on) so that the whole-person concept is considered and delivered through a more holistic, preventative and whole care system delivery. Greater use of the evidence that links physical ill health and mental health should be utilised. For example, factors leading to perceived stress, which may itself be a causative factor in occurrence of strokes and other physical illness. The board would go further by producing policies that join up government departments, such as those dealing with drug misuse and crime; treatment may need many departments and other agencies to be fully implemented (such as the Home Office, DH, social services, education and the voluntary sector). That could in the end lead to better outcomes.
Every quango including the National Institute for Health and Care Excellence (NICE) and the Care Quality Commission (CQC) would come under the jurisdiction of this board. It would direct and advise DH ministers and itself answer to the UK Parliament. This would be a remarkable model of governance that many might argue would threaten democracy; but the NHS is a remarkable institution
(2) Local levy
A local levy could be charged and collected through the council tax and ring-fenced to be spent to support the local NHS in England. This would be based on local needs and demands; for example maternity care could be supported with this type of funding, if for example, extra resources were needed to meet an increased child bearing age population. Funding for specialised services (such as burns units and trauma networks) would need to be considered out of an England-wide budget.
(3) Elected not appointed
Local NHS non–executive directors (NEDs) should be locally elected (perhaps every three years). By submitting to such a process, the candidates would be able to provide their own manifesto for improvements of the local population’s health. Healthcare and health services would have more local ownership and participation – and accountability.
Some other considerations in support of the three pillars above are:
Some of these points are offered in some ways at present by policy makers, but need to be pursued with much more vigour:
- 90% of the public’s healthcare is delivered by the public themselves; yet the public, like most NHS workers – as taxpayers and NHS funders- have little or no say on how the NHS is run, let alone reformed. An exception, so far limited in its scope, is the NHS foundation trust model in which local people may have a vote in electing some of the ‘governors’ who in turn appoint the NEDs. Other models of engagement and participation must be considered. NHS England has been working on a range of possibilities but there is a very long way to go.
- The NHS must stop the constant recycling of the golden cabal of failures (individuals) who move from one top job to another. Most of these individuals seem to go on to anoint themselves a level of importance that any attempt by the public, or indeed NHS staff, to understand this, is quickly met with contempt and disbelief by the public. The Secretary of State for Health should stick to his quite recent and very timely promise made in the UK Parliament that no managers in the English NHS who had failed in their job should be allowed to move to another similar one, as has very often been done up to now. To do that will require determination and negotiation with the plethora of NHS employing organisations. Yet carried through it must be, if for one other additional reason of producing equity alongside NHS clinical staff, who all run the risk of dismissal and sanction by their professional bodies, while NHS senior managers (or ‘Very Senior Managers’, to use a term that has crept in along with some huge salaries in the last few years) seem to operate according to not only an entirely different set of ethics but a grossly different disciplinary procedure.
- A vibrant NHS needs a strong and emerging voluntary sector, an engaging private sector, a creative and accountable social enterprise sector and an engaged public. It also needs a much stronger and transparent partnership with local authorities, social care, business, environmental agencies, education, community groups, religious groups, young people and entrepreneurs of various sorts. The Labour Party set out its stall on a new approach to NHS policy, in February 2014. That review (by the Oldham Commission) included a recommendation to better join up health and social care. That is something that is surely needed. It also explicitly mentions the importance of housing. Yet it is also a case of history repeating itself. Go back to 1945 to realise that Aneurin Bevan was actually appointed as Minister of Health role with a remit also covering housing.
- An even better NHS would look at how other countries do healthcare; promote more international collaborations and see technology, evidence, research and exchange as progressive and positive thinking, instead of a host of often disregarded ‘pilot initiatives’ which may often seem to demonstrate that ‘not in my backyard’ is a concept alive and vociferous in the world of the NHS.
- NHS changes and polices must be unambiguous about their impact on rural communities and people of ethnic minorities and be applied in practice as opposed to simply being policy statements of intent around such vague topics as ‘diversity’. Thus they should contain means of demonstrating how they are actually addressing and – more to the point – dealing with inequalities.
- In one view of the world, those with vested interests, doctors, nurses, royal colleges, the British Medical Association, other trade unions, NHS trusts, CEOs, some patient groups and organisations and the voluntary sector might be perceived as speaking for all but representing nobody in particular. It is lazy policy making when a government invites just these groups (and of them, ‘the usual suspects’ who with the best will in the world certainly cannot represent all needs) to meetings and discussions. NHS England, for instance, has made welcome moves away from that with regard to use of more individual patients and members of the public in recent years, it is acknowledged.
- Every citizen, group or set of professionals is an owner or ‘shareholder’ of the NHS. As taxpayers they should have every right to disagree as much as agree to what is proposed about the NHS. Engaging with the disagreeable is a sign of strength. That is a trait that seems to have gone out of fashion in far too many public bodies nowadays, when it appears that abilities in ‘good news’ management are more highly remunerated than having specialist caring, clinical or other skills. No doubt those of an especially critical nature might prefer the term ‘lying’ in place of ‘news management’, especially in the wake of the prolonged debacles over many years at Mid Staffordshire NHS Foundation Trust and possibly some other NHS trusts.
- care groups: such as children, mothers, young people, older people, men;
- settings (where the services or care are provided): ranging from hospitals, general practices, day and sports centres, the independent sector to supermarkets;
- conditions (disease and illness): a wide spectrum, including depression, CHD, measles and the consequences of hospital acquired infections. Prevention considerations should be integrated with that concerning good clinical assessment, diagnosis, treatment and outcomes.
- The current non-statutory function and role of public health has in many ways failed and may continue to fail. It is not wise to have an expensive system in which doctors and others working in public health have no patient or hands-on contact, yet give advice and what may come over as imperious commands to those dealing with patients. Many frontline practitioners despise this system. Public health practitioners should be people with dual roles; both in patient and community contacts and examining population public health. Such duality could also encompass academics, researchers, primary, secondary and social care practitioners.
- Who exactly runs the NHS in England? Is it the politicians; is it the DH or NHS England? Is it the NHS trust boards? The Clinical Commissioning Groups? Health and Wellbeing Boards? Or local councils’ Health Overview and Scrutiny Committees? There are also local education and training boards. Or perhaps the answer is to be found in Clinical Senates or Quality Surveillance Groups? The number of separate NHS bodies in England has bloomed under the Health and Social Care Act 2012. And the Secretary of State for Health has assumed renewed importance in the wake of the Keogh Mortality Outlier Rapid Response Review of 14 NHS acute hospital Trusts, and the setting up of the CQC’s Chief Inspectorate of Hospitals, judging by some of his recent UK Parliament and other statements. Practitioners are responsible for the treatment of their individual patient, but who exactly is responsible for providing the tools and environment required for care? Recent press reports suggest that seven out of ten members of the public don’t seem to know. If you are confused try asking the staff who work in the NHS! Do you think they all know?
- The underlying principles of the creation of the ‘Bevan NHS’, its journey and all its historical values tends to get lost in the political, management and ‘reform’ agenda. The anthropological and social conscience of Bevan’s NHS should resonate in all undergraduate and postgraduate training in health and social care. (Ideally it should be a more prominent part of the standard school education curriculum).
The emphasis must be on implementation to improve practice and service delivery. Thus a national institute with a specific remit to bridge policies, practices, services, and good outcomes is a necessity. It must bring together NICE, CQC, the practitioners, other staff, patients, the public, undergraduate and postgraduate training, professional bodies, drug companies, the independent and business sectors, the legislature and many more, into a functional and effective knowledge centre.
It is recognised that the main determinants of health encompass an enormous range of factors, as well as how the NHS performs. These include employment status, housing, diet, exercise, degree of isolation of an individual and the state of the physical environment in which they dwell. The key to dealing with these – instead of simply talking about or repeatedly measuring them is to create real action between different departments of government, public bodies, voluntary groups and the private sector – as well as with individual people. That would surely be preferable to many of the ‘partnerships’ that often do little more than continually pontificate Or, to be blunt, hold meetings with vague agendas for the sake of it and never have to account for their successes or failure to make practical achievements.
The whole of the health promotion or ‘prevention’ agenda is intimately connected with the state of the nation’s health and it is probably time for much tougher talking about some of the constraints and calls upon the NHS as deliverer of healthcare of people falling ill. The addiction of governments to tobacco taxation shows how difficult it actually is to achieve reduction in harm-inflicting activities like smoking. Yet unless we are all honest about that, then mere exhortations about, for example, changing lifestyle will do little or nothing to alter the fact that people with diabetes need to be treated because they have that condition now. So dietary advice means real dialogue between healthcare personnel and food manufacturers and caterers, for example, ideally with agreements at the end of it.
Concluding remarks
The above views are based on the evidence that the current NHS is not sustainable with regard to its structure, governance, management, cost and ambitions. Parts of it are decaying (think of agency or locum staffing, and some poorly provisioned maternity services in decaying buildings), parts are wasting money (ponder the information and communications ‘links’ between social services, primary care and secondary care, NHS infomation and communications technology system) and others that have been proven to have a record of inefficiency, incompetence or worse (of the which the CQC was until quite recently a well-publicised example, it has to be said). The cumulative effect of these and other factors is blunting motivation and inspiration among very many of those who work in the NHS.
Many of us came to the NHS because we wanted to care, a vocation of choice. Healthcare is an art; professional artistry and the science of medical advances require that the NHS itself be fit and healthy for purpose.
If you would like to contribute to the construction of these ideas email to; BevanNHS@healthfootprints.co.uk