When I stood as a Conservative parliamentary candidate in 2015, I remember preparing notes on every conceivable subject for my first hustings. But when it came to the NHS, I couldn’t bring myself to follow the party political line and just bash my opponents; no one has fixed it and no single party is to blame.
What I said, instead, was that we should have an independent commission to decide the future of the NHS and put it above party politics. It was a line that went down very well with the audience; when politicians throw numbers at each other we all get lost and a mature debate proves impossible.
So I strongly support the position Norman Lamb has developed as the party’s health spokesman, calling for an NHS and Health Convention to instigate a national conversation involving charities, professional groups and patients’ groups as well as politicians. In January, he was backed by 75 organizations and it’s a shame this policy attracted so little interest from journalists despite getting such widespread support from those closest to the health service.
Our headline policy pledge of a 1p increase in income tax, ring-fenced to deliver an extra £6bn a year spending on the NHS, stood out at the election. But, to my mind, our promise to create an Independent Office of Health and Care Funding to monitor health and care budgets, and reporting every three years, was just as important.
Independent is the key word because we need outsiders to bring a fresh perspective to the NHS, not the same old blinkered, inflexible approach. A parliamentary term of five years is a fixed timeline and politicians rarely look beyond it, but you cannot fix the NHS in that time. You need to change the timeline so it’s not dependent on the political cycle.
I am a project manager and my job often involves going into businesses struggling to meet the timeline for a project. The bosses often think the answer is to throw more money at it, as if that alone will solve the problem. But it’s not that simple. The solution is frequently to introduce phased timelines, rather than a single fixed timeline, with parallel work streams.
Rather than insisting on a fixed five-year timeline, for example, it’s often better to have a five-year timeline, a ten-year timeline and a 15-year timeline so the learnings from each phase of the project can be taken into the next one. In the long term, it’s a cheaper solution because when problems occur they are addressed and fixed rather than being continually patched up.
I think the same is true of the NHS. The days of the quick fix are over. For too long, politicians have been too lazy in their approach to the NHS; we have been too reluctant to learn from other countries, too constrained in our thinking and too reluctant to re-model outdated structures.
We all know that Brexit is going to have a disastrous impact on the nation’s finances. I’d rather see a 1p increase in income tax than £1bn spent bribing the DUP to keep the government afloat, but the reality is we need to start thinking much more smartly about how we fund the NHS. An independent commission to oversee its future is a crucial pre-requisite for smarter decision-making and we must continue the campaign to make it happen.
* Azi Ahmed joined the Liberal Democrats during the 2017 election campaign, having previously stood as a Conservative.
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29 Comments
Azi writes this with a sensible approach, needed more than ever, and an awareness that our NHS is in a mess.
There is in our discourse ,much that is factual ,for which we can be thankful.
There is with our service , much that is mythological ,about which we should be sceptical.
The model we have was never very sensible , as it was controlling , top down , completely dependent on central government , politicians in charge , not patients, or even professionals getting much of a look in.
Even the supposedly wonderful Matron, was often an excuse for a hierarchy and an elite that had the Consultant at the top, the suffering at the bottom of the strata of decision making. It’s not a system in practice that lends itself to Liberal or Democratic approval or delight.
It has been tinkered with by too many who have only succeeded in adding corporations to the powerful, again, not patients, though sometimes professionals get a look in .
The profit motive is not the answer , but it has not been the problem. If it had been, it would have meant many more sick people getting timely treatment , but it does not mean that because they cherry pick , the winners and losers culture of fastidious awareness of what can and can’t pay off, is rife, and is wrong.
We need the private sector. But it is the integration of the freelancers, the private therapists, and the self employed under used, from psychiatrists and physiotherapists, we need .
And the not for profit institutions with expertise and experience, from the Nuffields of old , to the BUPAS, making a difference to too few now, integrated in a loose federation of holistic provision, we could all benefit.
We have much to do, before during and after the essential increases we need , massive ones in front line funds being allocated properly.
I agree. An independent look at the NHS and how it is run and organised’s is a good idea. When health affects us all fro cradle to grave it should not be a political football to score points off. To get all the organisations to work together maybe there should be a focus on spreading the word of the idea on the internet and to ‘sell’ it to journalists.
The NHS does not need a top down re-organisation nor a commission to design the next re-organisation.
What is needed is for continued productivity improvements at grass roots level which requires continuing application and graft by individuals in the NHS. NHS management should be given time to bring this about through sharing best practice and other means.
Thank you Azi. A voice of sanity. It is not a put down to say that much of this should have been a no-brainer years ago. We are in your debt for the way you have articulated your points. Our health/care services will always exist in a political context but they are crying out for good grown up politics rather than the bad politics which has portrayed it all as certain sorts of “election issues”.
…….. an independent commission to decide the future of the NHS and put it above party politics ???
As if that’s ever likely to happen!
The concept of socialised medicine and health care is about as political as it ever gets. If you’re of a right wing disposition the chances are you won’t like. The situation is the same in America. The right don’t like the idea of “Obama care”. The left does.
The right wants a user pays system for most with, perhaps, a second class system for those who can’t afford to pay. The left wants a well funded government funded system to run alongside the private system. No-one is suggesting nationalising Harley St -except maybe the SWP. If there’s any dispute it’s about the level of funding. We don’t need an independent commission to know that the UK spends less on health than other comparable EU countries and less than half what the US spends.
The idea that we can have something for nothing if we just hit on the right magic formula is behind one reorganisation after another in the NHS. We don’t need an independent commission to tell us what we already know.
I fear the word “commission” as much as I do “tsar”. These are attempts to kick the can down the road and avoid facing the decisions bravely
The first is access. Anyone in these days of cheap air fares can have their pregnancy or ailments treated by the International Health Service. My solution (and I can hear the screams now) is a NHS Entitlement Card issued to everyone who is entitled to use the service (complete with photo). To access treatment present the card or a valid credit card.
Secondly, and worse, is that we are on a divergent path. Better care costs more in drugs and procedures and it extends life so more people, with more ailments live longer which means greater costs but leading to even longer life and so on and so on until the nation is bankrupt (yes, I know it already is – I meant so unarguably bankrupt that even those who say we are the richest country in the world and can have whatever we want accept that we are bankupt).
I haven’t an answer for that because the only conclusion is that no society can afford unlimited free health care as procedures get more complex and costly.
But who has to die?
I also agree with David Evershed that the day of complete collapse can be put back by essential efficiency improvements, but the point of unaffordability must inevitably come. In my youth a centenarian was unheard of and now there are hordes of them.
Thank you for an interesting piece!
A clear objective audit of payments in and out including costs, prices, surpluses, debts etc could be produced quickly so that we might be better informed in our discussions.
Ditto other government expenditures.
“As of 07/11 the proportion of government debt spent on infrastructure, healthcare, welfare, education, pensions, the military, the justice system, local services, roads. govt. subsidies, EU contributions, science funding and research, international aid and a few ill advised invasions and occupations amounted to £876 B (58% of GDP).”
http://anotherangryvoice.blogspot.fr/search?q=The+great+Neoliberal+Lie
Where does the rest go and why?
A willingness to pay for health is required. We unfortunately in this country seem to believe we can get something for nothing, we can’t and some hard lessons will have to be learnt before that gets through. When a politician declares we can do more with less what actually they are saying is soon we will do everything with nothing; just looking at the state of prisons and the police will tell you all you need to know about were that gets you.
David Evershed
What is needed is for continued productivity improvements at grass roots level which requires continuing application and graft by individuals in the NHS.
How, exactly? Give some examples of unproductive behaviour in the NHS that you think could be improved.
Compare the costs of the NHS with the costs of private medicine. If the problem in the NHS is unproductive behaviour, then one would find that in private medicine costs of treatment are much cheaper. Is that the case?
If the problem with the NHS is unproductive behaviour, how come so many staff are leaving it complaining of stress due to over-work?
Azi Ahmed
I am a project manager and my job often involves going into businesses struggling to meet the timeline for a project. The bosses often think the answer is to throw more money at it, as if that alone will solve the problem.
But hasn’t that been the line almost continually from every government since 1979? “The solution to problems isn’t always to throw money at it, so try something else”.
Might it not just be the case that after 40 years of such thinking, actually everything that could easily be done to cut costs has been done, and in reality the problem now does come down to lack of sufficient money?
As I have suggested, if there is an easy solution to be solved by waving hands and so improving efficiency in public services, wouldn’t we have seen private providers of such services doing so at lower costs? After all, they are in a market, and that should push them that way. How exactly does the cost of private health care and private education compare with public health care and public education?
From all I have heard of people working in these services, the line “we’re cutting your money, it’s up to you to be more efficient, throwing money isn’t the way to solve problems” pushed continuously for decades has led to short-term cuts that lead to long-term higher expense. And then, since it leads to more costs, government says “Oh look, we haven’t really made any cuts” and so it goes on in a disastrous downward spiral.
As for consultants coming in to advise, how many of them are inexperienced kids who think they know everything because they’ve done a business degree? So they propose something based on their theoretical knowledge and go away. A few years later, another bunch of consultants called in suggests the exact opposite. Nice big profits for the consultants there – after all, they’re being paid for it, and they aren’t going to say “What you are doing is fine, no change suggested”.
For example, one bunch suggests centralising procurement because the scale will help reduce costs. Another bunch suggests decentralising procurement because individual knowledge buying small amounts will save costs. I have actually experienced that.
Lorenzo Cherin
We need the private sector. But it is the integration of the freelancers, the private therapists, and the self employed under used, from psychiatrists and physiotherapists, we need .
And how many people do you know who have been ripped-off by private providers pushing unnecessary treatment on them because that makes them a profit?
And if it’s paid for by insurance it’s the other way round – in order to make a profit necessary treatment is not provided, with some excuse made for not doing so.
Isn’t this line “private sector good, public sector bad, baah” a little outdated now?
See this article on PFI. I remember when I was a councillor when PFI was being pushed very much with that line – it was being provided by the private sector so it must be good, and I was denounced (by the Labour group running the council) as being some sort of dinosaur for not following the line “baaah baaah”.
And now we find … ?
I am very much on David’s side. Efficiency and productivity improvements are available to the NHS but I also regard consultants as a blight on human progress.
My own experience of the NHS, watching carefully, is that I would give them at best a 3 out of 10. I am not surprised they feel stressed.
The main faults with most improvement programmes is that they are triggered by some “Very Senior Person” who engages some smooth talking consultant who sells them nonsense.
My messages are first, the people who will make the improvements are those doing the work but they need to learn how to ‘see’ the ‘waste’ so start simple (a 5S campaign was my start). Secondly, they some time resource as they have to identify the workteam’s key processes and measure the time those processes take.
The 5S they tend to enjoy but the real benefits come from measurement. We did it in our HR department and they discovered that the recruitment took a year! They then took vast chunks of time out of that because they had found where the waste was.
Lastly, expect to take years for them to become real experts as you are effectively training them all in a whole new skill.
I have other ideas on ‘peer review’ but I agree with David. Massive improvements are available.
Mathew Huntbach
You are looking for division between us all as ever, even on a day support you on the thread on Tims religion being mentioned.
I have never pushed either your line , or the reverse.
I am for what works for the most vulnerable.
Unnecessary treatments are not the issue, nor caps by insurance companies saving money. This is pie in the sky fantasy in a country with no real market for health amongst the population , in any real significant degree.
The saving, the cap , is in the NHS, starved of money, and flexibility.
It would be almost a welcome relief to have too much unnecessary treatment in a sector that almost already has a form of scrimping and saving built in.
The UK is ranked 6th out of the seven countries that form the G7 (a group of large developed economies) for healthcare expenditure as a proportion of Gross Domestic Product (GDP).
ONS’s new internationally-comparable “health accounts“1 show that the UK’s total healthcare spending in 2014 was £179 billion, or 9.9% of GDP.
As a percentage of GDP, the UK spent less on healthcare than USA, Japan, France and Germany and a similar percentage to Canada. The USA spent the most on healthcare as a percentage of GDP at 16.6%.
Out of the G7 group of countries, only Italy spent a smaller percentage of GDP on healthcare (9.1%) than the UK in 2014.
http://visual.ons.gov.uk/how-does-uk-healthcare-spending-compare-internationally/
We spend less than most on health. For those in love with the free market I’d look at the USA they spend the most and the government spend as a percentage of GDP isn’t far behind ours and few people claim their system looks after the poor.
@Azi Ahmed
Hi Azi, I missed your earlier post, so a belated welcome to the party.
I too very much agree with Norman Lamb’s suggestion of a NHS and Health Convention. 1p on income tax may help the NHS stave off the current crises, improved efficiency at the local level may help a bit. However, it may be as many fear, that we are facing far deeper long-term problems with funding for the NHS due to an ageing population and ever-increasing health costs. If so, we the electorate need to be engaged in the debate about what to do.
That’s GDP. Our economy is very large -but trades at a whacking loss, not a profit. Use any method you like – arithmetic, algebra, geometry, trigonometry, calculus, relativity – anything – the UK is bankrupt and in deep trouble and getting deeper all the time. Our ability to spend greatly exceeds our ability to earn and I can see no plausible trigger to turn us round and become profitable again.
@ David Evershed
Your confidence in the management of the NHS is misplaced. From what people tell me and my own experience the managers in the NHS are poorly trained (if they are even trained) in management. The staff are disillusioned, demotivated and stressed. This is why lots are leaving. There are no more improvements in productivity to be made, pursuing such a policy will only make the service worse.
I do favour some re-organisation – the democratisation of GP surgeries including their district nurses to give patients control locally. There needs to be a change of culture to putting the patient’s experience first. Both of these will cost money and more than 1p on Income Tax will be needed.
“There are no more improvements in productivity to be made, pursuing such a policy will only make the service worse.”
Just visit any organisation that has followed a ‘lean’ improvement process. Then sit in a hospital and quietly watch.
The NHS hasn’t even started an improvement journey. It doesn’t need management consultants, it needs leadership.
But, anyway, that only postpones the day of reckoning. Unlimited free health care foe ever is not affordable by any society and is a hopeless dream for a nation as bankrupt as ours. It will, it must, collapse. More money = better care = longer lives = still more money = still longer lives = yet more money = yet longer lives etc etc
Lorenzo Cherin
Unnecessary treatments are not the issue, nor caps by insurance companies saving money. This is pie in the sky fantasy
No it is not – I myself know several people who have been ripped off by private therapists and so on who make money from treating them, and so have gone on and on giving unnecessary treatment in order to make money out of it.
There is actually nothing at all fundamentally wrong with the NHS. It is well up there in the ‘second tier’ of ‘major developed world health services’ . It was not helped by successive governments ‘re-organising it’ again and again and again, with each re-organisation stuffing tens of thousands of pounds more into the pockets of (a) international private companies and (b) superannuated NHS administrators who masquerade as managers but who could no more manage anything than I could hang glide off the top of Mont Blanc using only my ears. There are, of course, some good managers out there – they are just swamped by the inept who are only ‘out-inepted by the Ministers in the Dept of health whose only aim is to try to avoid all responsibility.
The famous NHS Deforms’, which the Lib Dem consultative sessions in the Liverpool Lib Dem Party Conference in 2010 told Paul Burstow were fundamentally flawed were only the latest of these fiascos. There is now essentially no proper planning in the NHS and no local accountability whatsoever.
Britain’s NHS is funded substantially less than most of those other countries’ health services which achieve better results. It is also funded at a far lower level than the USA system which has appalling results and is only fractionally better under ‘Obamacare’ than it was before that – but is a major source of cash for investors in the huge insurance industry on that country.
Tony Dawson’s first paragraph is quite correct and is, of course, the reason why you should not throw more funds at it. It will only make all this even worse.
It needs enthusiastic, participative and inclusive leadership.
It also needs access control and to face the inevitable that sooner or later it is going to have to tell patients “sorry, it’s too expensive to keep you alive any longer, sorry about that, hope you understand”.
Michael BG urges ” the democratisation of GP surgeries including their district nurses to give patients control locally”.
Since most GP surgeries are privately run businesses this would be a very expensive nationalisation.
I sit on my own GP’s Patient Participation Group where we make plenty of suggestions for improving the service although we steer clear of advising on clinical issues.
The main GP surgeries in the area each provide a doctor to sit on the Clinical Commissioning Group who decide which hospitals to use for which services for example. The PPG has input to these individuals. Indeed one of them is my next door neighbour.
So despite the GPs being privately run there is a degree of local input if not democracy exactly over the local health service provided.
Thank you for this Article, Azi. You make some good points about the need for an NHS and Health Convention an Independent Office of Health and Care Funding to monitor health and care budgets that can take a longer term approach than the 5 year parliamentary cycle.
There are some serious areas to be tackled, not least the onerous PFI contracts that extract enormous rents from the Health services and are bringing about the financial failure of many trusts. The increasing use of agency nurses is another symptom of false economies and lack of investment in training, recruitment and training of NHS staff.
There has long been an urgent need for additional funding in the NHS. The NHS CEO, in a review a couple of years back, identified a £30 billion annual funding gap of which perhaps an overly ambitious £22 billion was to be found from efficiency savings.
Social Care for the elderly clearly needs to be integrated with health care both to reduce stains on NHS hospital facilities and to meet the needs of an ageing population. The funding shortfall here has been estimated at £10 billion.
These kind of urgent funding needs cannot be met by tax increases on a younger generation alreadsy overburdened with excessive housing costs and graduate tax repayments. We will need to tap into the accumulated wealth of the older generation.
“National accounts valued total housing rental values at £226 billion in 2014, comprising £59 billion of actual rental payments and £166 billion of imputed values for owner-occupied housing. If we assume that one-third of this amount is the value of the location, this equates to an annual location value of housing at £74 billion. Non-domestic property has been valued at £1.9 trillion. Assuming a location value yield of 5 per cent and a variety of location value assumptions depending on the type of property, perhaps £27 billion might be raised from offices, retail, infrastructure and other non-domestic property.”
A 1% land value tax (coupled with renegotiation of PFI contracts and investment in in-house staff recruitment and retention) could raise the funding needed and address the cost issues needed to put both the NHS and Adult Social Services on a stable footing for the 21st Century.
Infectious diseases pass between people whether they are entitled or not.
and why not take education, public transport, housing, pensions etc out of politics? We need political debate with a respected independent Commission giving some impartial comment. Each time a government changes, we have new ideas. These need to be tested before implementing so that there is a political risk to changing for its own sake. Powerful Select Committees can also help to provide some continuity.
@ Palehorse
When you sit on a ward in hospital where do you see over staffing, what I see are nurses run off their feet.
Wages for nurses in the NHS have fallen in real terms over recent years, this needs to be rectified and will cost money. There are staff shortages in the NHS and so more money is needed to pay for the extra staff. One of the problems in the NHS is lack of staff. My GP surgery had 10 doctors in 2008 now it has 3.
You wrote, “It needs enthusiastic, participative and inclusive leadership”.
I agree and it needs to train its managers and improve pay and conditions to motivate the staff as well as reducing the stress of those employed in it.
@ David Evershed
We have often talked of ensuring there is little privatisation of the NHS. GP partnership practices make profits. I don’t feel my GP treats me as a valued customer to be kept. I don’t think GPs should be in business to make a profit from people’s health. A central distribution of funds to GP practices is not a good way to generate good service. I imagine that most GP practices have few assets to nationalise. I have seen a report that states that GPs are reluctant to become partners. Therefore to make the NHS more patient focused patients need control and this is in line with liberalism.
Each GP practice in a Clinical Commissioning Group area does not appoint one board member on the CCG board. In my area there are 18 GP practices which elect three GP board members and the chair was a GP in the area (https://www.northhampshireccg.nhs.uk/about-us/governing-body/images-bio/).
Michael,
I don’t know what your career experience is but next time look very closely at the nurses rushed off their feet. Observe the amount of walking they do and why they do it.
The time I was in I eavesdropped and quizzed. A significant portion of time seemed to be trying to find something that wasn’t in the place it should have been in, chasing up something that should have been there but wasn’t and filling in the same information multiple times.
I saw no sign of the methods commonly used to eliminate these wastes (and frustrations). No sign at all.
I repeat – no management consultants should be used – they self breed new contracts. Only salaried staff should lead improvements. The programmes should be endorsed from the top but driven from the bottom. This was a large part of my job and frankly I could train you in a couple of months to see past the ‘rushing about’ to the point where you could see why they were rushing.
Throwing money at an organisation which is culturally inefficient just drives more bloat and treacle and makes things bigger, but worse.
Michael BG
Being more efficient in the NHS does not mean nurses working faster.
It means working more effectively, which requires changing processes amongst other things.
@ David Evershed
I have already stated that the management in the NHS is poor. I have never suggested nurses should work faster. I do accept that if there were better managers in the NHS they might be able by working with their employees come up with more effective and patient friendly processes.