The NHS at 70

I thought I would write some armchair opinion about the NHS, a much beloved and seemingly struggling Institution that turns 70 today and is under more pressure than ever. I don't have much first-hand experience, although I have worked in a few temporary admin roles in a hospital, have a mum who worked in the NHS for the last 25 years as a Ward Manager and have a number of close GP friends, so my opinions are not expert but they are not "tabloid" either!

We all love it

I think some people need to understand that everyone loves the concept of the NHS. I love the fact that with generally minimum fuss, I can get a range of benefits like free ambulance transit in emergency with paramedics, free acute care in Accident and Emergency (or whatever they might call it now) as well as a range of in and out-patient facilities, which are free at point-of-use. In reality, we get thousands of pounds worth of treatment, which for many people is way more than they have paid indirectly in taxes.

Statements like "the Tories hate it" or "the government want to kill it off" are disingenuous and miss the real problems that are occuring and most importantly, why. It is ultimately a question of money and efficiency - i.e. value for money but this too is too simple an approach. To measure the problem purely in terms of money assumes that firstly the NHS is fit for our modern world and secondly that it is largely a case of efficiency combined with extra government contribution that will fix it.

Hopefully most people will understand that it is not as simple as that!

Things have changed

Firstly, the NHS itself has changed massively in the past 70 years, partly because the world has changed and partly because the remit of hospitals 70 years ago was much smaller than it is now. 70 years ago, we didn't have MRIs and Cat Scans, we had more rudimentary X-Ray machines. Ambulances were basically vans with a gurney and a driver and for the most part, there would have been little need to visit A&E for small issues like cuts since their treatments would have been fairly close to what you would do at home: wash it and cover it.

An ambulance in 2018 might cost £250,000 or more each! That is a lot of money, especially since most of the people using it will not need most of the kit, but for the odd few people who do, it is necessary to have it on most or all emergency ambulances. Compare that to 1948 when the price for a basic van might have been the equivalent of £10,000 to £20,000 in todays money, over 10 times less!

The population has changed massively, in 1948, it was 50M, and is now 60M, which in itself, with no other changes would be an increase in cost of 20% but now also includes a much higher percentage of the elderly who will cost more per-head to care for than younger people.

Certain treatments were not available in 1948 and are today and they are expensive! Cancer treatment varies between some low-level chemotherapy or basic surgery right through to modern cutting-edge drugs that might improve life-expectency by a few percent but at an enormous price. People might not like the idea that they are not worth the money but the organisation NICE has exactly the job of providing a value on human life for the NHS and deciding what is worth spending and what isn't.

Prescription drugs were very limited in 1948 but now, people get all kinds of things via the NHS. There is a fixed charge for some people but for many, they are free at point of use and these alone cost the UK was a staggering £10B in 2017. I don't have figures for 1948 but it would have been significantly less!

The culture of society has changed. With any "free" service, there is a danger that the privilege becomes expected and it is not only more common for people to visit hospital (why not when you meet a super qualified doctor who will examine your cut knee!) but even for some to get verbally agreesive if the "service" they receive is not as expected. I heard recently of someone getting physically agressive in a doctor surgery because they were unhappy that the government are stopping prescribing (i.e. paying for) medicines that are available over the counter. This puts obvious financial pressure on hospitals but also the fear of mistakes and litigation makes some Trusts either avoid providing a service at all, or they have to spend more time and money making sure they didn't miss something. Of course, that doesn't always work, people do make mistakes so the additional money might not be adding much value!

It's about money

All of these things wouldn't be a problem unless it was about money. Of course it is, there is no bottomless pit of cash to pay for things that people want, whether libraries or old people's homes. There are still people who think that either the government print whatever money they need and therefore under-investment means that they don't care, or otherwise that they have some massive bank account with a few trillion in that they should spend on the NHS to fix it.

There is another idea that somehow "I paid my tax", which means that it all goes into a pot and pays for my care. That is, of course, also not true. Your tax paid for the government spending the day after you paid it, it is not in a pot and it is not "owed" to you. With inflation, the total amount of money you paid in tax would cover nowhere near what you cost to the NHS, especially since it wasn't gaining interest in an account somewhere! The simple fact is that the NHS today is paid for by what people pay in tax today. As prices inflate, either wages (and tax) would need to increase consistently, spending has to be cut or the government has to borrow and hope that somewhere in the future we will do some kind of magic economy thing to be able to pay the money back.

The NHS is NOT free! It is free "at point-of-use" but unsurprisingly it is very expensive. Approx £111B per year. Roughly 18% of all government spending.

So this brings us nicely to the common accusation that "The NHS is really inefficient", it has "loads of middle managers" etc. and that simply some more efficiency would change everything. This unfortunately is a mantra for people who do not understand most corporate environments. Of course there will be inefficiencies and we will find areas where money can be saved today but these things don't sit still, you might save £10M today by buying power but then another contract you just signed will cost you another £10M next year, especially with so much contracting that is required for Trusts to meeting targets and quotas set by Politicians.

The Corporate world i.e. any organisation with more than 500 people and 4 levels of management (my definition) is rife with inefficiencies. There are jobs that we might not think are needed but you have to have 3 people producing graphs if you are required by law to prove that you are meeting targets. Could 2 people do the same job? Sure but good luck finding all these amazing people to staff an organisation that employs 1.5M people! There is a reality that some people are rubbish, some are amazing and most are average. If you only employ 5 people, you have the luxury of choosing those amazing people, more than 10 empoyees, it largely becomes impossible.

Could people work smarter etc. Again, yes in theory but is a nurse going to be allowed to use their intuition to make something better or are they made to tow the process line to make sure things don't go wrong? This is healthcare, there isn't much appetite for risk taking!

The simple maths is that the demand and expectation for health services is too high for the money that the government are willing to/able to provide.

What can we do?

There are a number of measures that the NHS can and does already take to help with the crisis of a bulging NHS problem but another simple truth that is lost on many critics is that there is no simple answer, otherwise it would have been done. Labour's answer seems to concentrate on more money but of course this can't really come from anywhere except taxes and most people are not prepared to pay more.

Taxation comes from various places, the main three are Income Tax, National Insurance and V.A.T. there are others like beer and fuel duty and inheritance taxes but over 90% comes from these three. The controversy is about who pays them and how much they could be put up.

National insurance is supposed to pay for the NHS but not everyone pays it. Of course, theoretically everyone pays it. In fact, when I was unemployed, I missed payments because I didn's sign on! The reality is that any state payments like pension and unemployment are basically higher so that the individual can pay their tax straight back to the government so in reality, only people earning are paying it (and their businesses), which leads to a difficulty. Should I pay more NI just because the elderly and possibly people who don't work and have even more chance of health problems and free prescriptions are costing a large part of the NHS cost? It's a matter of degree, of course, but that is the problem.

Likewise, income tax is paid by people who are working. The socialist ideal is, of course, that those who are productive take care of those who aren't but that assumes that those who are not working are still giving to the community in some way and that pensioners are not simply travelling around sightseeing and the unemployed are not at home watching Sky TV! Of course, these are not all the people but there are enough of them to make it a touchy subject for tax payers.

VAT is an intersting concept because it is based on the idea that those who can afford luxuries can afford to pay for stuff. Ignoring the few really random places where VAT is paid but shouldn't be (and vice-versa) it works OK except, again, it is like punishing the people who have done well in life to pay for those who cannot look after themselves. If we loaded VAT even more, we could raise money but VAT actually affects pretty much everybody because plenty of things we consider normal, like cake, are treated as luxuries for the purposes of VAT.

So raising money by raising taxes is a tool but it would be unpopular, not just generally but because of the idea that I pay more because I am doing better in life, not because I need more from the state.

So the flip side of making something work is to reduce the cost of the NHS. As previously mentioned, there would be scope for making some savings and various governments have already done some of this but keeping on top of it requires employing some more "middle managers" and things change as soon as a new drug or piece of equipment becomes available or something else comes out of patent and is made cheaper. The NHS have done well convincing Pharmacies to dispense generic drugs in place of named brands of the same thing.

The only big way to reduce the cost is to reduce the demand! This, again, is contraversial for the simple reason that not everybody needs the same thing. If you, for example, said that you could only visit the doctors a certain number of times before needing to pay, would that be fair to someone with a chronic illness? Would we be able to do it in a way that allows people with known genuine problems to visit multiple times and others to have a limit? You could charge people, again very unpopular because, "I pay my taxes" but the useful part here is that a) you could charge people who miss appointments i.e. they lose their payment and b) It provides a mechanism that makes people think, is my cut knee really worth £5 to see the doctor? Again, it creates problems for those with long term conditions and the elderly are potentially very vulnerable if they are living extremely frugally and are less likely to pay money to see a doctor. If you start exempting people then you fall back to the problem that only people who earn have to pay - which is unfair and doesn't solve the issue of reducing demand.

You could, in addition, reduce what treatments are available "for free" and have a system like many dentists and some hospitals. You get basic treatment for free but pay a bit more and you get more time and a private room or something like that. Of course, many people don't like, "two tier systems" "one for the rich and one for the poor" or "one for the 1% and one for everyone else" but unfortunately, there aren't many easy ways to distinguish people other than money or quota and since the main problem is lack of money, why not offer nicer food/services/beds/whatever for those who are willing to pay a bit more money. People could even get free upgrades!

 Conclusion

None of this is easy. Once an idea or service has become the norm, changing it in any way is hard and causes a backlash. Some backlash is expected, some is unreasonable but most people will probably agree that some changes need to be made.

The other difficulty is there will always be people who will lose more than others. In fact, the Labour Party frequently use the hackneyed expression, "The poor will be hit the hardest" which in most cases will always be true! If the country benefits but a small percentage loses out in some way (small percentage might still mean 100,000 people!) is it still worth it? Of course, the answer is always "yes and no". Yes financially and no, it will be a real problem for some people. Even with planning and time, changes will never be embraced with open arms and the population has to understand that we cannot afford the NHS in its current form (as well as many other services!).

The NHS, to their credit, have tried to encourage people to use services correctly - go to the pharmacy instead of your GP, go to your GP instead of A&E but there are no sanctions for people who ignore it. If I go to A&E anyway, I'm not going to be turned away (although I know in some more extreme cases you might) and the problem doesn't go away. If they could actually dictate what will and won't be looked at in A&E, that might help, also if they let more nurses carry out lower level diagnosis and treatment (again, I know this does sometimes happen) then we might reduce the need for a doctor looking at a cut hand.

Could we use technology more? I would personally be more than happy for a nurse in A&E to look something up on the computer to find out whether a wound needs referring/X-ray etc. or whether to simply bandage up and send me away.

Ultimately, only the people who work there can say what will work internally. Of course, more money and less people would help but that is not something a GP or hospital worker has much control over. There are plenty of well-meaning and able healthcare staff who could tell you in 5 minutes what the major problems are. Perhaps then you could list them all, estimate cost-benefit and knock a few over. If we scrap healthcare targets and gain £10M a year, is it worth it while at the same time losing some visibility over how different hospitals work etc.?