PART ONE:
1. “Coming, ready or not!”
The realities, the politics, and the future of the NHS.
The realities, the politics, and the future of the NHS.
“Nothing lies like the truth.” Nelson de Mille.
*The issues remain unaltered, despite the lapse of time. Indeed, startling so. And so I reprint this talk, given as the Annual Lecture to The National Association of Primary Care Annual Conference at the International Conference Centre, Birmingham on 15 November 2001. There were a thousand doctors present. Over-ambitiously, I prepared much more than I could deliver in the time. I have taken this opportunity to print the text in its entirety.
The topic I have been given by the examiners asks me to address the present, future, and politics of the NHS. How to fund and guarantee the delivery of prompt access for all to appropriate quality care is clearly the question of the day. And the question is asked and influenced more by culture and politics than by any other factors.
I accepted your invitation even though I do not have the detailed knowledge and experience which you have in actually delivering care, in doing it day to day. And so I hesitate, with the words of Dickens’ A Christmas Carol in my mind. Where he said “it is always the person not in the predicament who knows what ought to have been done in it, and would unquestionably have done it too…” And when I look at the complexity of what you do I have a sense that every day the more I know, the more I know the less I really know.
For me, this lecture, however, is a return to the perennial issues that engaged me at Brighton – to try to see services from the patients’ point of view. To be concerned about access, quality, funding, responsiveness, behaviour, culture, patient voice, and the impact of political realities. Cash, capacity, choice, competition, and compassion – if you like. As I consider these dilemmas and continuities I am reminded of what the Australian marine biologist Julian Pepperell wrote: “May the fish that get away lure you back again.” I have retained this commitment despite my experiences at Brighton. Indeed, this may be because, as W. S. Gilbert says in the wonderful recent film about the Savoy Operas, Topsy-Turvy, “There is something inherently disappointing about success.”
This lecture is necessarily a rapid and rough ride over a large and bumpy field. And too cursory a look into some rather well-swept corners. But I will try to offer a framework for considering the culture and political nature of British health care, the daily realities that culture and politics shape, and how a genuine transformation can occur. I try to figure out why things mean what they mean – if you take my meaning.
I will address the following questions:
1. Can the NHS as presently structured ever deliver the promised equity, ‘fairness’, reliable individual access, choice, improved performance, and patient guaranteed care??
2. Must we go through the present cycle of increased investment but little cultural change to demonstrate to public and politicians that it cannot do so?
3. Will the Prime Minister himself insist that the next general election is about health-care, funded, purchased, and provided on a different basis – and if so, why?
4. Is higher taxation and either voluntary or compulsory health insurance inevitable and a necessary financial model, if we want to financially empower the individual so that we can actually deliver the founding ideas of the NHS?
5. How can patients become more self-responsible – and, indeed, professional lives become more liveable?
These questions get to the ground of all the dilemmas. Most fundamentally, how to make sufficient money happen, how to enable individual choice and provider competition to happen. So as to increase choice, control costs, improve quality and productivity, change the culture, and expose poor performance to scrutiny and direct incentive for improvement. And what that means in individual lives. These are cultural and moral questions. Each helps us to ask how we can attain an equitable, accessible, reliable and affordable system of care and a different way of seeing ourselves, too. With much more cash and more capacity, with more choice and competition, with better outcomes and higher life expectancy, and with higher morale and professionally satisfying work.
A system which encourages consumer choice and more accountability, both of professionals, providers and of consumers themselves. A system which requires patient self-responsibility, personal self-awareness, individual self-care and the responsibility to make cost-conscious, cost-effective – often difficult – choices. Balancing risk, with the individual making the inevitable and necessarily personal trade-offs. Learning as an adult. Being an adult.
If we want this we had better think seriously about how to structure an approach, what it is going to cost, and how it is going to be financed. Is this achievable only through higher taxation to match European levels of investment, and more direct payment through insurance or through other devices to increase private investment?
There are many different realities. Yours will depend on what you do, the pressures in your work, and how you view the world. I take it that for politicians the political realities in health care mostly concern votes, re-election, and surviving change. For them the issues are short-term. The realities for professionals are, of course, about treatments and results. But these lives too include the influence of politics on patient benefit, and professional satisfaction. The realities for the patient concern access – or its denial – diagnosis, choice, and outcome. They ought, too, to concern self-responsibility, self-care, life-style, and a proportionate view of what is possible. But there are few direct incentives encouraging and rewarding this. Too few appreciate that the best way to avoid the cure is to avoid the illness. And that the most appropriate rationing is probably to ration oneself. Without direct and personal economic incentives it is very difficult to get people to do what they envisage to be against their short-term interests.
However, the overwhelming common reality in our present system is that politics is more important than patients, doctors, or medical practice. And it is a particular political mind-set which insists – albeit with benign intentions – that “rational co-ordination” and more planning is pre-ordained and can correct the failings of a centralised structure. It is indeed this structure and its assumptions which disempowers everyone involved, including the politicians. And because there is no free market in health care, never think there is no market. There is. There is a political market. It follows the rules of universal suffrage. Votes are bought in it. And, it seems, that every attempt to change the nature of the NHS either makes much of it worse, or merely reinforces the systemic failures.
It is in the political structure where these tensions resonate. It is here, too, that interest groups block change if they can. It is here that politics itself blocks the path to more dynamist, more innovative, more creative solutions. Politics itself has institutionalised these difficulties. But I will suggest it will be the political imperatives of an electoral system which will now impel and compel change.
When he was Minister of Health the late J. Enoch Powell said that politicians are concerned with the general consequences of individual decisions, but doctors – indeed, all those associated with primary care – are concerned with the individual relationship with the patient, and with the consequences of general decisions made by politicians. These tensions persist. Rudolf Klein called them the tensions between “an absolutist ethic of treatment and a utilitarian approach to resource use.”
b. The major constraint to change is cultural, and thus political. “The prison of awe.”
The major constraint is cultural. This is, indeed, the crucial political reality. Max Weber said that man is an animal suspended in webs of significance he himself has spun. The iconographic status of the NHS makes prisoners of us all, ministers included. [1] For the cultural, practical, and political problems of British health care are a common inheritance. Perhaps the most important constraint on reality, present, and future is this “prison of awe.” This mythical mirroring of realities. This credulous willingness to believe. The NHS a symbol of sanctity in a wild world. We are all prisoners of this occult status of the NHS. Or have been, until lately. Emotion, perhaps inevitably, is at the root of much of our difficulty. It is, curiously, because of this that the NHS is both fundamentally stable and constantly volatile. An NHS constantly changed but persistently the same. The British have been married to the NHS, as Venice to the sea. But, as Professor Nick Bosanquet has said, “the power of the ideal often swamps any objective assessment of the means.” [2] Thus we have often confused an ideal – best feasible care – with an institution.
A fundamental example concerns the notion of public service. And the proper protection of “the public domain”, in the interest of the well-being of all. Is it really true that public service can only be given by public sector organisations? And must we only choose between state monopoly and open markets? What do we mean by “public service”? We need to consider how private and voluntary means also regularly deliver public purposes. Public enterprise has shown it can serve the public interest. The Concordat is re-defining public service by realising that good service to the public – in harmony with ‘public-service’ values – is given by many organisations in the voluntary and in the independent sector. This has long been so. Long-term care. Acute care. Mental health care. The entire Hospice movement. Services delivered to high standards. We are now beginning to see more diversified provision and more from the private sector, whilst retaining the public service ethos by which the NHS has defined itself. And the clock has not struck thirteen.
To try to get the job of NHS reform and modernisation done within the old nationalised structure New Labour has very significantly increased spending. And it has shifted ground remarkably, too. The two-part Concordat, although still a very small part of all that the NHS does, is crucial psychologically and politically. [3] It is the first open-minded major bulletin of change for the strategic development of public-private relationships. The Concordat is one sign of the search to find politically-negotiable bridges to a changed system. So, too, in my view, is Mr. Alan Milburn’s Fabian Society lecture, his comments concerning choice of GP and hospital treatment, more provider freedoms and incentives to improve performance, stressed when he appeared before the House of Commons Health Select Committee as it reviewed Department of Health expenditure. There was a significant shift in thinking since The NHS Plan was published. But there is a good long way still to go.
Fast-track surgery units and specialist centres such as orthopaedics; overseas buying; the NHS renting private care from the independent sector; foreign companies setting up units here – all these increase provision and flexibility. The search for real change is on. However, the problem of how to get more sustainable revenues remains, as does how to empower the individual. And these are the unavoidable issues. The great guns, if you like. How they come about and how they change power relations – and the controls exercised by politicians – is crucial, too. For cultural change is essential. And this can only be prompted in large part by empowering service users financially, jointly and individually, in mutual-aid organisations. And empowering those who give service to do so. Indeed, it is not only insufficient to increase revenues without such a change. For the changes in quality, provision, responsibility, and funding which we seek are, I believe, otherwise unavailable unless there is significant cultural change.
The NHS is wholly politicised. But it is not this government alone which has politicised health care. Nor is it this government alone which has micro-managed the system. Nor are Tory claims that they will reverse this at all credible, at least without very significant cultural changes. For the NHS is inherently political, endemically centralising, and necessarily limiting to patient information, patient choice, and user responsibility. Its financial structure, too, necessarily limits the funds available. Of course, any health care system is political in some senses. But not all are centralised, bureaucratic, or limiting culturally in quite the way that ours is. Ours has entrenched centralisation and bureaucracy, because it was built on political assumptions which rejected dynamic user-led evolution. We live in a system where government decides what it is appropriate for the ind...