What is the future of the NHS in the 21st century?

In his 1942 Report, Sir William Beveridge, a Liberal patrician, identified five ‘giant evils’ — Want, Ignorance, Squalor, Disease and Idleness. The Welfare State was founded in the immediate post-war period to improve the social conditions in the UK. The country was then bankrupt from war exertions; despite warnings, mainly from Conservatives, that the Welfare State was unaffordable, the Labour government, trusting in Maynard Keynes’ assertion that ‘we can afford whatever we want’ went ahead.

The National Health Service was born on 5 July 1948; strictly, the term National Health Service applied only to England and Wales; there were very similar services in Scotland and N Ireland, though these weren’t called ‘the NHS’. Responsibility for Wales passed to the Welsh Office in 1969. With devolution, there has been divergence in the administrative structures of the four health services; in N Ireland, Social Services are integrated into the health service while elsewhere they are the responsibility of the local authority.

The health service in England is by far the largest. The Ministry of Health in Westminster and the Secretary of State for Health, at present Jeremy Hunt, are only responsible for England. Changes in organisational structures, often called ‘reforms’ are usually first introduced in England; the regions may choose to adopt them later, or come under political pressure to do so.

When first introduced, it was naively thought that once disease had been controlled, funding requirements for the NHS would reduce. In reality, such was the extent of ill-health that the service came under financial pressures almost from the start. While all service provision was initially ‘free at the point of service’, charges were introduced for prescriptions; later charges were more generally applied in dentistry, eye examinations and spectacles etc. Enoch Powell, when Minister of Health, thought that there would never be enough money for the NHS.

The Conservative manifesto before the 2010 election indicated that there would be no ‘top-down’ reorganisation of the NHS; as soon as they were in coalition with Liberal Democrats, they began such a reorganisation. This struggled through Parliament and emerged as a different creature at the end. The result is remarkably complex, as this video from the King’s Fund illustrates:

All organisations have problems; for the health services these have been about funding, staffing and the provision of services — what services, where and how. The population is changing; there are more older people, fewer younger people. Health costs are, for the individual, greatest at the extremes of life. In the not so distant past, management of many conditions was ‘expectant’. If you had a heart attack, you were put to bed to ‘rest’ and were dosed up with morphine, and that was about it. Today, you can expect a cardiac angiogram and a stent, and with luck, rehabilitation. And you need your angiogram and your stent right now. Medicine has changed from being ‘passive’ to being ‘active’; and such changes need even more staffing and equipment and thus more funding. You can read about the daily life of a junior doctor here, with expanded background information here. The health services are a ‘near-monopoly’ in terms of training, jobs and service provision.

In the past, the pyramid structure of the health services meant that more ‘worker’ medics were needed than ever could become ‘bosses’; this discrepancy was often covered up by immigrants from the sub-continent. More recently, the pyramid has ‘flattened’; and the EU is now a significant source of manpower. In nursing, what was once a ‘calling’, an occupation for life, is today reliant on migrants from both the EU and, for example, the Philippines.

To all of this, there is now the complication of Brexit and in what way the UK, or even just NI, can be expected to change thereafter. We don’t know if things will remain more or less the same, or whether the UK will become a low-tax, low-regulation, small-state ’Singapore on Thames’. Locally, we don’t know what will happen to the border and to cross-border cooperation in, for example, children’s heart operations. We might hope, but we have no clarity. We don’t know if the ‘free at the point of service’ model of the health services will continue, whether the state-funded and state-provided model will continue, or whether there will be ‘creeping Americanisation’ and privatisation. We can expect that there will be curbs on immigration, with the potential for recruitment of staff; we might expect that the UK will become less ‘migrant-friendly’.

Already, some consequences of Brexit are apparent. The EU’s medicines agency will move from London to Amsterdam; what was once a shared resource will, in future, have to be newly established and fully funded by the UK. The UK has also indicated a withdrawal from Euratom; although a separate legal entity from the EU, it is subject to the jurisdiction of the European Court of Justice, thereby apparently crossing a ‘red line’. This has major implications for the supply of isotopes used in medical diagnostics and cancer treatment. (The EU’s banking agency will move to Paris; in April 2017, David Davis said he saw no reason why either should leave London.)

A group of right-wing Conservatives published a pamphlet in 2005 about ‘direct democracy’. It included a chapter on Health. It’s not clear who wrote which chapters, though Jeremy Hunt was one of the group. The Health chapter relies on dubious evidence indicating that the NHS is neither effective nor efficient, makes unfounded assertions, and it quite clearly calls for an American-style privatised system. You can read a cogent critique here. There is an action against this pending.

The NHS wasn’t founded as a ‘socialist experiment’ rooted in ideology. The basic principle had been in operation in for decades in places such as Tredegar in south Wales. There, workmen paid a halfpenny per week to subsidise the local health services — the basic funding concept of the NHS. Nye Bevan worked in Tredegar, and was the local MP and Minister who steered the NHS Bill through Parliament. The physician AJ Cronin also worked there; his pre-war novel The Citadel describing conditions there is widely thought to have been a major influence in the formation of the NHS and the Welfare State. Harry Leslie Smith grew up in great poverty in the pre-war years; his memoirs are a poignant story of what conditions were like for many people then.

By contrast, neo-liberalism is a theoretical ideology. Initially, it railed against central ‘socialist’ — communist — planning; it was taken up and expanded as Reaganism and Thatcherism, with assistance from Ayn Rand. Such ideology now embraces the idea of a ’small state’, one where individuals are entirely responsible for their destiny, where ‘red tape’ and regulation should be reduced to a minimum, where the ‘rights’ of individuals should be minimised, and where private enterprise is (almost) always better than the state at the provision of services. There can be little doubt that hard right-wing Brexiters have embraced this private enterprise model. Private enterprise is neither altruistic nor it is charitable; it exists purely to make a profit. The theory has it that private enterprise is more ‘efficient’ than the state can be, and so provides services more cheaply, yet still turns a profit. I said that individuals were responsible for their destiny; this is a reworking of the Victorian moralistic idea of the ‘deserving’ and the ‘undeserving poor’. Those who through no fault of their own were impoverished could seek assistance; those who were considered to be indigent deserved neither pity nor mercy. There are distinct echoes of this today in the application of universal credit and other ‘benefits’, for they are ‘benefits’ and not ‘welfare’.

Many of the activities in the infographic above lend themselves to privatisation, and many have been. It’s estimated that about 8% of new NHS contracts go ‘privately’. As Brexit is a time, we’re told, to grasp opportunities, we can expect much more of this. A note of caution; Hinchingbrooke Hospital was run for a while by a private consortium. Unable to run it and make a profit, they walked away. Walking away is not an option for the state. And when a private contractor has fulfilled a quota of whatever they provide, then that service stops until the next financial year. As for funding, the NHS has been expected to make ‘efficiency savings’ when many Trusts were in deficit. Many see this as ‘death by a thousand cuts’, itself a precursor to red-blooded privatisation. Deliberate underfunding of the health service is a political choice, though it may be camouflaged as ‘austerity’; and austerity is the bed fellow of neo-liberalism.

Private Finance Initiatives (PFIs) were popular for a while; they were introduced to the UK by John Major, but greatly expanded under Labour.  A consortium would provide the capital for a project, and the state would then lease it back for a period, often about 30 years. This model was politically attractive, for it kept the costs off the government’s balance sheet. It’s now very clear just how expensive this is over the course of the agreement; The Irish News reported on this recently. Further, given that interest rates are so low, there is little economic argument for the government not borrowing. Indeed, the previous chancellor, George Osborne, provided an excellent example of how governments can borrow. He boasted that the government had paid off the South Sea Debt. The South Sea Bubble burst in 1720; it was a fraudulent scheme, involving the elite. To avoid a scandal the then prime minister, Robert Walpole — who had profited from the scheme — borrowed to pay off the debts. It took nearly 300 years to repay this. No individual could ever borrow over such a term — balancing the budget and avoiding debt which are ideas originating from personal financial management do not apply to governments.

The banking crisis in 2007-2008 again indicated problems with ‘rampant’ and at times criminal capitalism; when the banks went bust, it was governments — for which read taxpayers — who had to rescue them. Yet it seemed no time before the recidivists were saying that the time for remorse was over; taxpayers would disagree.

Locally, problems with the health service are well known; the closure of GP practices in Fermanagh and Portadown, the difficulty staffing the A&E at Daisy Hill, and the waiting times in hospitals, some of which extend now to several years. The Bengoa Report lies gathering dust; health service costs are much higher here than in Britain. There is no local Executive, no Minister responsible for decisions; there is stasis. The two major political parties have totally opposing views on Brexit, with the DUP in favour and Sinn Féin against, views graphically represented in the geographical distribution of Remain/Leave votes in the Referendum. There are problems enough without the complication of Brexit. But many fear that if Brexit is accomplished as true-Brexiters expect, then the health services will be sold off and privatised, and that provision may well become ‘means tested’ with many failing that test. Low taxation will not be a sufficient reward for something that we as individuals simply can’t afford. If you think that this is outrageous scaremongering, then look at the US; there the President is determined to roll back ‘Obamacare’, what he calls the Affordable Care Act. And in the US, medical and hospital fees are a leading cause of personal bankruptcy. In the UK, there is still a ‘free’ health service, even if it is imperfect, and treatment under it neither requires wealth, nor does it bankrupt. But for how long?

  • notimetoshine

    More money or an end to the NHS as we know it.

    If I have one issue with the healthcare model in the UK, it is that there is a disconnect amongst the population when it comes to what the ‘value’ of healthcare is. Of course we pay for it through taxation, but it isn’t an ordinary, everyday expense, the way a utilities bill or insurance bill is. That I feel has lead to people not realising the value of their healthcare, and the need for it to be funded accordingly.

    The NHS is very efficient in terms of the service it provides for its cost. Per capita spend on healthcare in the UK is comparatively low when compared to other developed nations yet it provides a fairly comprehensive service. (https://www.kingsfund.org.uk/blog/2016/01/how-does-nhs-spending-compare-health-spending-internationally). So it isn’t like the health care spend as it stands currently is unreasonable. In fact there is plenty of room for expansion. We just have to suck it up, realise the COST of the healthcare we demand and fund it accordingly.

    Healthcare needs more money. Not a Billion here and a billion there, but a fundamental increase in long term spending. Something along the lines of a penny or two on income tax is required. (This was interestingly something the Lib Dems touted quite strongly in the last election).

    With an aging population, living longer with complex (and expensive) conditions and the increased need for social care, it is high time we accept that if we want to maintain and improve our healthcare system we are going to have to fork out for it.

  • hgreen

    Since the fundamental principles of the NHS are one of the few things most people in the UK agree with, the NHS needs to be made independent from government with a cross party group of MPs providing oversight. As an independent body it can then plan for the long term rather than react to the brainfarts of the next govt/minister that comes along.

  • Sean Danaher

    Hi Korhomme

    thanks for a very nice article. I’ve seen the video before and think the structure is madness. I have one major disagreement (I’m nor a medic my self but my wife is a very senior one) it that the NHS has been reorganised so often over the decades I’m reminded of the Bob Cryan theory of management. (Bob was my former HoD but now VC at Huddersfield – his son was impressed when Patrick Stuart phoned to offer him the job). Bob’s theory was that you had to radically reorganise an organisation every 5 years before the bastards below you figured out what was going on!

    I’m quite worried, despite the Brexit battle-bus claim “We send the EU 350M per week, lets fund the NHS” the future is uncertain. I think it was John Major who said putting the “right wing of the Tory part in charge of the NHS is like putting foxes in charge of a chicken coup” I know that your reading list is very long but it is worth looking at Colin Leys & Stewart Player’s book for some background on creeping privatisation and Americanisation:
    http://www.merlinpress.co.uk/acatalog/THE_PLOT_AGAINST_THE_NHS.html

    For a Modern Monetary Theory view as to how to fund the NHS I would recommend Laws & Adams shortish article “Is world leading NHS healthcare an affordable proposition?” http://www.progressivepulse.org/economics/is-world-leading-nhs-healthcare-an-affordable-proposition I’ve posted this before (Seaan O’Neill commented that it was excellent)

  • Barneyt

    There are a few ministries I’d like to see freed from party politics. When you have one group who believe all ventures should return a profit and another that sees it as a state provided service paid for through taxation, then we are stuck in the current mess. We would require social doctoring on a grand scale to move in a different direction

  • lizmcneill

    If you’re going to move away from the NHS model, I don’t know why anyone would choose the American one. Their efficiency is poor: http://www.insulinalgorithms.com/us-ranks-50th/

  • notimetoshine

    A great idea and one that has been mooted before by the BMA (I think).

    Of course the politicians would never go for it, being able to claim success on healthcare is the holy grail of British politics (not that they have found it yet).

    That is exactly what the NHS needs, policy continuity, and long term planning that extends well beyond the lifespan of most governments.

  • notimetoshine

    It kills me to hear about the uncertainties in the future of the NHS. The public needs to learn the value (and cost) of healthcare. Nothing wrong with the NHS (and critically social care) that wouldn’t be solved with a penny or two on income tax.

  • Korhomme

    Thanks!

    You’re right about the constant reorganisations of the NHS; it almost seems that every new administration has to show its macho-mettle and change things.

    What happens to the NHS depends on which party wins elections; it is a failure of the first past the post system that so much has to change with changes in government. Also, as it’s Budget Day, this yearly charade only confirms that governments in the UK look to the next election, never further.

    I remember the article you posted, and it’s where I read the quote from Keynes, though I slightly mis-remembered it. I’ve ordered Leys and Player’s book.

  • Korhomme

    This is one of the links above:

    https://twitter.com/NHSMillion/status/933089105533161472/photo/1

    It clearly shows what’s been happening over the past few years; and that of course was a political choice.

  • notimetoshine

    There is a lack of creativity in politics in the UK (and much of the world) that is depressing. So blinkered by ideological and partisan beliefs, pragmatic and technocratic solutions never get the hearing they deserve.

  • notimetoshine

    Sheer, wanton, incompetence. While I am not sure I subscribe to the Labour trope of the Conservatives getting rid of the NHS by stealth, I have to wonder what the Tories think the end result will be?

    Will we end up with a two tier health system, with poorly funded public provision for those with long term medical conditions, the poor and the elderly and variable quality healthcare plans for those who can afford it?

  • Claire Mitchell

    Thanks for this. Lots to think about. I haven’t really got my head around Sláintecare ( http://bit.ly/2yfbTLF ) but it’s fascinating that Ireland seems to be moving towards an inclusive national health & social care system, while the UK may be moving away from it somewhat (under the Tories, of course under Corbyn, this would be different). My dad is actually in Dublin today meeting loads of regional health managers – he’s worked with the NHS a lot and they’re exploring what works and what doesn’t, to help move towards an effective Irish model.

  • john millar

    “If you’re going to move away from the NHS model, I don’t know why anyone would choose the American one. Their efficiency is poor: http://www.insulinalgorithm…”

    Not in my experience The treatment in the USA is super -once you get past the $64000 question “how do you propose to pay”

    My experiences of the NHS have all been positive.

    However

    The UK is the only place where you can turn up and be treated -free and without question -It is abused- eg The EC countries are scrupulous in chasing up payment for UK citizens treated abroad The UK is dreadful at reciprocation.

    (It is funded from taxation and can be a target for” health tourism” and having spent some time in “casualty” on a weekend where there were almost as many police as nurses some sanctions are necessary to curtail abuse)

  • lizmcneill

    And if you can’t pay? If large proportions of the population can’t afford preventative care or early treatment and first come into the healthcare system via the emergency room when they can’t ignore their condition any longer? Hence the inefficiency at a national level.

    In the UK if you have money, you can go and get BUPA or whatever and I’m sure that’s very positive too.

    Why doesn’t the UK chase up payments?

    If the drunk patients aren’t deterred by the thought of a criminal prosecution for assault, I doubt a fee is going to do it either.

  • john millar

    “And if you can’t pay? If large proportions of the population can’t afford preventative care or early treatment and first come into the healthcare system via the emergency room when they can’t ignore their condition any longer? Hence the inefficiency at a national level.”

    Nobody in NI is asked to pay –access to the NHS in NI in my experience is available to all.Prescriptions are free.

    “In the UK if you have money, you can go and get BUPA or whatever and I’m sure that’s very positive too.”

    Sadly the world is ill divide .If you have money you can buy a better car than I can.

    “Why doesn’t the UK chase up payments?
    If the drunk patients aren’t deterred by the thought of a criminal prosecution for assault, I doubt a fee is going to do it either.”

    Answer Poor administration and failure to make people accountable for their actions. Lack of political will.

  • john millar

    “It kills me to hear about the uncertainties in the future of the NHS. The public needs to learn the value (and cost) of healthcare. Nothing wrong with the NHS (and critically social care) that wouldn’t be solved with a penny or two on income tax.”

    It would also be helped if the NHS could refine its priorities and decide what it is in business to do:

    Heal /treat the sick and infirm or provide career paths for a slew of managerialism

    Try a cost/number analysis how many interact directly with the user /parient what are the relative costs direct interaction and support of interaction?

  • Korhomme

    In the US, a significant percentage of the population cannot afford healthcare insurance. If you are rich, you do get a good service; for most people it requires good employer-provided insurance.

    But, (right-wing) politicians in the UK might chose the US system, not because of the healthcare it provides, but because of the profits they can potentially make from it. Fees for everything.

  • Korhomme

    Emergency treatment is free to all in the UK, that is, it is free in A&E. There’s some uncertainty whether it’s free if you need to be admitted.

    Elective treatment under the NHS requires a period of residence in the UK —IIRC this is 6 months. But most of the UK is bad at at checking this. One English hospital was reported as asking women to show their passports if they wanted to avail of maternity care.

    There is no system of registration in the UK, where you must inform the authorities where you live, and inform them of any moves elsewhere.

    The NHS really has no systems for charging patients in the way that EU countries have.

  • lizmcneill

    The efficiency point is relating to the USA system.

  • Korhomme

    What you suggest is certainly a possibility, one level of care for those who can afford it, and another for those who cant.

  • Korhomme

    It’s been estimated that the billing systems for health care in the US, and the administrative costs of insurance are together about 20% of the total health care costs.

    The US insurance system can have exclusions. This is one of the contentious areas in Obamacare and whatever Trump wants to replace it with. For instance, there may be no cover for contraception; and if your employer is sufficiently ‘Christian’ they can insure you as an employee with such an insurer.

    Exclusions, things that aren’t covered, are always a potential problem with any insurance, whether for health, or for your house or car. In some places, I understand, if companies want to underwrite health care insurance, they must take on all comers, and they may not discriminate against those with pre-existing problems. (Your travel health insurance is likely to have exclusions.)

  • sam mccomb
  • notimetoshine

    It is what I think would be the likely outcome. I can’t see a fully privatised system, but a two tier system (with all the inequalities and damage to society that goes with it) seems like the back door way to privatisation. Along with massive asset stripping of the NHS.

  • Sean Danaher

    Hi Claire. Thanks looked at the link. One problem in England at least is that the NHS is centrally funded and social care is done at a council level, so it is very difficult to integrate. It looks as if Sláintecare is taking a very strategic top down approach. Would be interesting to know what your dad thinks.

  • Zig70

    Judging by the mbc, the future is female. Something is wrong there.

  • Korhomme

    There’s said to be a further problem with health care an social care in GB. Health care is ‘free at the point of service’, but social care is means tested. The thought is that the differing cultures and ethos of the two services don’t mesh well together. I don’t know just how accurate this is; it is interesting that NI is the only region where the two services are integrated.

  • murdockp

    The northern Ireland politicians care more for the local jobs the healthcare facilities support than the healthcare provision itself. For example in.my home town newry they take to the streets protesting about hospital department closures as if they know about medicine and as if they are experts but with no competence in this complex area.

    Having had two sick family members I now understand why departments in small hospitals are being run down and transferred to the majors hospitals it makes sense to meet seeing first hand the difference in care.

    Justin mcnulty recently looked ridiculous oit protesting and only took the streets to out SF SF which in newry cannot be done.

    If the politicians backed off and let the medical professionals deliver what northern Ireland needs we might stand a chance of having a service that works.

    Unfortunately politicians see a hospital protest as a vote gathering PR exercise.

  • murdockp

    Should the NHS consultants be forced to give up their private practices? You can’t have it both ways.

  • murdockp

    Ironically PFI allowed the too but the early deals allowed the PFI consortia to make too much money.

    Many PFIs will now be coming to the end so it is a good time for the government to strike new deals.

  • Claire Mitchell

    He’s not been in radio contact yet! But i think there were about 5 different departments there – including finance. Obv trying to do things in a joined up way. Will watch this space.

  • William Kinmont

    Would we have the economy of scale in NI to even support a private system. IS there enough of population here who could afford the insurance to justify the privates expanding provision here our would it all be located in Gb

  • Korhomme

    That depends on what you mean by a ‘private system’. At present, in NI private providers do things that aren’t (usually) available on the NHS, such as cosmetic and aesthetic surgery; or they do things for which there are long waiting lists. So, yes, there does seem to be enough demand to support this.

    If you mean a parallel system, where the ‘consumer’ or ‘client’ — what were once called patients — can chose to have ordinary things done in a private hospital or an NHS one; or where they could chose either for their emergency problems; or where a private hospital could offer the full range of services available on the NHS — to include cardiac surgery, neurosurgery etc — well, that is much more debatable. There are some hospitals in London that offer such services, but they have a much bigger and richer catchment area.

    The insurance that is available in the UK differs from that available elsewhere. Here, if you buy insurance, it will pay the full cost of treatment (if that treatment is on its approved list). Elsewhere, ‘private insurance’ is a top-up, so you can get a more ‘comfortable’ level of service — but much of the total cost is still picked up by the basic scheme (in the UK, the NHS). That is, in the UK private insurance means that you pay the whole cost twice — once through tax and national insurance, and a second time as insurance premiums. Were this to change, it might ‘drive’ a greater expansion of private care; I have never seen this suggested.

  • Korhomme

    I ‘d suggest that this could be taken further. Rather than the first past the post, winner takes all system, continuing coalitions mean that there must be general agreement on so many issues. Coalitions are always derided as being ‘weak’; well, I’d rather have ‘weak agreement in the longer term’ than strong meddling for electoral advantage in the short term.

  • Korhomme

    If so, then all employees who do a bit of part-time work, whether paid or not, should be obliged to give this up.

    So, no teachers doing a bit of private tutoring on the side, no volunteers for charity work…

    Why should consultants be different?

  • William Kinmont

    If private was to expand would staff still double job NHS and private or would they become full time private ? Who would fill the NHS gap

  • Korhomme

    The NHS is a near-monopoly employer; it has, AFAIK, a monopoly on training. As I understand you cannot become fully trained in your specialty by working in private hospitals. Normally, becoming a consultant is the entrée into private practice.

    In other places, training may involve both ‘public’ and private providers.

    Full time private consultants are a rarity, though not unknown in the UK. They may specialise in things that the NHS doesn’t do. There can be positions for junior staff in private hospitals, but such jobs have been described to me as ‘sinecures’ and are designed more for legal cover, and to allow the junior to prepare for examinations.

    To expand private provision requires, to my mind, a rethink of insurance coverage. It would then be possible, for ‘ordinary’ treatment to be available in a fully private hospital, where all the staff work entirely outside the NHS. We are a long way from this in NI, and I’m doubtful if there is any such provision in the UK.

    One problem for private providers is the expense of fancy scans and intensive care; these are not always ‘cost effective’ and may only be available in public hospitals.

    It’s not a very accurate comparison to veterinary work but: the equivalent would be ‘private’ vets doing only small animal work, and ‘public’ vets doing the TB stuff and working in abattoirs. At present, you do ‘double jobbing’ in a way, though you might not think of it as such.

  • William Kinmont

    In Sweden they have government practises providing mixed cover in the more remote areas.
    For medicine your postgrad training is necessarily very formalised and in comparison a slow process. Traditionally our graduates were thrown in at the deep end and had to quickly cope on the job. Now things are slowing down the big corporates have structured programs for new grads but this is as much about restricting them to consulting and stringing out their surgical experience as consulting is where the buisiness needs them.
    Either way as new grads only stay in practise on average 7 years and we have a big shortage prolonged formal training is not a luxury we should be indulging in just now.
    Separately our staff shortage is beginning to bite and we are starting to have waiting lists for routine proceedures, only few weeks at present, but is becoming a thing locally now phoning round

  • William Kinmont

    This fits on end prev reply
    Phoning round for time rather than price.
    Farm client the other day complained that he Was on a list waiting 2 plus years for a new knee. Initially I thought 2 years a huge time as he woudnt wait 2 hours for my visit. Explained that his father would have had to wait all his life for no new knee as there was no such thing and his father before that would have gone private as there was no NHS .
    Perhaps the problem with waiting lists is the perception they are a bad thing. Could it be sold that it is a privilege to be on a list ?

  • William Kinmont

    Private providers have the back up of the NHS providing their 24/7 safety net if something goes wrong. They also have the GP network harvesting their clients for them. If the NHS could bill them for this ?

  • Am Ghobsmacht

    Excellent post Kornhomme.

    Could I ask you a dumb question, a rumour control of sorts?

    Does the NHS receive fair pricing for its medical supplies?

    I have nothing to base this thought on other than idle pub chat but the figures bounded around are astronomical, such as dozens of pounds for saline solution and a similar price for bandages.

    I don’t believe them, but, then stranger things have happened, can you settle this for me so I can refute such claims?

    Okaythanksbye

  • notimetoshine

    I can’t think of anything more damaging than PFIs. Possibly the worst innovation in funding public services in some time. Though having said that I am not sure if it is the concept of PFIs themselves that is the problem or the poor decision making in creating the PFI contracts (see Sheffield City council and its trees).

  • SeaanUiNeill

    Another problem of the US system is how even the cover that employer provided insurance works is problematic. It can be invalidated with chronic illness and I have contact with people bankrupted by the requirements of laying for the fourth year of an extended treatment.

  • SeaanUiNeill

    John I’ve encountered even well of professional people in the states with chronic conditions financially ruined by the bills when the insurance opted out. Employer schemes particularly can have many loopholes such as six month limits on treatment. I have been in the US system at times and it is brilliant, yes, if as you yourself point out, you can pay, but if you can’t…….

  • Korhomme

    The short answer is that I don’t know for certain.

    Take the saline solution; tap water isn’t sterile, but the water in the bag of saline must be; and likewise it has to be free from antigens and allergens. I imagine that getting water to this state of purity is quite difficult.

    There have been probes into the cost of NHS supplies, usually in England. Pills come under suspicion at times, and occasionally the prices are reduced.

    Needles etc are all disposable; in the past, needles were cleaned, sterilised and reused. They could become quite blunt. Today, this would be unacceptable; the risk of leaving minute traces of germs inside the needle is too great. There was even a suggestion that instruments for brain operations should be disposable because of the risk from prions and thus ‘mad cow disease’ if they were reused.

    There was (?still is) a factory in Ballymoney supplying needles, and one in the south (?was it it Sligo) supplying ‘butterflies’. These are sterilised using gamma radiation, not a method that hospital depts use. But as the UK is going to withdraw from Euratom which controls etc the supply of radio-isotopes, there could be future problems.

  • notimetoshine

    It is this cult of managerialism that has infected so much of our public sector. Newton Emerson wrote a great piece warning of its dangers in the Irish News I think it was a while back.

    The problem is, these consultants and managerial ‘experts’ think that a one size fits all approach to managing a complex organisation is applicable to healthcare. Obsessed with meeting ISO targets.

    I think we need to get back to Clinician centered management, putting the medical staff back in the driving seat. I remember watching that BBC programme hospital, and one thing that stuck in my mind was the plethora of ‘Business Managers’ who as far as I could tell were not professionally qualified medical staff making very serious decisions on the future of patient treatment.

    See also the second series of the excellent Jo Brand comedy ‘getting on’. A former nurse has morphed into a management consultant and he has this great line ‘I’m not here for the patients, I am here to save the trust money’. Sums up the less than patient focused attitudes of many NHS trusts nicely.

  • Korhomme

    I did say that it was only a rough comparison!

    I guess the new graduates leave after 7 years to start a family; you said previously that most were female.

  • Korhomme

    In the dim past, your farmer would have had an amputation without anasthetic for such knee arthritis!

    Curiously, farming is apparently a high-risk profession for hip/knee arthritis; I’m not sure why. And joint replacements are so successful that the demand far exceeds the capacity to supply. People I know who have had knee replacements haven’t waited so long, but theirs were a few years ago.

  • Korhomme

    Medical treatment in the US is a leading cause of personal bankruptcy there.

  • notimetoshine

    That is what scares me about medical insurance schemes. I have a moderately serious pre existing condition (nothing dangerous but requires careful monitoring and treatment) and I have to wonder that in any insurance system could I afford it? I have reasonable career prospects in a profession, but I have read stories of medical insurance for people with pre existing conditions being ruinously expensive (if available at all) even if they are quite comfortable financially.

  • William Kinmont

    My guess too. Possibly also economics too wages good enough for singles but not to pay childcare and work.
    Would be good if powers that be would do some work and take away the need to guess

  • sam mccomb
  • notimetoshine

    From anecdotal evidence I have to assume that social care is a major bottleneck. I have friends and family members who are members of the medical profession and a constant refrain from them is the problems that social care is causing the NHS and the impact it is having on patient outcomes.

    I myself have been my grandmothers primary carer for several years, and I can attest to the nightmare that is the social care system. She was admitted not too long ago with a UTI and chest infection and needed a couple of days in hospital. She was medically fit to go after 5 days, but as it was the weekend we didn’t quibble over her staying another day or two. She remained in hospital for a further THREE WEEKS while a relatively small care package was put in place (the family was doing the majority of the care). Her doctors were at their wits end trying to get her out of hospital, the environment was causing a rapid decline in her dementia and it was taking an increasing effort on the wards behalf just to keep her safe. Her doctor herself made it clear that everyday she spent in hospital was causing a decline in her mental state. It was a nightmare. It took a week to see a social worker (there only being one covering the ENTIRE hospital) briefly and then another two weeks to get a basic care package in place.

    It took her several months to recover to her baseline (which was lowered as a result of the stay) and has resulted in her needing MORE care than if she had been discharged fairly quickly.

    I have since found out that the social work team that looks after people like her is massively understaffed and it means that if a family contacts them with an issue it can be four to six weeks before someone is available.

    This inability to access to social care and to quickly make changes to her care package has adversely affected her health both in terms of her cognitive decline and crucially on her physical health. Maybe in cases like these social workers need to be considered medical personnel, certainly the delay in getting anything done when we require changes to her personal care have resulted in distressing but preventable physical complaints which have required medical treatment. Sheer waste!

  • Korhomme

    In all spheres there are tensions between managers and professionals; the managers don’t understand the work that the professionals do, and vice-versa.

    My particular bugbear were ‘waiting list managers’. A bright young thing would come and lecture/chide us about how to solve the problem. The BYTs were unaware of why there waiting lists. Previously, most patients would be given a date for operation, often in the next week. A few people, for example those who were the sole carers of disabled kids, would need some time to arrange respite, but they could be accommodated.

    Mrs Thatcher introduced ‘efficiency savings’. The hospital or Board would get a letter telling them that they had been ‘awarded an efficiency saving of 5%’. Translated from NHS-speak, this meant 5% less money. This meant that, for example, there was no money to pay nurses overtime if operating shifts overran, which they often did. And that meant that not everybody could be treated, and that led to waiting lists.

    So the waiting list BYTs were telling consultants to fix a problem which was one of political ideology and often not of their making.

  • Korhomme

    I’m saddened to hear your story; alas, it seems all to typical and common now. And the doctor was quite correct; taking someone from their home environment and keeping them away from it causes mental deterioration; this is only too well known.

    I’m not sure whether it’s purely funding cuts or lack of staff which are responsible for situations that you found yourself in. I have heard it said that as hospitals are ‘places of safety’ there is no need for social services to rush to get someone discharged. I don’t know if this is accurate or fair.

  • notimetoshine

    Well I have to assume it was typical, three of the women on my gran’s ward were in a similar position.

    Having now spent several years dealing with social care I think that you are right that funding and staffing levels are a problem. For a start we know that there is a major shortage of social workers (and who would do that job for the money on offer?

    But it is the actual domiciliary care that seems to be the problem. The home carers are ridiculously low paid. Once you factor in the cost on their cars of driving about the country it wouldn’t be a stretch to say they are paid under the minimum wage. There was a great panorama documentary about staffing issues in the sector and as one manager said, you can get the same or better money stacking shelves in a supermarket (with more job security), so why would you take a job caring that involves dealing with intimate personal care, often combative clients and poor working conditions? Unless we realise the value of this work, and pay accordingly there will be staff shortages. I can attest that my grandmother has had in the past six months at least 30 different carers in and out, none stay very long. That is damaging to someone with dementia but indicative.

    Interestingly the best care providers and the one everyone wants locally is the Trust’s own Domiciliary care team. Their staff are better trained, better paid and have more job security and boy does it show in their work. Their staff stay with them, build up a relationship with their clients and certainly provide a better service. But they are very hard to get. Maybe privatising care provision is not a good thing, but what can you do with such low budgets?

  • SeaanUiNeill

    As I say, personal contact with those who have experience of that.

  • Korhomme

    I’m a bit away from the front line, so I can’t be too dogmatic. But I have seen reports of domiciliary care where there are supposed to be 30 minutes given. But there are two episodes reckoned per hour, and no allowance given for travel. The result usually seems that care reduced to 15 minutes; barely enough to say, ‘hallo’.

  • Korhomme

    Such inequalities are a major cause of premature morbidity and mortality. Likewise, wealth inequality.

  • Korhomme

    The NHS collects a quite remarkable level of data on a monthly basis. It’s not quite at the level of counting paperclip usage, but it’s not far off. I’m unsure what is made of all this centrally; more importantly, I’m very uncertain that what they are collecting is appropriate.

  • Korhomme

    What’s happening in Sheffield is a disgrace; there is no real reason for it.

    I did a piece here a few years ago about the Glasgow trams:

    https://sluggerotoole.com/2015/01/25/from-king-billy-to-the-glasgow-trams-a-brief-history-of-government-debt/

    The trams were a sort of precursor of PFI. The problems with PFIs is their inflexibility, or the extreme cost of getting something done outside the contract. The contracts can be several thousand pages long; who can have oversight of that?

  • Korhomme

    You describe the usual problem with insurance — exclusions, things that aren’t covered, and pre-existing conditions. This is similar to, for instance, car insurance.

    The problems can be overcome, but it requires government involvement. If part of the health system is insurance based, while part is ‘state funded’, then companies that wish to enter the health insurance market are required to treat all customers equally; no exclusions for pre-existing conditions, and no marked increases in premiums. Likewise, they should cover for almost all eventualities. (I heard of one problem years ago; a woman had a gastric band or bypass for obesity, the insurance paid, no problem. The woman lost a lot of weight; but then her skin was ‘too big’; this is a not uncommon thing to happen after major weight loss. The woman wanted the excess ‘trimmed’; her surgeon was happy to do this, but the insurance company refused to pay.)

  • William Kinmont

    The big corporate practises have back offices and computer systems that “know” the spending power of rovers owner from address, demographic etc and monitors employees financial intake accordingly for complex appraisal. I have heard rumours that the systems even alter treatment protocols accordingly.
    Long term if i was an employee i would worry about poor financial performance against my name would limit employement opertunities once the corporates become the only employers around.
    Mrs Jones with Moggy on the table doesnt realise that some where in an office block in Sweden or somewhere an algorithm is working out how much is in her purse.

  • notimetoshine

    Oh the time constraints and the pressure it puts those staff under is very much the norm. The difficulty we had in getting more than 15 minutes for her lunch was appalling. Also I know that when the carers visit my grandmother, their next call is 15 miles away (travel not paid of course), so they are under huge pressure to cut their interactions with clients to the bone.

    It is no wonder the staff rarely stay long. I wouldn’t work under such conditions.

  • Jim Jamison

    With respect Korhomme, that’s not accurate. Even back in the 1980s the waiting list problem was caused not by deferring the admission of a small number of patients with particular requirements such as you describe, but largely by inefficiency in the use of expensive resources. See my earlier post https://sluggerotoole.com/2017/08/26/until-we-deal-with-the-real-reasons-for-our-long-hospital-waiting-lists-we-are-just-throwing-good-money-after-bad/

  • Korhomme

    It may not be accurate, but it is how I remember things.