We are not tinkers who merely patch and mend what is broken….we must be watchmen, guardians of the life and health of our generation, so that stronger and more able generations may come after.
Dr Elizabeth Blackwell (1821-1910) the first british woman doctor
Three cold fronts blowing into the NHS threaten a perfect storm: codependency on Big Pharma, the harsh bites of austerity cuts, and the dependency of an aging population. As a consequence of these three, and in particular the need to reduce the health budget’s ever bigger bottom line, privatisation and industrialisation are in danger of stifling a healthcare culture once led by values rather than price. NHS staff at all levels from CEO to Care Assistant are urged to do yet more (and better) with ever less. When this doesn’t work, staff high and low in the system get the blame, the more so when various kinds of stress-related fallout follow: poor practice, patient complaints, absenteeism and early retirement.
Can the NHS survive? For some it looks like a foundering ship with staff crossing hoping their resilience will hold out long enough to keep hands on the pumps until the storm abates. Will it though? No doubt there are some efficiency savings to be made, and future governments guided by a ‘business as usual’ model will use competitive market pressure – privatisation by any other name – to keep costs under control. But unfortunately for those destined to use the NHS (should it survive the next fifty years) privatising England’s social care using competition to keep costs under control at a time of rising need has so far produced poorer quality of care1.
Many believe the only solutions will be to reverse the Health Bill at the next election and inject more money in. But will that solve the NHS’ long-term problems if, as has been predicted health care funding could consume 23.5% of GDP by 20652? Back in 2002 Derek Wanless saw the sustainabilitycrunch coming when he predicted the NHS would – if we were short-sighted enough to carry on with business as usual – become unsustainable if the NHS budget were allowed to hit 12% of GDP; he thought by 2020. He proposed that a ‘fully engaged scenario’ could steer the NHS tanker off those economic rocks. Now however, with a flat-lining NHS budget the ship may stay off these rocks, but only because it sinks before it reaches them. Some will wonder whether the officers on the bridge are asleep, or on a deliberate scuppering mission?
A decade ago Wanless criticised the lack of political will and Government investment put into moving health and social care in the ‘fully engaged’ direction. Perhaps Gordon Brown – though he had commissioned the Wanless Treasury report and though he may have got its message – ran scared. Who wouldn’t? For ‘fully engaged’ depends on a society widely committed to citizenship and a democratisation of the NHS; communitarian aspirations which might have worked ten years ago against backdrop of improving education, economic growth, narrowing inequalities and social justice (Halcyon days of yore!), but few would bet on them getting traction nowadays. Sir Derek didn’t have to reckon with The Crash, austerity measures and a neoliberal regime keen to shrink the state and let the income-gap widen.
In reality the 2065 prediction is context-free. Business as usual wont work, for if present economic ecological, social and spiritual trends continue, then by 2065 our children will be heading for their 100-plus year old pensionership, dosed with obligatory multi-pills that will keep them alive on a war-torn, over-heated planet vastly overpopulated by obese media-junkies fed on processed GM algae. In such a world in might be that a high-tech, industrialised, pharma-fuelled NHS would be precisely fit for purpose, but unless that is the path we want to travel we need a re-think. Short-term productivity uplifts and efficiency targets won’t revive the NHS, but neither in the long view will a return to bigger budgets – even if as has been suggested the money came from ring-fenced increases in National Insurance.
Even if a future Government were to reverse the Health Bill, the NHS would still be broke and broken. Even if the 8% pre-austerity annual budget increases we used to expect were restored it would only serve to slow the tanker down. The NHS sustainability crisis will remain unresolved until we stop thinking about health and healthcare in the way that created the greathearted, but over-ambitious and dysfunctional system we have now.
We ought to aim higher. Is it too much to hope that in our lifetime the NHS could become part of a well-run holistic health and social care system where Big Pharma no longer writes the rule book, in a culture where its workers feel valued and social progress and inter-dependency are basic givens? Sad, is it not that this sounds like a pipe dream? But the alternative is a nightmare healthcare system struggling hopelessly to patch up the walking wounded of a society in terminal decline. Because it isn’t just the NHS that is in crisis – it’s the culture and the Earth itself. Can we, in addressing the NHS/staff sustainability crisis take the big picture into account? Change the world? Someone’s got to.
1 Centre for Health and the Public Interest. Oct 2013. The future of the NHS? Lessons from the market in social care in England.
2 ‘Health spending in context’ Presentation by Paul Johnson,Institute of Fiscal Studies, to the Reform Conference ‘Rising to the Nicholson Challenge’ 13 June 2013.