We need to talk about Kevin
As often seems to be the case in January, the NHS was back on top of the news agenda this week. At times for good reasons as when Theresa May made a speech promising to end the burning injustices surrounding mental illness, at times for less good reasons as Accident and Emergency Departments struggle to deal with winter pressures. It is one of those moments when more fundamental questions are again raised about the future of the NHS.
We know the NHS is much loved and cherished by the public, the nearest thing the English have to a religion as Nigel Lawson’s oft quoted quip would have it, but it is also something we find, as a nation, difficult to talk about in all but the most banal platitudes. If put to the test, an overwhelming majority of the public would vote to keep the NHS but what sort of health service do we want and at what price?
The next couple of years are a critical time for the NHS as it faces the simultaneous challenges of growing demand, the consequences of austerity and the uncertainties flowing form Brexit. For one I believe it’s time we took a more fundamental look at some of the key questions which face the service and its development to ensure that there is a genuine consensus across the political spectrum which can ensure we have a sustainable NHS which is fit for purpose in the 21st century.
There are a number of key questions which should be part of such a long term review.
The first, and most pressing, is to look again at the 1948 settlement so as to bring health and social care together as part of an integrated system of funding and delivery. Social care is fundamental to the care of some of the most vulnerable people in society, whether frail elderly people or looked after young people. When it is not there, inevitably demand on the NHS increases, often at greater cost. The issue is, at last, on the policy agenda and there is a wealth of work to draw on how this might be achieved, including the report of the Kings Fund’s excellent Barker Commission.
Secondly it is time to institutionalise the commitment to give parity of esteem to mental health. I, like others, was happy to welcome the Prime Minister’s speech on Monday on mental health but the laudable objectives she set out cannot be achieved if the underlying inequity in funding is not addressed. As the LSE highlighted in their 2012 report “How Mental illness loses out in the NHS” the treatment of mental health problems accounts for 23% of demand on the NHS but receive only 11% of the funding. I would accept that such a shortfall cannot be tackled overnight but a longer term settlement for the NHS might commit, for instance, to eliminating this differential over a ten year period with a fixed additional uplift for mental health in each year of that period.
The third issue relates to the shape and balance of services. The 5 Year Forward View, still a valid road map for the future of health and care services whatever operational difficulties the NHS is currently facing, is predicated on a vision of community care with hospitals playing a less significant role than at present. This is, of course, a journey which mental health has already been down and is, for me, the direction of travel which we must follow to deliver a sustainable NHS. Whatever we think are the causes of the current pressures on A&E and other parts of the acute sector the one incontrovertible fact is that a year on year growth of 3% for hospital services is unaffordable. While an adequately resourced and well explained model of care closer to home can be popular with the public, that support can be lost easily if community care is seen as care on the cheap and essential services are not available when they are needed. This change needs long term and unambiguous political commitment and adequate transitional funding if it is to happen properly. However, without it, our chances of sustaining the NHS for next 20 years are slight.
My fourth question relates to how we define the mission of the NHS. It might be thought that there was an obvious answer to that question but health care need is not an absolute quantum. There are always choices to be made about priorities. Beneath the surface warmth we all feel about the NHS there is a more complicated reality and some hard choices, often made now by default, about priorities against finite resources. Of course the NHS is there to save lives but, for me, I would like to see a greater emphasis on improving life chances (for instance through increased investment in children and young people’s mental health services) and relieving suffering in the decisions we make about the development of services. When much of what we can do to improve lives, in particular in the area of mental health, remains unfunded we should not assume that all future medical developments can necessarily be supported. I believe NICE has been, in general, a positive development in our health care system but I think there is a case for revisiting the basis it is given for making some its judgements.
The last point, of course, relates to funding. Just as health care need is not an absolute quantum there is no right answer for what level of funding the NHS should receive. However there is a case for taking it out of the realm of day to day political decisions and linking the decision to an external benchmark such as the average spend for comparable European or OECD countries. The NHS is, in relative terms, a cost effective system but it is striking that, over recent years, the spend as a proportion of GDP has been falling and the gap broadening in comparison to other developed economies. In such circumstances something has to give.
Day in, day out NHS staff do some brilliant work supporting the millions of patients who seek its help. However it is a system under strain. Positive change, of the kind outlined in the 5 Year Forward view, is possible but it needs a broad political consensus with the proper engagement of the public and adequate transitional funding if we are to deliver a model of health and care which is sustainable. How we do that is challenging in an era where politics has become so polarised. A Royal Commission, as some have called for, might be one route but only if there is an absolute commitment across the political spectrum to implement its findings.
We do need to talk about Kevin.