Future NHS funding: kneejerk populism ≠ enduring strategy

This is an expanded version of a comment written in reply to an article in the Guardian of 19 June 2018 (http://tinyurl.com/yd5wcnp5).

Polly Toynbee is precisely right; not enough extra money, with dubious provenance, applied in a populist manner without any careful planning, will result in little change.

In system terms, the whole supply chain needs to be reviewed, and the incentives carefully applied to ensure any impact at all. There are four main stages in this supply chain, and they all need to be considered:

1. Demand is rising because of our increasing healthcare needs as we age and have to manage increasing numbers of co-morbidities (think of someone with diabetes, high blood pressure and chronic leukaemia who is (perhaps not surprisingly) also depressed, for instance), but there are also rising ‘wants’ as our expectations keep rising, often because of irresponsible political promises of ‘more and better’ services. These haven’t ever been addressed, with the result that health services are seen as a ‘free good’ used as we might use our cold water tap. As one might expect from politicians who depend on re-election to continue in office, there have rarely been any serious attempts to manage (for which read ‘contain’) demand, and the new rhetoric is no different, continuing to use the same language as before.

Screen Shot 2018-06-19 at 08.56.342. Primary care, in the shape of general practice, is the Unique Selling Point (USP) of the NHS, managing the vast proportion of most people’s diseases (and dis-ease), but perhaps more importantly, choreographing patients’ journeys through the intricacies of institutional care to ensure that their care is appropriate in human as well as clinical terms, and preventing duplication of investigation and intervention. GPs, who are seeing little recognition of, or encouragement to treat people (and not just physical symptoms), are currently leaving practice in their droves, and recruitment is becoming ever more difficult, as their sense of overwork and under-appreciation grows. Yet general practice is barely mentioned in the rhetoric about ‘increased performance’ and ‘reduced waiting lists’.

3. Acute hospitals continue to do what acute hospitals do, which is to treat diseases, not people. Their perspective on real life, and their ability NOT to intervene are both conspicuous by their absence; surgeons measure themselves by their operations, physicians’ fingers itch to treat, and the current markers of success generally drive activity ever-upwards, rather than measuring patient outcomes and (rarely sought on an individual basis) genuine user satisfaction. Giving new money to the acute sector will merely produce more of the same, yet that is precisely what seems to be intended…. and don’t get me started on the way that mental illness is considered as an entirely separate part of the NHS…

4. As patients become medically fit for discharge from hospital, many will continue to need some sort of social support, whether in the form of occasional visits from carers, or intensive support of their long term conditions (see co-morbidities, above), and not everyone can afford to pay for it themselves. Yet funding for social care has dramatically dropped over recent years, and the drive to balance the public expenditure books as quickly as possible means that these services are rapidly disappearing, without any apparent, viable alternatives appearing. The new initiative overtly turns a blind eye to this, expecting the health system to improve without any reference to this end of the supply chain.

Only if all these factors are taken into account can we have any chance of improving the health service, but we are not seeing any evidence whatsoever of a strategic approach to public spending in general, and health services in particular. Sure, more money is required, but more thought too, and an analysis driven by logic, empathy and long term thinking, rather than tomorrow’s headline in the Daily Mail.

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Jo Cox: politics as they should be

Jo Cox

A young, inexperienced MP died horribly yesterday.

I didn’t know her, never met her, had barely even heard of her, yet several aspects of this dreadful event have really stuck with me with me, and made me think a lot about the state of our Society today.

My first reflection is the fact that Jo was obviously in politics because she cared. Unlike many of our MPs, she had had a career before politics, and so had ‘found herself’; she wasn’t using her role as an MP to put herself on the map, and justify her existence. People like David Cameron, George Osborne, Peter Mandelson, Nigel Farage, even Tony Blair, none of these have known much of the real world outside Westminster, having moved from education (often in the rarified atmsopheres of private schools and ancient universities) straight to the Westminster Club, whereas Jo was on a genuine mission to make a difference, having already made a significant mark in her first career at Oxfam.

My personal view is that one shouldn’t be allowed to become an MP until one can point to real achievements in other, more tangible areas of work, but that’s by the by…

My second reflection is how Jo’s inclusive attitude to people and issues were at a stark contrast with the whole tenor of political discussion in this country at the moment, as can be seen in the debate about Europe. Next week, we will all vote whether or not to stay in the EU. Most of us will cast our votes on the basis of beliefs and emotions, largely uninformed by any real evidence, thanks to the destructive, aggressive way in which any facts and statistics have been used.

I believe (and I rather think that Jo would have agreed) that the UK lives in the ‘society’ of Europe, and that it makes no sense to drop out and abandon these old friends in the hope of finding a whole new set of allies in the broader world. It smacks of childhood fantasy to jump into a completely unknown future in the Micawber-like expectation that ‘something better will turn up’.

Moreover, the self-centred ‘me, me, me’ philosophy of the Brexiteers shames me; any balanced, successful society has to balance self interest and altruism; it’s the way we build trust, and work with others to mutual benefit. To have got this SO badly wrong smacks either of childlike selfishness and lack of understanding, or of a genuinely malevolent egotism that thinks it’s OK merely to ‘look after number 1’. The flavour and sense of  Jo’s speeches, and of the way that the causes she espoused were so broad and inclusive, suggest that she might have shared this view of the politics of the referendum.

The obverse of this, the one potential silver lining to this unmitigated misery, may be that everyone involved in the current debate will now take the time to rethink their approach, and (dare one hope?) even their philosophy, so that we approach the referendum next week in a calmer, less heated way.

And of course, none of these reflections cover the human tragedy that has occurred; to see a young, vibrant, motivated, attractive, lively mother and wife, woman and campaigner, snuffed out so senselessly, makes me cry every time the thought comes back to me, and I’m a (very!) grown man….

Rest in peace, Jo, and may some good come out of the senseless waste of such a valuable life.