In a week when the NHS has been under intense political and media scrutiny, you could be forgiven for getting caught up in the excitement. Was the British Red Cross right to say there is a “humanitarian crisis” in the NHS? Is Jeremy Hunt really going to downgrade the four hour A&E waiting time target? Who is right on NHS funding: Theresa May or Simon Stevens? Does the disagreement between these two amount to a dangerous stand off? How long will Simon Stevens last?
For policy wonks and Kremlinologists it’s all great entertainment. But it’s not the psychodrama in Westminster that matters: it’s what is happening in emergency departments, wards, clinics, surgeries and homes across the country. Crisis or no crisis, there are aspects of the current situation which are clearly unacceptable.
A calmer look
Let’s have a calmer look:
The pressures in emergency departments are symptomatic of a widening gap between demand for and supply of services across the whole of health and social care. This has been foreseen for more than a decade, but we have reached crunch point now.
The problems are not simply the fault of ‘winter’, nor are they solely the consequence of an ageing society.
When patients are waiting and sometimes dying on trolleys it is newsworthy. When people are receiving little or sometimes no care at home or in the community, it is typically not newsworthy. Both situations are part of the same problem and they are both intolerable.
There are now so many expressions of pain coming from the NHS front-line, that it is no longer credible for these to be dismissed as special pleading, the parading of bleeding stumps or the crying of wolf.
The funding settlement for health and social care in the 2015 spending review will need to be revisited before 2020. Having bizarrely ignored health and social care in the 2016 Autumn Statement, the Government needs to get a grip in the March Budget.
Sorting out the finances in the short term should not be at the expense of reforming services in the longer term. Both are needed.
‘Sustainability’ and ‘transformation’
The latest media frenzy over the NHS takes largely as read the current pattern of services and the need to prop them up rather than to change them. To use NHS England’s rather Orwellian terms: ‘sustainability’ is crowding out ‘transformation’.
To the extent that change is on the agenda, it is more about changing patient behaviour (in particular our tendency to go to A&E) than about changing the system (which among other things creates strong incentives for us to go to A&E).
This is not just a fault of the media, but a problem facing those designing and delivering services right now. As NHS Improvement boss Jim Mackey notably acknowledged at the Public Accounts Committee (PAC) this week, the relentless focus on controlling the money comes at the expense of improvement.
It’s not as if there isn’t already an improvement plan. The 2014 Five Year Forward View is still the best summation of a modern consensus about how the NHS needs to transform itself. It still needs to be implemented. Government needs reminding that this is its plan, too: the Department of Health aligned all its planning against it. And the vision of “a new relationship with patients and communities” as set out in chapter two remains central to the Forward View. Among other things, delivering the Five Year Forward View requires political leadership.
One of the many ways in which Theresa May has differed from David Cameron is in her relative lack of interest in health and care. Your political and philosophical preferences will dictate whether you think that is a good or bad thing. I would prefer Mrs May to be putting her back behind Simon Stevens’ efforts while actively fostering a ten year and indeed 20 year forward view for how health and care should be done, and how it should be funded. She doesn’t have to start from scratch. There is lots of work that can be built on, including the Dilnot and Barker commissions as well as the Five Year Forward View itself.
What matters to patients
There are now some signs that the Prime Minister may be moving in that direction. She has appointed a new health advisor, announced a review of health and social care integration, and set out new plans for mental health. Better late than never.
There have been calls to do this strategic work on a cross-party, non-partisan basis. That would be great, if achievable. But more important than political consensus is a consensus that reflects what matters to patients, carers, citizens and front-line health and care professionals. Co-production, not top-down reorganisation, must be the watchword for all coming reform efforts.