Can there ever be a National Health Solution?
In its current form, the NHS is in danger of becoming an insoluble problem
The Conservative government is under fire for allowing the NHS to get into a state of crisis (even if the Prime Minister won’t call it that). And the Labour opposition faces challenge for wanting to use private hospitals to fix the problem.
We have been here before. In 1997, the Blair government took over an NHS widely seen as being in a mess. Their decision to involve the private sector through Private Finance Initiatives (PFI) and independent sector treatment centres (ISTCs) was far from a success. The contracts were, with hindsight, often over-priced, feeding the notion that private healthcare is only ever a rip-off.
But state control of hospitals isn’t working either. Right now, NHS hospitals cannot attract sufficient staff to carry out their functions. There are over 130,000 staff vacancies. In the year to June 2022, more than 34,000 nurses left their role in the NHS – two-thirds of them under the age of 45. Pay appears to be a major issue. There were strikes by nurses last month, and more are planned for this month, in pursuit of a 19% pay rise. Neither the Government nor the Opposition believes that is affordable.
We also have many hospital beds unavailable for sick people as a result of delayed transfers of care – beds occupied by patients who are well enough to be discharged but who don’t have adequate care at home or in the community – disparagingly called “bed blocking” in some quarters. Before Covid, around 5,000 hospital beds in England were typically occupied in this way. At the end of 2021, that figure had risen to over 12,000. That is a very significant number of beds not available to deliver healthcare given that, in total, the NHS in England has only 100,000 general and acute beds – and it’s a hugely expensive way to accommodate people who are not in need of in-patient care.
I doubt that anyone wants to re-design the NHS at this point – there have been too many failed structural reorganisations in the past – but if one was starting from scratch today, designing a national health service in a country where only private care existed, any sensible design team would ask whether they needed to nationalise the hospitals in order to deliver the promise of free healthcare: “Can’t the government just pay for treatment”, someone would be bound to ask, “without government ministers being put in charge of hospitals?”
And therein lies the real issue. The NHS is not one but two institutions. First and foremost, it is a promise: to provide healthcare that is free at the point of delivery. We pay for this promise through our taxes, based on our income, but regardless of our state of health. And we benefit from the promise through access to free healthcare, when we need it, regardless of our income.
Second, the NHS is a delivery mechanism: a provider of healthcare through GPs, hospitals and all the other providers that combine to deliver a national healthcare system. (And, currently, there is an unintentional third component: the default location for thousands of delayed transfer patients stuck in hospital until social care gets fixed.)
Governments are usually elected for the policies they espouse and their vision for the country, not for their ability at taking operational control of a huge organisation. An incoming opposition may never have been tested in this role. And yet, by using the NHS banner to denote not just a promise of free healthcare but also state control of the delivery, successive governments have saddled themselves with the burden of managing the biggest employer in Europe and the world’s largest employer of highly skilled professionals.
Any new involvement of the private sector in the NHS is seen as an attempt to undermine the sacred promise of a national health service. It shouldn’t be. Not least because if one just stops to think for a moment, one realises so much of the NHS delivery already comes from the private sector without people noticing or minding. GPs, dentists, pharmacists and opticians are private businesses and have been since the inception of the NHS. Some community services, such as district nursing and health visiting, are now provided by the independent sector. The Red Cross provides additional support when people are discharged from hospital. Hospices are mostly run by charities.
In 2019, the Nuffield Trust estimated that 22% of English health spending went to organisations that are not NHS trusts or other statutory bodies.
There is a powerful argument that, if the government promises to pay for healthcare without controlling the means of delivery, it could find itself over a barrel when negotiating with private providers. (What if independent hospitals refuse to do a deal at a sensible price? Or if they withdraw from a local area, or an unprofitable speciality, in order to focus on services where the money is better?) But, as we know only too well right now, controlling the hospitals doesn’t guarantee that they will have enough staff. It’s a different barrel to be over, but it’s a barrel, nonetheless.
I said earlier that I doubt anyone wants to re-design the NHS at this point. But don’t we have to?
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You've noted the two key parts of the NHS and both are in big need of reform in my view. We are currently trying to provide a perfect unrationed private system for free and it just doesn't work. Health demand will always be huge so needs rationing. This needs to be tackled through incentives to consumers of healthcare as well as a more honest rationing of the service that can be provided. As for delivery, a mixed economy and attempts at genuine competition between state and private feels like a good place to aim for.
Simon, without some fundamental re-purposing and re-design, the NHS will surely continue to fail. It is the scale and scope of the change that makes it a nettle that few, if any, politicians will wish to grasp.