THE SATURDAY ESSAY: We cannot maintain the NHS, and we must not sell it to the free market

Mutuality is still the only practical answer

Over the decades spent discussing the NHS, lauding its past and debating its future, every tired medical analogy has been applied: it’s in intensive care, it’s in rude health, it’s out of danger, it needs a transfusion and so forth. But these are merely wordplay that looks good on a tabloid page, and sounds concerned at the Dispatch Box. They address but one thing: cash shortages. This has indeed been the flaw in the NHS since 1947: in a world of medical breakthrough and higher expectations, no amount of money for the NHS would ever be enough to meet demand. The solution applied – by every shade of government – has been rationing. But you cannot ration health care: and therein lies the insoluble equation.

Over that same period, every Opposition has used lachrymose appeals, stunts, exaggerated disgraces in service and puffed-up propaganda to suggest that ‘our’ NHS (which it isn’t, and never was) is being starved, stealthily privatised, or ruined by waste and overmanning – while every government has bent the stats, obfuscated with targets, denied reality and invented ‘new’ services rather than actually deal with the problem. And once again, the reason they don’t is because they can’t: to repeat the irrefutable truth, there is an infinite demand for healthcare, and no way you can ration it.

My solution is two-fold and simple. First, restrict the NHS to services that we the People can afford. And second – equally important – save the NHS from both State and private business destruction by mutualising it in perpetuity. The reaction of most folks when I say this is “Aha – attacking the principle of free!” (the Left) and “Aha – the market must decide!” (the Right). Both are entirely predictable, because our major Parties these days are interested solely in the rear-view mirror. It’s why Britain is in near-terminal decline as a whole; but it is by far the biggest reason why the NHS as we know it has all but disappeared.

There are two golden rules I have learned in life when it comes to providing services with a heavy social responsibility – what used at one time to be grouped together as The Social Weal. The rules are these: give it to the Right to run, and within five years the ideals of the service will have been destroyed by greed; but give it to the Left to run, and within five years the commercial solvency of the service will be destroyed by overmanning and uncommercial management.

Two years into his mealy-mouthed plan to simply suck all the NHS’s hospital money out and then sell that infrastructure off, Andrew Lansley is on the verge of letting every Hank, Richard and Henri bid to take over larger group-practice primary care. Give it another year, and almost every Foundation Trust hospital-service provider will be in financial trouble…at which point the private sector will get what it wants – the massive taxpayer investment in hitech equipment and buildings – in a fire sale.

Before Lansley, Gordon Brown of obviously fading memory poured vast amounts into the NHS in the early Naughties (once New Labour’s probationary period was over). This was immediately followed by yet another internal reorganisation, wasting a colossal percentage of the money that had been ‘invested’. So then he poured some more in, and management costs sky-rocketed. Following which Alistair Darling put in still more, and Connecting for Health happened (or rather, didn’t) under the criminally mishandled negligence of John Reid and Patricia Hewitt. It is a classic metaphor for CfH that when I began researching this piece and opened the NHS’s pdf on the subject, my pc crashed.

Originally expected to cost £2.3 billion over three years, by June 2006 the total cost of CfH was being estimated by the National Audit Office to be £12.4bn over 10 years, and the NAO also noted that “…it was not demonstrated that the financial value of the benefits exceeds the cost of the programme”. In the same year, the British Computer Society concluded that “…the central costs incurred by the NHS are such that, so far, the value for money from services deployed is poor”. Officials involved in the programme were quoted in the media estimating the final cost to be as high as £20bn, indicating a cost overrun of somewhere between 440% and 770%. A massive cover-up operation then began under Alistair Darling, but a senior Treasury official told me in late 2009 that the all-up cost (for zero deliverables in almost every aspect of it) was £23.2bn. I have no reason to doubt her.

Study those preceding three paragraphs, and you should be able to see why I’ve applied my two golden rules for many years now. The formula is universally applicable.

The mutual approach to affordable healthcare avoids both these problems by protecting the resultant service from takeovers, while keeping it out of the hands of political agendas and self-aggrandising civil servants. But to understand why this would be a better way to provide freedom from health anxiety of the citizen, everyone must understand that, although lack of focused funding is the original root of evil in the NHS, the problems of providing excellent healthcare affordable by ordinary citizens go way beyond even money. Healthcare and medical provision is an incredibly complex area, and the people working in it – at all levels and in all disciplines – are, shall we say, only human.

The first thing to ditch is this idea of ‘our NHS’. The NHS is run by Westminster and Whitehall entirely for its own purposes which are, in no particular order, job protection, demonstration of target success, narrow-minded budgetary control, job creation, media spin, stabbing the Minister of State in the front when things go wrong, proving a spurious competence, and sticking up notices everywhere saying everything is just fine. Created by these people was a further group, Management, who work in the hospitals on the upper floors where few ever venture. Their job is going to meetings, mishandling the administration of almost everything, designing car parks far too small for the hospital, putting in hugely expensive entertainment equipment for the patients (the cost of which to patients is equally hugely expensive), watching surgical procedures to ensure everything is done properly, cancelling everything towards the end of the fiscal year, avoiding any procedure that might result in litigation against the Trust, and commissioning depressing art for the corridor walls.

Believe me, the last thing this monster might be is ‘our’ National Health Service. Nor is it in any real sense national, because the services and quality available vary enormously from one regional Trust to another. But this begs the question – which Nye Bevan asked towards the end of his life – should it be a national service? His revised vision (having already spotted what it was turning into) was one of a network of clinics feeding into regional hospitals, the region remaining as a sovereign body on a cooperative basis. My vision of a mutualised and localised service is not dissimilar.

The sheer bureaucracy involved in running a ‘national’ one-size-fits-all service is horrendous. Official figures last year showed that roughly 1 in 4 health workers is now a bureaucrat: 188,530 of the 837,000 staff employed by the health service are managers, administrators and clerks with no direct involvement in patient care. Five years earlier, administrative staff in the NHS numbered 168,730. Nowhere in the NHS statistics does it explain the value added by that extra 20,000 staff. And bear in mind, NHS management has serial form when it comes to using dissembling definitions that disguising the real function of employees.

Although the overall percentage cost of management in the NHS has fallen from 5% to 4%, this too is a weasel statistic: it takes pure salaried admin costs, and sets them against all NHS expenditure costs. As drug discoveries and technical breakthroughs come onto the market, the total plant, procedural and medication cost rises on a curve whose gradient is ever more steep….and shall be for evermore – until the whole basis upon which healthcare rests today is changed by future dietary education, alongside DNA, cell stem and other forms of preventative medicine. Thus, management costs can appear to be falling, whereas over time senior managers are still getting rises and bonuses not available to medical staff. Between 2006 and 2010, for example, the cost of NHS bureaucracy under New Labour rose to £1.9 billion – a 41% increase.

Nor will Lansleyite Tory reform philosophy address this. What’s being proposed is yet another massive restructuring, and it isn’t going to do itself: administrators and managers initially scheduled for redundancy have, hey presto, turned up in new organisations doing the same job. Since 1980, there have been thirty restructures of the ‘national’ health service – that’s a staggering number. The mind boggles at how much it has all cost, but Kieran Walshe, professor of health policy and management at Manchester Business School, and an expert on NHS reorganisation poor bugger, believes there is “little evidence” that such changes produce “much, if any, improvement”. Writing in the British Medical Journal in late 2010, he said that “for someone who has spent more than six years mastering the health brief in opposition, Andrew Lansley seems to have learnt little from the history of NHS reorganisation”.

What Walshe may not have fully grasped back then (it’s only become brutally clear in the last three months) is that Adnrew Lansley doesn’t care what the admin costs turn out to be: he knows that by the end of 2014 at the latest, that’s going to be the private sector’s problem…and they will deal with it swiftly – as the attitude of Virgin Healthcare, for example, is already proving.

The only way to make affordable healhcare work, therefore, is to scale down the size of each regional operation to a manageable level, and mutualise it within the local population. Only this can replace ‘their NHS’ with ‘our health provision’.

It would be wonderful if, having done that, all our problems were to end. But they won’t – and there are several glaring reasons for this.

The first is the medical profession itself. If you remain of the naive view that somehow GPs and hospital consultants are above the rest of our money-grubbing culture, then it’s time you were disabused of it. Their salaries and hours worked have risen and fallen respectively in recent years…and no matter how you cut it, that can only result in lost productivity alongside rising costs. To see a senior consultant privately for just fifty minutes in 2012 will set you back an average of £200. Simple calculations like this either don’t matter to the privatisers, or they are simply too privileged to have thought about the minute fraction of the British population (as it enters the worst depression in its history) that could ever hope to afford that kind of money. Taking out an insurance to obtain that for myself now, aged 64, would cost me around £550 per month. I don’t have any kind of money lying around doing nothing at the bank, let alone that much per month. I merely have some money lying around doing nothing thanks to the Zirp scam. And bear in mind, according to the ONS, I am in the top 9% of the population when it comes to capital, pension and property.

Andrew Lansley suffers from that most tedious of Tory myths, the belief that everyone in Britain wants to be Alan Sugar. Not only is this not true, it is especially inapplicable to doctors. I have gone on the record many times to say that no medical practitioner should be allowed to do anything except diagnose and offer a prognosis. At a pinch, I’d allow them to prescribe, but as infrequently as possible. The average medic’s business sense is more akin to that of  Honey-pie-Plonker than Lord Sugar.

Let me give you some examples. In primary care, blood tests are done a few at a time, and expensive procedures are avoided wherever possible. This frequently leads to misdiagnosis, and the prescribing of pointless drugs. Later still it can cause late or even non-diagnosis of a serious problem, at which point the NHS does come into its own…but by then, the condition is serious enough to require everything from MRI scans to major-league surgical intervention…..and even more medication. This is the kind of false economy that results from trying to ration healthcare.

At the hospital level, costs are even more tightly controlled by Management. To be fair, these are often well-meant and necessary, but you can rely completely upon consultant attitudes and behaviour to negate them at every turn. For example, a patient is referred and then admitted. Avoiding high-cost examinations and working with blinkers on an initial hunch, the consultant’s team arrive at a dead-end. The management then put pressure on about bed availability, and in a bid to save time the team now does every test under the sun…at the same time mindful of the litigation possibilities if something has gone unspotted.

At least half of these tests are in any real sense wasteful and unnecessary, but the patient being prodded, poked and scanned receives only vague and equivocal answers to questions about why a large hosepipe has been inserted into his or her rectum when the problem appears to be one of earache and tinitus. Once again, non-committal responses are standard procedure: mainly because of fear of being sued for misdiagnosis, and terrifyingly often because they really don’t know.

There is, I am bound to observe, a semi-autistic secret squirrel syndrome that is irritatingly common among hospital doctors per se. But they also display that insouciant grasp of Time so frequently found among academics…which many of them are by both inclination and appointment. A good example of this happened to me only last month, when I undertook a three hour round trip costing £55 in petrol to be told by a consultant that (thanks to management incompetence) the test results I’d come to be told about hadn’t arrived. My observation that a young A. G. Bell in the American colonies had invented a remote sound communication named after the Greek terms tele and phone didn’t go down that well. But the fact is that, in a commercial environment where the patient really ought to be a client, saving the client that journey with a simple phone-call should be Page One for any administrator. No doubt senior management had decreed that the phone budget needed to be cut if targets were to be met, but being serious for a second here – these are the people Mr Lansley would have us believe are wised up and geared up for business. Bollocks they are. And indeed, why should they be?

Somewhere in this process of cheeseparing in order to increase waste, that part of the plot remaining is frequently lost. After my wife had this year taken up a hospital bed for five weeks, her headaches remained, her condition was undiagnosed, and there was no prognosis for her serious brain lesions….beyond “it’s stable for now”. A simple csf fluid procedure designed to reduce her headache was turned down flat by the surgeons “because it might not work”. She was discharged with pain relief in the form of a small box of OTC paracetamol. At every stage, attempts to limit cost and minimise the chances of litigation wound up increasing both.

One could once again sense the dead brain of the accountant behind all this, but in truth an equal problem was one of medical attitude: tramline thinking restricted to narrow discipline-specific thoughts, an absence of multivariate analysis, and the ever-present terror of being sued. There are no winners in the process, but the loser bigtime is the patient.

Nursing standards present another and entirely different problem. In fact, the problem divides into two issues: very poor morale, and yet more evidence of the over-qualified demanding undeserved entitlement.

To say that the NHS isn’t attracting the nurses patients need is rather like saying the Metropolitan Police need to cut down a little on their Newscorp dining habit. I’ve observed middleweight and junior nursing in five separate hospitals over the last fifteen months, and the great majority displayed the same problem: uncaring, undisciplined, uncommitted and underpaid. The only ‘over’ that applies to them is ‘weight’. The problem is yet again one of budget constriction, but it is also one of culture: every Government since Attlee’s has cynically reduced the respect given to this calling – and even though it isn’t a calling any more, it bloody-well should be.

If the creation of a money-culture is more down to the Right in Britain, then a sense of self-importance and precious “I’ve got a degree” bollocks is pure New Labour. Sadly, this inflated pomposity has also infected nursing. Sluice out bedpans? Me? Are you kidding? I know three oldish former nurses, and to be frank they’d sail through to a first class honours degree in Britain’s contemporary redbrick Universities. None of them would ever have dared to suggest to Sister or Matron that clearing away the bodily functions of the ill might be beneath them. Loathe the Tories as much as you like, but New Labour muddle created the ‘I’m above that’ crap. It is a massive obstacle in the way of proper medical care everyone should be concerned to lose at the first opportunity.

Travel with me now to the Unison website, where you will find this statement of intent:

‘UNISON is the UK’s largest public service union with more than 1.3 million members. We represent the whole nursing family, including nurses, midwives, health visitors and healthcare assistants. We have a large network of branch representatives and national and regional officers, who are committed to providing you with help and support when dealing with problems at work.

We represent our members in many ways, offering help and advice at work, raising your professional/local concerns or by highlighting issues that will affect all health workers at a national level. We work together to make sure our members’ concerns are heard – whether it’s about pay, health and safety, discrimination or the future of our NHS.

We actively campaign on issues like pensions, health and safety, salaries for student nurses, regulation for healthcare assistants and an end to discrimination and harassment.’

Is Unison concerned about standards? The aims of Unison in the context of obscenely skewed social values are frequently laudable, but the Union’s lack of any interest in restoring professionalism is the shame that hangs over every trade union in the UK. And ‘an end to discrimination and harassment‘ is a good objective given the ever-present Management drivel with which these people have to contend. But ‘to promote the highest standards of caring in the nursing profession’ would be nice too. How ironic it is that a trade union opposed to free-market money-obsessed economics can only think in terms of jobsworthiness and money.

Overall, in fact, beyond the consultancy and management problems, my observations of the NHS we tolerate are that it is the senior nursing staff and junior echelons of administration who keep the limping, torpedoed ship on course for any port in a storm. The emergency admissions administrators and assistants in particular were dedicated beyond belief, and I have yet to meet a senior theatre nurse who didn’t have a passion for the job.

In conclusion, let me summarise by reaffirming that we need to take the ‘N’ off NHS, take affordable health care away from both the State and the profit-motive, take medical provision out of the Eton & Highgate Political Wall Game that is killing it, give it to the mutual sector to manage, give medical staff guidelines about what they can and cannot cure, and then within that proscribed remit, give unlimited health care to all citizens without the means to afford BUPA’s rapacious fees. Those last two items are central, really. We must stop trying to do everything, only to then find ourselves being forced to ration at random. Far better, surely, to do the important life-enhancing things at the top level of quality, rather than achieving a bare mediocrity at the lowest common denominator.

There is one final step I sense that Britain needs to take if affordable healthcare is to survive. This would mean addressing a much broader Anglo-Saxon problem, that of the litigious “I’m entitled” culture. Obviously, patients must be protected against gung-ho knife wielders, the BMA, the Medical Defence Union, and chronic incompetence. But we need to make a start somewhere when it comes to reining in the ambulance-chasers.

Official figures  show that the cost of settling legal claims already made against the NHS, and expected to be made, rose from £11.9bn in 2008 to £15bn in 2010. These are the latest figures I could find; hands up all those who think the problem is getting better. (£15bn, by the way, is 13% of the total NHS budget).

My personal solution of choice would be to throw every medical and accident claims lawyer into the nearest pit of quicklime, but I do recognise that this would be both unpopular at Westminster and, let’s be fair here, premeditated murder. However, there are some things lawyers get up to which really should be stopped immediately. One is the use of television as a means of marketing thinly-disguised opportunism in the shape of no-award-no-fee services. Another is the whole idea of lawyers having marketing departments: what are they selling, social war? Yet another is placing a cap upon the number of lawyers allowed as a percentage of any political Party’s MPs.  If I told you that in Brown’s valedictory Cabinet , for example, lawyers were over-represented by 2800%, woud you be surprised? Then be surprised, because it’s a fact…and the current Cabinet isn’t far behind.

Those on the Hard Left of politics will doubtless see this essay as emanating from a bourgeois middle-of-the-roader, while the Mad Right will view my outlook as pandering to the idea of healthcare entitlement. As to the former perception, I would argue that the future I lay out here is infinitely more radical than anything else on offer….and far more likely to work to the advantage of the patient. As for the latter, I plead guilty as charged. The first job of every State is the protection of the individual citizen. But if the society it protects cannot, in the 21st century, bring the solution to life-quality reducing and life-threatening illness within reach of every citizen, then it is not fit to becalled civilised.