The crisis in the NHS held against the background of wider union unrest, Dr David Cliff explores some of the challenges ahead for this most valuable institution.
When the NHS was conceived of in 1948, its resources were adequate for purpose. Indeed for the first couple of years of its inception it was underspent and under capacity. The British public, not used to healthcare free at point of access, made relatively few demands and had relatively few expectations. Patients were somewhat overawed with the sheer novelty of being able to easily and affordably access healthcare, normally something that hitherto was only achieved for ordinary working people by charities or extraordinary self-sacrifice by families.
It’s a world of difference, when the service that is so popular, has gone beyond basic physical healthcare needs into the far more sophisticated offering that expands mental health services into notions of well-being, offers surgical and biomedical techniques that work with advanced robotics through to gene restructuring and more. It addresses matters that are not just about physical survival but about quality of life, including matters such as fertility, gender identity, advanced prosthetics, the list goes on. Indeed, the success of the model has created what might be described as a ‘supply induced demand’ phenomena where the more that is on offer, the more it creates its own demand.
Add to this, the fact that these interventions improve and extend life so that people live far longer resulting in concomitantly increased demand for health services as they age. The social and emotional contract between the public and the health service is now generations deep with high expectations and with correspondingly high emotional and taxation support.
So why with this level of consensus are people dying waiting hours for ambulances, spending days sometimes in corridors, whilst approximately 15% of the hospital population sufficiently healthy to be discharged cannot be so because of systemic failures elsewhere.
Many would have us believe it’s a result of the Covid pandemic, a phenomenon upon which much systemic failure within government has been attributed. Then there is the increased transmissibility of influenza following lockdown restraints and other winter pressures. Ministers refer to these factors’ ad nauseam, and, in the context of health, there have been so many ministers! Few, if any, will ‘fess up’ to the pattern of underinvestment, tokenism, drip feeding and ideological wars that occur at the heart of government over the NHS.
The fact is that not uniquely across Europe, Covid acted simply as a stress test of the system that has become unfit for purpose without the cracks being too obvious to the public. The health service, always a political hot potato has been subject to a form of political palliative care for so many years. It has been subjected to almost annual restructures, with liberal amounts of tension between public and private delivery ideologies, and now screams for radical reform. The most radical of which, is resolving the social care divide that continues to be kicked down the road by a government who pledged to put the situation right. As a young social worker, I saw the tensions in this divide forty years ago. We knew even then about the changing demographics of an ageing population.
The politics of an electoral system that is first past the post and for only five years at a time, results in a short termism in an approach to an institution as large as the NHS, which of itself is transgenerational in nature. A service of this scale requires far more longitudinal planning and cannot remain a political ‘football’ between polarities of left and right, public and private debates that feature amongst our contemporary political elites.
I remember working in the health service and noticed it was often doctors and nurses that filled the void between management thinking, political imperatives and resource priorities when it came to serving the public. No matter what was happening in boardrooms, somehow the vocational direction of our healers was enough to fill the interstices between policy and delivery. But treat your staff like heroes when you need them and then villains during times of recession and those vocational identities will erode. Passion for the job will diminish, burnout will ensue and most of all for the passionate, the unending drudgery of more for less as the avoidable death toll mounts whilst the government constantly talks about more money being invested against the daily grind of being called on to do more with less, day after day. They watch their entrepreneurial colleagues making much more through agency working. Small wonder so many of our vocational healers no longer wish to heal, some of them find better staff engagement, better support and better conditions working in Aldi!
When the clearly privileged in government won’t transparently admit to whether they are NHS users themselves or not, this is truly an indicator of people in power having lost touch with the lived experience of ordinary people. People often follow leaders that are substandard, a point well elucidated by Etienne de la Boétte as early as the 1520’s. People will tolerate much, placing trust in those whose who purport to lead, even where there are ideological differences evident. But the consistent and systemic failure of leaders in an arena where life or death may be involved, as in the case of healthcare, can easily be a game changer. Radical healthcare reforms have always been more just ‘sameness with difference’ as a little extra jam was spread ever more thinly across burgeoning need. The public very clearly will prioritise greater healthcare spending if effective. Other public services would also function better, for example, the police would no longer have around 40% of police cells occupied with people who require psychiatric care and could begin to attend to matters more criminometrically aligned to their core function.
Real reform will be expensive for us all. A bit like paying the nurses will be necessarily expensive but by default we pay agency workers far more pro rata and asset strip the workforces of other nations to boot. But if we want the service fit for the future, reform we must, so let’s pay for the right thing whilst doing it!