What kind of NHS can we really have?

Julia has also written the opinion piece today’s CityAM

The spotlight is on GPs – and as the 2015 election looms, it isn’t going to be switched off anytime soon. The survey that broke last week on the 30% of GPs who think patients should be charged for attending A&E got a predictable amount of ‘alarmed’ coverage. “Americanisation” bleated the Royal College of GPs (RCGP) at the spectre of credit cards and cash payments casting a shadow over our ‘free’ NHS, even as patients interviewed in the news VT admitted going to A&E to have their knee re-bandaged and to get some paracetamol. Then yesterday Sky News had their first ‘Life and death’ NHS feature (they are having a week focused on the NHS) in which they featured GP leaders calling for 10,000 more GPs and associated staff, with an estimated annual cost of £1Bn. Apparently it is the only solution to being able to deliver seven-day-a-week working.

It would be easy to dismiss this as the media stirring, but the media is trying to fill a vacuum: There is no narrative from politicians on the enormous challenges the NHS faces. We hear piecemeal from MPs and Ministers about one section or another of the NHS: maternity, A&E, GPs, your local hospital, obesity, winter pressures etc. The public is confused and bewildered. We all know the population is aging and there’s more technology but surely the NHS budget was protected, so what’s the problem?

The problem is that no politician is setting out the bigger picture. To give you an idea of what that looks like consider the following:

• As a nation we have become much more dependent on professional health services. Over the past 10 years, visits to the GP have doubled; visits to major A&E departments remain stable at just under 15m a year, but the extra walk-in, urgent care, minor injury centres have spawned another 8m visits a year – a 50% increase in our use of rapid-access services. Emergency admissions are up 35% in the past 10 years.
• The reality is, the more care we provide, the more demand we create. And when we offer rapid access (only 4 hour wait in A&E!), surprise, surprise, that’s where people go. And when the economy is under pressure, unemployment rises, mental illness rises and more people want to see their GP.
• To carry on delivering services as we know them will cost us an extra £30Bn per year by 2021/22 – and only if we manage to make the ‘productivity’ improvements of 4% currently required (and historically never previously achieved), e.g. streamlining outdated, labour intensive treatment pathways.
• The only way to afford this is to raise taxes, take money from other public services or introducing co-payments. Many people think raising taxes specifically for health would be acceptable, but then we need to remember the changing worker to retiree ratio…
• In 1948 only 11% of the UK population were over 65 years of age; it’s now about 17% and will rise to roughly 23% by 2030. In Europe as a whole it will be closer to 27%, but the UK is also predicted to be the most populous country of the continent. This means the ratio of working (tax payers) to retired people over the age of 70 will fall dramatically; in 2010 it was 5.3:1; by 2030 it will be 3.7:1 – that’s a massive 30% drop.

Therefore raising taxes to fund a growing budget from an ever decreasing proportion of the population is a context and cost that public need to fully comprehend. Taking money from other public services is a possibility, but against a background of existing cuts it is unlikely to be popular.

Of course there are still savings and efficiencies to be made, there always will be and we have to find better ways of keeping purse-holders accountable and encouraging stewardship. When best practice is not adopted, we have to not only ask why, but then apply penalties for defiance! When the public abuse the system (30% of A&E attendees are there due to having got drunk) we need to consider charges (but never blanket charges as suggested by the 30% of GPs). Much greater public involvement and engagement is absolutely necessary (the current culture of NHS secrecy also breeds unhealthy dependence), achievable through patient-held electronic records e.g. Patients Know Best and through peer-to-peer patient support networks e.g. Patients Like Me. We may live in an Age of Consumerism, where especially those under 65 years think they can have the NHS on speed dial, but without a new mindset of involvement, stewardship and where possible, control, the covert and patronising model of care delivery will crumble.

This still leaves us with the fact that we need to raise more money to keep the NHS as it is, or have a national discussion about the future of the NHS: what the NHS is there for, what it should be expected to provide and what it will look like. Both these scenarios require political leadership. Without it, we will carry on with bungs here and there to prop up services; ongoing bickering over saving your local hospital; an ever increasing post-code lottery of what treatment is and isn’t available locally (just as we have seen in social care) and a bewildered public wondering what the hell is going on.

This article first appeared on the ConservativeHome Website on Thursday.