Throughout my decades of working with the NHS, the system has remained change-suspicious and predominantly reluctant. But what happens when no change is the risk? As we enter a new political era, after years of Conservative-led austerity, what might a hung parliament mean in change terms? It would be easy to think that this could curb the Conservative’s ability to impose further cuts, and thus feel relieved. However, in the absence of more available funding in the Treasury coffers, I am more concerned about the potential for impotence across all parties when it comes to agreeing a new way forward, risking leaving us with the existing way forward that we all know is both failing and putting lives at risk, not to mention careers.


The NHS Division

Whereas Brexit was undoubtedly divisive at a national level, the NHS is probably more so at a cross-party level. Labour, with a much stronger degree of support, are vehemently opposed to further NHS austerity, the continuation of many principles of the Health & Social Care Act 2012 and many of the more recent changes to funding models or reform… but they lack the strength to impose change. They do, however, coupled to sympathetic partners, hold far more ability to resist it.

Both Scotland and Wales believe in a healthcare system different to the direction of travel to England. The Liberal Democrats have long campaigned, under Norman Lamb, for a cessation of austerity and additional emergency funding. None of these parties have the ability to introduce an alternative to the current plan. Collectively with Labour, they represent a formidable force of resistance to more of the same.

So, if not more of the same, then what?

Herein lies the problem. The Conservatives are forming a weakened Government, on an already significant degree of criticism for their healthcare policy. The pre-election leak of a tender discussion to invite significant US Accountable Care Organisations into the UK to assume capitated responsibility for billions of care funding appears to be the desired direction of travel. That appears to sit at odds with just about everybody else’s view. Just how do they progress that in the absence of a big enough majority?

The answer is predominantly that you can’t. You are stuck. The more radical your plans, the greater the majority support needed to carry them through. The more bland and benign your plans, the lesser their likelihood of solving deep-seated NHS problems to the degree necessary.


NHS Funding

The Conservatives are also caught between a rock and a hard place over funding. Labour wanted to increase funding through additional taxation of what is probably best described as the upper middle & upper classes in income terms. A large part of this group has been traditionally Conservative. With a shaky hold on power, it is highly unlikely that the Conservatives will want to attack their supporters but without that additional taxation income, or the ability to move the care responsibility to ACOs, and with a commitment not to increase borrowing significantly, they are left with the sole funding option of repatriating funding from other sources, such as the Social Protection budget, or Education.

This is not going to happen. Social Protection and Education, the only budgets big enough to provide any meaningful funding to the NHS, happen also to be the favoured pots of spending for Labour, with its enhanced ability to resist raids on them. The Conservatives have already been heavily criticised for their austerity in policing and counter-terrorism and matters such as these will also need to be addressed if their thin, non-majority support is to remain.

At the risk of sounding depressing, we are faced with a somewhat depressing reality:

  • Commitments not to borrow substantial sums
  • Likelihood of prolonged economic uncertainty over Brexit negotiations (based on calls already to slow down the process)
  • Almost no ability to repatriate funds from other budgets of any meaningful size
  • Reduced ability to bring in money from outside sources that could be construed as either privatisation or what I’ll term ‘foreignisation’ of our health system
  • Major political risks to the party not quite in power if they increase taxation

That picture pretty much guarantees no meaningful additional funding and yet, at the same time, the real likelihood that any alternative plans will take years to progress through protracted political debate, with no party having the political strength to impose their will.


The Typical Outcome of Disagreement

These early thoughts, to be tested by reality, are in complete alignment with the typical outcome of an approximately even disagreement – stalemate or stagnation. This is the true risk we now face.

The NHS itself will demonstrate (is already demonstrating) that a change of plan is vital to avoid a clinical and staffing catastrophe. I would argue that this is already patently obvious but there will come a point where even Jeremy Hunt (assuming he survives as SoS) has to admit that the plan as it stands is not working. However, agreeing the need to change is not the same as agreeing what change is needed. This is hugely problematic when you have such powerful and evenly distributed opposing views.

No Party holds a mandate. The loss of a majority quite potentially means that the only significant change the Conservatives could lead is one that is acceptable to both their own party members and the majority of other parties. It will not be lost on the other parties that opposing Conservative healthcare policy is a sure-fire way to have the Conservatives seen as failing the NHS and push towards another election. Whereas you might think they could be accused of holding the NHS to ransom for political gain, that would unlikely hold true if their opposition to the changes proposed was seen by the population as protection of the very NHS principles and rights of the under-dog that has given them their more powerful position. In effect, they could be seen as holding the Conservatives to account in doing the ‘right’ thing (in the populations eyes), which just happens to be the ‘wrong’ thing, apparently, in Conservative eyes.


Non-political Conclusion

This article has no politically leaning. It in no way suggests what is or isn’t the right thing or wrong thing to do for the NHS. The point that I believe we should all be reflecting on is that we face stagnation because no party has a strong enough mandate to carry significant change when the ideological views are so polar opposite and there isn’t a majority to rely on. If the NHS was even remotely currently stable, that stagnation could be seen as a welcome rest. But our NHS is not stable. It is quantum leap away from stable. It is teetering on the edge of a catastrophe and it has been waiting to see which way the wind blows.

The Conservatives have plans. They are wildly controversial. They were banking on a blue wind, of near-galeforce strength. They have ended up with a light breeze, maybe sufficient to ruffle a few feathers.

With this new-found reality, I would suggest that our NHS reality is an immediate future much the same as a drought-ridden nation of little internal resource, faced with a squabbling bunch of aid agencies that say “we’ll get back to you in 5 years’ time when we have finished squabbling over a right thing to do that we can finally agree on”. In the meantime…

14 responses to “5 Years of No Change?

  1. Deeply concerning article, it’s a shame that the general population are not realising that their public services are going to disintegrate slowly with further privatisations. As a doctor in the forefront of the NHS dealing with children with disabilities, complex medical conditions, their need of multidisciplinary and multi-proffesional input , our childre will suffer further, so will their educational funding in schools and social care and mental health input that they will need. Dark days are ahead of us, I see no light at the end of the tunnel.

    I can see how our capacity is being stretched and we are being asked to do more and more, NHS is still riddled with its inefficiencies due to management/administration level issues, it is surviving a lot on goodwill. But will it last? Will there be more changes in the name of efficiency and cost cutting risking further service cuts. Privatisations are already happening back door, Virgincare has won tenders for community health services, they are fighting it out legally in places where thier tender has not been renewed, is this regularly in the press? No, as press is being gagged by the very same people who want this privatisation to go ahead for thier own vested interests, i’m afraid to say but this is the beginning of the end of our beloved NHS.

    1. Yes, I tend to examine things from a behavioural standpoint, rather than an ideological or political one. We have the same problem in our Trusts – take a Board with roughly divided opinion between say radical change and more belt tightening and the default is more belt-tightening and nobody can get agreement for radical change. That isn’t so much a cautious safe approach as simply a behavioural trap that defaults you towards no major action (which feels risky without complete consensus). This is bad enough in Boards, where in theory there aren’t the same political or ideological differences. Add those in at a Party level i.e. a divide Country-level ‘Board’ and it is a scary recipe.

  2. Having retired from a full time senior post to get away from the stress of endless change for the sake of change, the prospect of no change for 5 years seems quite attractive. A fairer way to get the money for the ever increasingly expensive care of an expanding and aging population provided with ever increasingly expensive treatments, would be a type of co-paying that is means tested. Enoch Powell remarked in the book he wrote after being Minister of Health that the only topic an MoH is destined to discuss with doctors is money. In the case of the BMA he could have added their salaries.
    In the Republic of Ireland during their financial crisis doctors took three pay cuts. Could we see that here?

    1. Hi Edward, I don;t disagree about co-pay, as long as we all appreciate that every Western nation that has it has a higher GDP spend on healthcare than we do. That makes a taxation increase cheaper but less palatable overall and co-pay more expensive but less palatable in those that are using it!

      My concern with no change is that what we face is no change from the current plans – which in themselves, year on year, are leading to more quality failings, more retirement & emigration and more financial failure at an individual Trust level. I don’t think we should ever change for ‘change’s sake’ but we absolutely should change when continuation of the same presents such a catastrophe in motion.

      Pay cuts for doctors – we are having them. However, they are mediated through taxation & pensions and affect net pay, not gross pay. Pretty much every doctor with a consultant-level salary has seen a net pay cut for like-for-like earnings and my wife, over 5 years, has seen a net pay cut despite a significant gross pay rise (which feels like a hamster wheel). However, an absolute pay cut would bring a raft of undesirable effects, including work to rule, far greater exodus and an exodus of trainees too, I believe.

      Thanks for your comments!

  3. I agree with you that if we continue the direction of travel imposed by us working at the coal face with STP’s. The only outcome is a reduction of quality of services and further fragmentation of services, disenfranchisement of the work force and further early retirements and constant pressure.. There will be a huge problem to find a workforce to support the NHS as we are seeing now. We need the extra income now, not later.
    Having been working in a trust which is involved in a success regime, I have only witnessed further rationing, reduction in service provision and more bickering, among ALL the stakeholders. Followed by this there appears to be a paralysis at senior level to make decisions and move forward as private stakeholders wrestle with NHS Trusts and other stakeholders for the immeasurably smaller pot of money available. Very difficult times and very depressing for anyone working in the NHS.

    1. I couldn’t agree more. The system (especailly at the top) behaves as though the money is the risk whilst completely ignoring the effect on morale, which represents a far greater risk. You can temporarily fix the cash by 1-2% on income tax and have that start flowing in ‘days’ comparatively but if you disengage the workforce to the point of retirement and emigration, it can take 10 years to restore order given the recruiting and training time for a consultant. And then there’s nurses… very scary.

  4. l feel that NHS and the public has to go through this scary period of cuts, deterioration of quality of services and further privitaization, since not enough people realized and felt the impact on NHS to vote for a radical change. The radical plans for changes are there in one party’s manifesto but unless majority of public vote for them, we will keep on travelling down the same difficult road. My hope is for people who did not vote for radical change in this election might be able to change their minds after seeing further deterioration and disintegration of NHS in next 5 years.

    1. IF… the NHS lasts 5 years. Actually, my greater fear is that by the time the need for a radically different approach is accepted by sufficient for it to happen, we will have done so much damage to morale and the workforce that what we decided to do next with it won’t be possible. Having just learned that Jeremy Hunt gets to stay as SoS post-election, I am convinced their is no change of direction on the cards.

      1. Andrew, The NHS WILL survive.
        My sincere wish is to see that it metamorphoses into an institution that can be flexible with patient centred and focussed processes and pathways that eliminate the strangulating “silo” policies and procedures that create so much waste.
        This before I get to the stage when I become a serious burden on society. Hopefully prevention will prevail and I can remain in the work place to “do my bit” on a reduced salary contributing to society.

        This crisis is not about pay, salaries and clinical performance it is about a National business that is run on Sixties foundations made of sand.

        Of the total NHS staff bill what proportion is on Clinical Staff and what proportion on “others” ( and that should include so call directors that are still retaining clinical status)?

        There is a huge waste of cash spent on Void areas of properties retained by the system, the archaic method of invoicing and accounting that keep an army of people off the “unemployed” list (thanks to the Bliar / Brown era ) not to mention the mirror imaging in the Social Services.

        Merge the two, knock down the silos, resolve this senseless “cash chase” and arguing through and across organization and create one Organisation per region. That will bring economies of scale on the non clinical releasing cash for clinical —- simples.

        Oh – sorry …. that is STP is it not?

        1. As someone rightly commented on HSJ earlier, STP is potentially in major trouble with this election result because who will want to upset their local population whilst viewing their political existence as rather temporary and tenuous…? Much that I can;t disagree with though and we will also need ‘healthcare’ just not necessarily in the form of now. By the time you’ve changed the whgole structure, the funding form, the relationship of patients to it and the guiding principles, you’d have to argue that you have a new health service… not that this in itself is necessarily a bad thing.

  5. If we want to keep an NHS we have to agree what we can and can’t afford and what it can provide. The biggest problem is that no politician of any flavour will address this question. We can’t provide everything for everyone – no-one anywhere in the world does that. The unpalatable question is what should not be provided, Treatment for smoking related problems – doubtful that some/any tax has been paid to fund treatment for this. Treatment for obesity – probably better to stop the feeders providing calories for the obese – an operation and the never ending sequaelae to “treat” this border on the immoral and criminal. Treatment for infertility – distressing but not the responsibility of the state. Treatment for alcohol related problems – a substantial rise in taxation for off-sales might go some way to address this, The NHS will fall apart soon unless someone addresses these problems – I won’t hold my breath.

    1. And of course the reason we are at this point is due to a decade of politicians shying away from the real issues. I and numerous others have long (10 years now) campaigned for an adult debate on the issue of healthcare system sustainability, rather than the ‘just one more year of cuts’ repeated sticking plaster approach that is so damaging. We are now at a level of healthcare expenditure as a proportion of GDP at which Don Berwick said no western nation was providing a robust and secure health service at…

  6. The Liberal Democrats at least had the nous to say in their manifesto that the NHS needed increased funding and that people would have to pay if they wanted to keep it in anything like it’s current form. I think their idea of a tax ring fenced for health care spending was a step in the right direction and one that the public could see the sense of.

    Other issues that remain to be sorted out are the ever closer union of the NHS and Social care services and the fact that the burden of savings targets facing trusts creates a situation where it stifles the risk and innovation that is required to address our current problems. Furthermore, it seems such a shame that there cannot be some sort of removal of the NHS from recurrent political interference. I appreciate that with all the money that the NHS consumes it is not possible to avoid political interference. However, some sort of cross party group or delegation to an apolitical civil service management board might be seen as less divisive than the current system where each new minister just can’t wait to change everything like some sort of dog scent-marking it’s territory! Enough!

  7. In the current political situation (Brexit, hung parliament), the NHS will simply not be a priority (i.e. put enough money in to minimise bad press coverage and that’s it, apart from encouraging things that might save money). This feeds in to your thesis of HealthCrash (yes I am the proud owner of the book).
    Having worked in the NHS for well over 30 years in the hospital sector I would conclude that there are a myriad of problems but 2 stand out.
    Firstly, the NHS, for a long time, and certainly since the internal market, has been finance-led. This has resulted in poor decision making and infected most health centres and hospitals. I would contend that a safety and quality driven NHS would not only do what it was set up to do but also be cheaper in the end (individual departments that have this ethos often come in on budget (including overheads) and the “management” are grateful but don’t know how or why). This comes from the very top. If medical “Heads of Departments” also had training in running the budget and did so (i.e. directing with administrative help not managing) rather than having to argue with managers for the last paperclip, this might come about. Yes I’m sorry but General Management is a problem. Highly motivated professional staff can have their aspirations knocked out of them quite easily.
    Secondly disempowerment of patients and populations. The NHS was primarily set up to help the poor with their health (the private sector was already serving the well off in a timely way and a manner appropriate to technology at the time). What helped the poor were TWO things. One, the fact of the NHS (free at the point of use paid for by general taxation) and two – access to it – local GPs and the district hospital movement (bringing together disparate local facilities on one site, no further away than the various parts were previously). Major centralisation initiatives (taking facilities to distant sites and closing acute services etc, more included in most STPs) are totally against what local people in many localities want and know they need. This is NOT in keeping with evidence and is massively disruptive. For example Bristol University demonstrated that Acute Trust mergers did not improve quality or save money in the short or long term yet this is still the model. There is good evidence that in acute services, time matters (“golden hour” for major trauma – that’s why we have helicopters, 1% increase in mortality for acute, unsorted medical admissions for every 10 Km from A&E/acute services, increased maternal and perinatal mortality after 20 minutes travel time to acute maternity units – which is why no mother in Holland is further away that that). Disease-specific arrangements are rarely based on much, if any, evidence (and there is often bias in the way it is sought) – and even where there is, the differences are a lot smaller than you might imagine. A “general direction of travel” argument is often the limit of the intellectual effort.

    If we could have locality combined acute/community/GP trusts with a unified budget (and therefore no perverse incentives), a fully functioning DGH for every 250,000 population (average, depends on geography either way) and a quality/safety led ethos we might just “save” the NHS – and hey – we might find it’s cheaper. The main issues would be de-managerialisation and re-enthusing of the clinical staff and I don’t underestimate the difficulties in that. The people on the ground usually know what’s going wrong but are powerless.

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