NHS reform: Why the NHS must change to survive.

The NHS in its current state is a bureaucratic financial nightmare and cannot survive.What started out as a global icon in healthcare is now grotesquely inefficient and totally unsustainable.

History and origins.

The NHS was launched on 5 July 1948 by the then health secretary Aneurin Bevan. Bevan had been a champion for social and welfare reform and argued that every citizen should have a right to free healthcare.As such, the fundamental ethos behind the NHS was that it would provide free medical care to all Britons and would be funded through general taxation – the concept being that the rich would pay more than the poor.

The NHS was founded in an era of post war optimism and the vast majority of people were very keen to see the NHS prosper. Prior to the NHS was a deeply fragmented system of hospitals and localised health services.Although some of these schemes were free for rate payers and certain groups, they were not free and accessible to all, and there were only a limited amount of free and charitable run hospitals.What the NHS did was to nationalise all of these institutions and offer a framework for modern and universal healthcare.

Then and now.

The NHS was formed after the war in a time where people were very much used to hardship and austerity. Prior to the formation of the NHS many people had experienced no kind of health care and as such the NHS was a massive leap forward. It was a pillar of welfare reform and greatly helped post war Britain to move forward with a healthier and stronger population. Back then however NHS provisions were much more basic than they are today and expectations were much lower. People were happy with basic healthcare because it was far better than what they had experienced before.

The problem today is that the NHS is much larger and provides far more services. Moreover, these services are considerably more expensive due to advances in technology and medical research and the population is getting older with people living longer.The UK’s membership of the Euro zone also means more foreign workers and immigrants have access to the service. This all means more people are using the NHS and for much longer. Todays society also bring with it much more demanding health needs.

The one thing that hasn’t changed with the times however is the expectations of the NHS.The organisation still provides free healthcare for all at the point of need and is still funded through general taxation. So what’s my point? Well my point is that the Founding principles of the NHS are not financially viable today. The problem is one of cost and frankly without significant change the NHS will burst at the seams.We are putting more stress on an organisation that is costing more and more every day and we simply cannot afford it.

This may sound controversial and I’m sure this article will upset a few people. I am however just trying to be realistic. I love and believe in the NHS but we have to be realistic about our expectations. No body can deny the spiralling costs and our ageing population.These are facts. Bearing this in mind, ask yourself where the additional funds are coming from? How can the NHS be sustainable when costs are going up but people are not willing to pay more?

NHS funding.

Funding the NHS has always been an issue. Even back in the 1940’s the NHS was hugely expensive and went massively over budget.This is one of the reasons why prescription charges eventually had to be introduced.Today though the NHS is much more expensive.According to the guardian, UK expenditure on health (excluding family health services and GP) for 2011 – 2012 was nearly £1.7bn. That’s a huge amount of money.

Many people reading this article will argue that the NHS is easily sustainable with this kind of funding and that the reason why the organisation is struggling is that the money is being wasted on bureaucracy and management etc. whilst I would agree to a certain extent I think we need to be realistic as to how much money could actually be saved. Public sector organisations have always been poor with finances and efficiency but whenever the government mentions marketisation people automatically assume the worst.

So how else do you save money without significant change? Moderate reforms such as Introducing targets, bringing in private investment and running health trusts more competitively and accountable have already been tried. All of these ideas have been heavily criticised by the public and to a large extent have made no real difference. So the question is; if you cannot make the NHS more financially viable through moderate structural and operational changes then what are the options?

How about cutting funds in education or defence or pensions and putting that extra money into the NHS? Well not really because all of these departments are financially stretched too and this would result in somebody else missing out.This just isn’t an option and again the public would run riot.

The way I see it is that the current structure is just not working and previous attempts to make it more efficient have failed. The system needs to change fundamentally. Whichever way you look at it the NHS needs more money and until the public get to grips with this nothing will change. This extra money needs to come from somewhere else which is why I am in favour or either an additional NHS tax or a supportive insurance contribution. Of course this would all have to go hand in hand with a significant change in structure and a change in attitudes. There is no more money and unless funds are infinite then significant changes need to be made.

Public opinion.

As touched upon above, public opinion is a massive issue. Britons are so passionate about the NHS that it is just untouchable. No government has ever been able to make significant changes because of the potential public backlash.What government for example has ever been elected on the back of a pledge to completely reform the NHS? The government cannot touch the NHS and the electorate will never vote for a government who intends to significantly change it.This is the fundamental problem.

So when you really sit down and think about the situation what are the options? Unfortunately I don’t think the majority of the population truly appreciates the extent of the situation. People truly do not understand how stretched the NHS is and will not accept that the organisation needs to reform to survive. Unfortunately this reform will not be popular but is absolutely necessary.The NHS is at crisis point and cannot function in its current state.

The Health and Social Care Act 2012.

The current Conservative government in its attempt to scale back public spending and decrease the national debt acknowledged that the NHS needed to be reformed. Subsequently, the then health secretary Andrew Lansley introduced a bill of reform to parliament which suggested that a lot of red tape could be cut by sending the £80bn health budget directly to General Practitioners (GP’s) who would be responsible for choosing and buying health services on behalf of their patients. The idea being that GP’s know the needs of their patients better than anyone else and would be best placed to commission these services.

As thekingsfund point out however it was not seen to be appropriate handing such vast amounts of money directly to GP’s who in essence have never before been responsible for such huge budgets. As such the Bill was amended to include the formation of Clinical Commissioning Groups (CCG’S). These would be locally responsible for managing budgets and hold responsibility for the health of the local population. These CCG’s would be made up largely of GP’s but also include nurses, Doctors and public representatives. They will be responsible for buying services competitively from foundation trusts (hospitals), private hospitals, the voluntary sector and other health services etc.

It all sounds fairly simple doesn’t it? well actually its not as straight forward as it seems and we have to consider wether this is all for the best. The problem being that the structure is not as streamlined and straightforward as we have initially been led to believe. For example, the CCG’s will be supported by two new bodies: Commissioning support units and clinical senates. The former is responsible for giving technical support and support with contracts, and the latter for giving advice on specialist care for people with complex needs. Also above the CCG’s sits NHS England. They will be responsible for mainly specialist commissioning and the commissioning of GP services.

There are also dozens of other bodies and entities in support and accountability roles. thekingstrust points out this all makes for ‘considerable complexity’. For more info on structure check out: http://www.kingsfund.org.uk

The On 27 March 2012 the Health and Social Care Act 2012 gained Royal assent and the recommendations of the Act came into force on 1 April 2013. This shake up of the NHS is considered to be the largest restructure in the history of the organisation.  I am of the opinion however that these reforms do not go far enough and I feel the government has merely created a new system of bureaucracy and it it not clear where responsibilities lay and who is accountable to whom.

This is typical of all reforms. Governments tend to change things around a little and rename a few departments. They never go far enough in really streamlining the services offered and scaling back on the services for which we should not be automatically entitled to. As I have mentioned however, what government could ever suggest such controversy? They would never get elected. As such, we the electorate are partly responsible for the issues facing the NHS.

Looking abroad.

According the the World Health Organsisation the NHS is ranked at number 18 in the world. Whilst nowhere near the worst ranking we are far from the top. What I find interesting is how different the top ranking healthcare services are to the NHS. Practically all of the best healthcare services are far more reliant upon the private health sector and insurance schemes. People always tend to screw up their noses to insurance but it is not necessarily a bad thing. It stops people abusing the system and prevents a culture of hypochondria.

The French healthcare system, which is considered the number 1 in the world, adopts a system of obligatory healthcare insurance whereby every citizen pays in.  All citizens get a healthcare card entitling them to health services and pay an initial fee when visiting their doctor or dentist. This is then reimbursed by the government by up to about 80% with the patient expected to pay the rest. In many cases this fee is fully reimbursed particularly for people paying a top up fee on their insurance. The French pay more into healthcare than the British but the system is considered far superior with mostly modern, well equipped hospitals and high quality care services.

Japan also run an insurance based healthcare scheme whereby all citizens have to have medical insurance. This is either through employers or through paying into the national health insurance program. The government has strong control over medical fees and as such can keep prices down. Patients are expected to pay up to 30 percent of fees with the government paying the rest.

Im not saying that either of the above healthcare services are ideal, but what they both share is that patients are expected to pay a contribution towards health care and treatment. Both systems also work very well. Such models as these may not be completely compatible with the NHS but I think we need to explore how an insurance based health service could work.

Providing that it is affordable to all and nobody misses out, there is no reason why this wouldn’t work in the UK. The NHS should still act as a safety net and provide emergency and critical care, but for the additional services and enhancements, a insurance based system could really help to free up the NHS and could prove cost effective.

The Future of the NHS

It is my opinion the NHS should be there to offer a safety net to people who really need it. The NHS offers far to many luxury services which we now all feel we are entitled to. The services offered by the NHS should be scaled back so that more money can be put into vital services such as cancer treatment, stroke rehabilitation and mental health (which has historically been under-funded). The NHS should focus on critical health issues and accidents and emergencies only.

If people want luxury services then they should access private health care or pay extra for it. This is where I think much more attention should be directed. There should be far more cooperation between the NHS and the private sector so that we can free up the NHS to people who really need it. Im not at all advocating a privatised system but rather a reformed system where the NHS is less relied upon.

Things have changed so much since 1948 and we really need to get over this sense of entitlement that we all have. Yes we do all pay for the NHS and are right to be passionate about it, but we need to be realistic about our expectations. If we want more from the NHS then we need to pay more. If we want better core services then we need to think more about what the NHS actually offers. It cannot be everything to everybody and as such in its current state it cannot survive.

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