The NHS needs space to grow, not boundaries within which it must stay, says Charles Alessi.
The relationship between the citizen and the state is undergoing significant change, and this evolution is set to continue. This is exemplified in healthcare. Relationships between clinicians, patients and local populations, which were once secure and robust, are now becoming more tenuous, in some cases, and fractured in others. The trust, which formed part of that relationship, was once never questioned; the underlying respect is no longer so evident.
A state of malaise has existed for some time. It would be invidious to point fingers at where the responsibility for this lies, but the very wide availability of immediate information via the internet, despite being a positive development, is a significant contributor. Thinking back to mad cow disease, weapons of mass destruction, duck houses, and mid Staffordshire will make it obvious that other contributory causes explain why this relationship is now in need of some attention, or, worse perhaps, admission to an intensive care unit.
It is no surprise that there seems to be a disconnect between what is said specifically about health, and how it is perceived. I recall those days in school, where we all sat in a row and whispered a few words at one end, and waited with baited breath to see what transpired at the other. I still cannot quite comprehend how “yellow bananas” became “your old pyjamas”.
If this disconnect is applied to the difficulties we all seem to be having with reconfiguration of hospitals in England, it is no surprise the message becomes garbled and, in many cases, it is precisely the wrong end of the argument that receives most air time.
The impression abroad is that England is constantly reforming its healthcare systems, and has been doing so since the 1970s. There is an element of truth about this: as the anticipated outcomes were not delivered, reform has followed on the heels of reform, political party has followed political party. This has continued through to today, with the Health and Social Care Bill being described as revolutionary and radical, when, in reality, many of its constituent parts are merely a natural continuation of the “Blairite” reforms.
Is there anything about these present reforms which offers more hope than their precursors? Opinion is varied, but I believe the localism agenda offers us new opportunities to deliver better and more relevant care, if we, as Clinical Commissioning Groups (CCGs), are allowed the oxygen to breathe life into them.
Healthcare delivery and expectations in England need to change. We are fortunately in a better condition than the US, where, should healthcare spending continue at the present pace, 100 per cent of their Gross Domestic Product will be consumed by 2065. It should come as no surprise that we are moving in a similar direction; as the population ages, treatments become more complex and costly, and money tighter. The most recent OECD figures for health make interesting reading, as, for the first time, health spending in the United Kingdom in 2009 exceeded the OECD average (9.6 per cent) and stood at 9.8 per cent of GDP (of which 84 per cent is via public funding – the NHS).
Levels of trust and engagement at local level in natural communities are still strong. In many cases, the contact with primary care is the sole anchor point for many of the more needy families. The relationships between primary care and the populations it serves are still what make the NHS stand out from most other healthcare systems in the developed world (the “jewel in the crown”, as described by Don Berwick, the ex-administrator of Medicare in the US). In terms of quality, the NHS, with all its problems, is still one of the best-performing healthcare systems, in the company of countries such as Switzerland, where the cost is significantly higher, as evidenced in the latest international Commonwealth fund review.
We, as clinicians in CCGs, need to exploit these local connections and energetically start to design healthcare around the needs of the population, not institutions, but now with the full engagement and support of the population in question. The days of paternalistic, top-down leadership are not congruent with the connected iPhone generation.
We need to enjoin our populations in the design and delivery of health and social care; localism shows us a new way of delivering this. It has far greater impact, when talking about delivery and design of healthcare, to more connected and empowered groups of people, where the local relationships are established, and there is trust and respect for the views of the clinicians, who are discussing and leading potential change. An essential component of this package will be the local authority and the local democratic mandate it brings. We await the unveiling of reforms around social care, and hope these will complement the current health reforms. In truth, there is no way forward, save for a more locally-determined and delivered agenda. In England, we have had more experience of top-down systems than anywhere else in the western world; and our success has been very limited. If one had to look to a more centrally delivered model than in this country, the obvious places are Maoist China or Stalinism in the USSR. Is this really a desirable aspiration?
There is some justifiable concern that local politicians do not welcome the notion that, in part, they are responsible for the delivery of health. This is understandable, as it is far easier to stand with large banners outside well-loved local health institutions, resisting change, than to be identified as part of the delivery of change. Perhaps this also is a reflection of the stature of local politicians. At present, the aspiration of every young person, who aspires to a political career, is to appear on the national stage and be a national player. Our aspiration for the future should be to emulate the devolved government of some of our European colleagues, where local democracy captures the interest of its people. Countries such as Germany offer federal models, which illustrate what can be achieved. Adoption of a more devolved model of government will also change the perception of the capabilities of local government, and make the health and social care reforms more likely to succeed.
There is another essential component to assist in the delivery of health and social care. For there to be a reasonable chance of success, there also needs to be a shared and truthful narrative. A narrative which acknowledges that the discussions need to be about prioritisation of resources within a population-health-defined envelope, not the attribution of blame on other sectors within health or social care. We need to move away from the tribalism that exists amongst healthcare professionals, where relative worth is defined by whether one belongs to the primary or secondary tribe, which, in many respects, mirrors old class systems. Again, we need to appreciate that this way of working no longer fits within the instantly connected working practices of the 21st-century.
Our challenges are many, but the redesign of primary health to make its outcomes more predictable and rout out unwarranted variation is a significant aim. Without a more dependable and predictable primary care, which is more closely aligned to its local government, the likelihood of success is diminished. The reconfiguration of the secondary sector also remains an unrealised ambition. We, sadly, still think in terms of structures and institutions; perhaps we need to consider reforms in terms of the care pathways and co-morbidities of our populations? There is no reason why we should continue to persist with the model, for example, where mental health is delivered in a way that is separate from both primary and acute care. This only institutionalises both the tribalism and the structural barriers we need to manage out of the system.
Finally, the last and most important ingredient to success is the population, and the individual. They both need to be genuinely in a position of control in the determination of their destiny. They need to own their medical records, not merely to gain access to a record of their health, but to ensure that they are the most important determinant of the style and model of health and social care they receive. Accountability in health systems is one of the most discussed areas of health care policy internationally. Localism shortens lines of accountability and makes change more likely to succeed.
We are at yet another defining point in the healthcare reform agenda. The NHS has been compared to a living organism in the way it functions; three species come to mind: one is the human species, which has survived and evolved over the years to accommodate the environment and predation it lived within; another is the dodo that was unable to adapt to the changes and thus became extinct; the third species, which has survived despite the changes to the environment and predation, and is largely unchanged over thousands of years, is the cockroach. It would be a gargantuan tragedy if the NHS was perceived as a pest, which needed to be controlled and exterminated, to prevent it from becoming an impediment and barrier to change.
This essay appears in The next ten years published by Reform.