We need to recalibrate our view of what we expect from the NHS and what we wish to pay for. Patient expectations and NHS budgets do not match

Myatt comment graphic

Accident and emergency was out of the headlines on the day I wrote this. So the issue is over?

I say has it has barely begun. And it is part of a much wider pattern.

‘Winter pressures are multifaceted. Meanwhile, the people keep coming’

Some commentators say this winter’s pressures were caused by endemic inefficiency, or that we can solve the problems by sacking managers.

Others demonise the elderly and the ill informed for their lack of grasp of correct patient pathways, for turning up at A&E with non-life threatening ailments.

Some may even use the “C” word – no, not collaboration or capacity, but competition.

Many more reasonably point to funding that has not kept pace with demand or the inadequacy of social care funding.

Of course, it is multifaceted. Meanwhile, the people keep coming.

Unsustainable demand

The issues in A&E tell us lots of things – not least that staffing shortages kill you, even if you have the funding. Global health inflation means more countries want doctors and nurses, so they cost more or you can’t get them.

It is a signal that healthcare as we know it in the western world may not be viable forever and a day.

Lots of people have, of course, said that if we don’t think differently about the NHS, we won’t have one in the form of hospitals, social care, GPs and community care.

Of course we need to do stuff differently. But even with new models, we will not be able to contain health inflation and deliver to a high standard.

Costs and expectations will keep rising as we find new and ingenious ways to keep people who otherwise would have died alive.

‘Expectations will keep rising as we find new, ingenious ways to keep people who otherwise would have died alive’

We keep inventing ways to prolong and enhance life to buy our way out of our greed, idleness and sloth.

A paper by the King’s Fund on future costs showed that between 1950-51 and 2010-11 spending on the NHS grew by around 4.04 per cent annually in real terms.

However, over a similar period (1955-56 to 2011-12), real GDP in the UK grew each year by 2.54 per cent.

If the next 50 years follow the trajectory of the past 50, by 2062 the UK could be spending nearly one-fifth of its entire wealth on the NHS and employ around one in eight of the working population.

First world problem

Global appetite for better quality healthcare presents a further challenge.

Once people have access to good quality healthcare, they recognise it as a basic right.

Meanwhile, the burgeoning middle classes around the world are getting their first economic freedoms and demanding what we have – so would I , if I were them.

I recall during a visit to India I asked a prominent individual in healthcare which, if any, established healthcare system was being copied in India.

The answer was unequivocal: none of them. “They would all bankrupt us.”

‘As a society we have to review what we want and can afford, and work back from there’

I’ve written elsewhere about the lack of any meaningful societal debate about funding and trade-offs. Slender funding rises - far below long term historic health inflation trends - are offered by political parties that promise the best health service in the world.

As a society we have to review what we want to and can afford, and work back from there.

I don’t think we can afford to continue to buy more healthcare, to continue to professionalise, to add more into the basket of our tax bill or our co-payment or our insurance scheme. If in another 50 years it is 20 per cent of GDP, then in 100 years, it will be 40 per cent.

We will all live forever with round the clock nursing, or more likely terminating our existences in line with agreed plans. 

The irony is that in our heart of hearts many of us know that we’re passive recipients: proud of our rights but careless with our responsibilities.

We have passed our own sense of neighbourliness to the council; care of granny to the care home; our cough to the GP; and our poor diet and lack of exercise to the local acute hospital.

New perspectives

If we want to come up with a sustainable answer, we need to think about how we live, revisit our own expectations of ourselves and those around us, and recalibrate our perspective of what can be paid for – not just to balance the books, but to enhance the quality of our lives and our neighbourhoods.

One unconscious consequence of our transacting out our relationships and our responsibilities is the atomisation and isolation we see in our society.

A million older people in the UK describe themselves as “always or often lonely” and the half of older people say the television is their main company. 

‘We need to think about how we live, revisit our own expectations and recalibrate perspectives’

We need to look hard at what is paid for and what activities might in the future be completed as a civic act alongside paid employment or dealt with voluntarily in communities.

I do not wish to do a disservice to the millions of unpaid carers whose relentless and thankless struggle is often paid lip service – quite the opposite: what I am saying is that in the possible future I foresee, there will be more unpaid caring for every one of us. This should be a matter of civic pride and rewarded as such by society.

Innovation under way

More widely there is a social change happening – imperceptible, perhaps, but a change nonetheless.

Innovation charity NESTA’s list of 50 new radicals shows that people are trying to find ways to deliver social good for free using the competencies of people in communities, and harnessing their energy and skills for a wider social purpose. Some might call this a social productivity gain.

People are thinking about how we live, how care homes and schools can be combined to break down generational boundaries and combat isolation, how exercise groups can combat loneliness or how older entrepreneurs can become mentors to the needy looking for a break in life. 

We need to apply this same thinking to health and care. To expose the issue to the talents of our neighbourhoods.

‘We may need to train all of our children with basic nursing and medical skills to support this new civic culture in a decade’s time’

I’m told that it is too hard to shift more activity from the payroll. It’s hard for the volunteers and the community; this is skilled work that people can’t do for themselves, that public health efforts are both in train and long term and that even then, these efforts might not make much of a difference.

But if we all had a better view of the constraints and more practical knowledge in our own homes and neighbourhoods about mental and physical health, social care and wellbeing, we could do more for ourselves as active participants and pool what money is left for complex work. 

We need to open up our minds and ask what we really could and should be doing for ourselves. Increasing our own confidence and flexibility where health is concerned rather than seeking to medicalise, professionalise or commercialise our own wellbeing.

We may need to train all of our children with basic nursing and medical skills to support this new civic culture in a decade’s time. Arm the next generation with the skills to self-manage for themselves and their families.

The free apps, social movements and technology will follow. 

No one has the answers, however within our neighbourhoods we have the talents to find the solutions, if not for today’s crisis then instead for the one a generation hence and given the future challenge, how many choices do we have.

John Myatt is strategic development director of Serco Healthcare and a commissioner for the HSJ/Serco Commission on Hospital Care for Frail Older People