Andy Cowper on what he calls ’the Campaign for NHS defunding

The striking success of CND – the Campaign for NHS Defunding – is one of the more interesting developments in recent British politics and public policy. This is surprising, when you think that the NHS consistently tops polls of why people say they are proud to be British.

NHS funding is, of course, still marginally increasing: it isn’t scheduled to be cut per person in real terms until next financial year.

Defunding and demand

So why am I calling what’s happening “defunding”? Because demand is outpacing the marginal financial growth. NHS Commissioning Board chief executive Simon Stevens covers some of the reasons in his five paradoxes: the first of which is worth quoting in full:

“We’re getting healthier, but we’re using the NHS more. Life expectancy has been rising by five hours a day, but the need for modern NHS care continues to grow. Demand for health care is highly geared to our growing and ageing population.

It costs three times more to look after a 75-year-old and five times more to look after an 80-year-old than a 30-year-old. Yet today, there are half a million more people aged over 75 than there were in 2010. And there will be two million more in 10 years’ time. 

“Demand is also heavily impacted by rising public expectations for convenient and personal care, the effectiveness of prevention and public health, and availability of social care. Even more significant is the steady expansion of new treatments and cures, of which the public are often unaware”.

No sense of urgency

Why is there no real sense of urgency in British politics about the NHS? The latest “Isues Index” data (the long running Economist/Ipsos MORI poll) suggests that it’s highly salient to the public. But the issue that’s running it a close second – the slow motion car crash of Brexit – gives us one clue about what’s consuming most of the oxygen in the vacuum of our current politics.

Part of what could be at work here is one of Cowper’s Universal Laws of Healthcare: the Inverse Scare Law. This suggests that the frequency and volume of NHS crisis stories may be in an inverse ratio to their political effectiveness

It’s not as if the various think tanks and national representative bodies have been under Trappist vows of silence about the NHS’s financial plight. This clear and cogent analysis and explanation from HSJ’s former news editor and now Nuffield Trust mainstay Sally Gainsbury is as good an example as you’re going to see.

For some time, her work has explored the “mismatch between expenditure and income as a trading gap, which has emerged as a direct consequence of deliberate NHS policy over the last decade”. This briefing is extremely illuminating on the accountancy tricks, non-recurrent savings and the real, underlying deficit for 2016-17 being £3.7 billion, rather than the headline figure of £791 million.

It’s important work: go and read it.

Another recent warning about NHS demand and finances came from NHS Providers, whose chief executive Chris Hopson wrote about the discontent of our winter for The Guardian.

So there seems to be a consensus that the NHS demand/funding mismatch is a real problem among comment editors (a bizarre bunch at the best of times); representative body leaders (who of course have skin in the NHS finance game); the taxpaying and voting general public; and almost everyone you talk to in the NHS apart from Tim Briggs, to whom we will return.

The latest British Social Attitudes Survey also suggests that the public’s views are turning against government spending less.

The obvious group who don’t seem to be buying into this consensus is the government. The Opposition has been worrying at the NHS for years: this is of course what oppositions do. Healey, Burnham, Alexander and now Ashworth have made efforts to get the issue before the public (with increasing levels of effectiveness), but it doesn’t feel like the main order of the day at Westminster.

Why has the NHS lost the narrative?

This is down to a range of reasons, some of which are slightly complex.

That BSA survey’s health questions are now funded not by government but by the King’s Fund, and their latest headline findings found that in 2016, public satisfaction with the NHS overall was 63 per cent; satisfaction with GP services was 72 per cent (and as in past years, that was higher than satisfaction with any other NHS service); and satisfaction with accident and emergency services was 54 per cent in 2016.

These are not great figures, but given the NHS’s homeopathic funding increases and the growing population (in number and obesity), nor are they dreadful.

Part of what could be at work here is one of Cowper’s Universal Laws of Healthcare: the Inverse Scare Law. This suggests that the frequency and volume of NHS crisis stories may be in an inverse ratio to their political effectiveness.

Logical and theological thinking

There is a lesson here for Labour. The frequency with which their attack line has been that the NHS is being privatised has, frankly, not got beyond their political base. The boy/girl who cried wolf is a real thing.

There is also a strong counter narrative of NHS inefficiency and waste

Privatisation is when something that was formerly a government-owned service or utility (like British Airways, British Telecom and British Gas all were) is sold off to the private sector investors. You can literally buy shares in a privatised organisation: that’s a lot of the point.

If you want to constantly claim the NHS is being privatised, you need to be able to tell people where they can go and buy shares in the NHS. Not in Virgin, or Spire: these are private sector companies to whom the NHS contracts out services. A bit like GMS GP practices, or dentists.

The debate about whether private or public sector is best for the NHS is in the main about as helpful as debating whether the NHS should be run by Catholics of Protestants, or Sunni or Shia Muslims, in addressing the real fundamental problems of variation (Tim Briggs’ point with Getting It Right First Time and management and process inefficiency.

So much of this private/public debate isn’t really a debate: it’s statements of religious faith on both sides. There’s too much theological thinking in an area where logical thinking would be far more use.

Who else might be a trusted messenger? Clinicians? You’d like to hope so, but the omens are not good. The British Medical Association was broken in the court of public opinion by the junior doctors’ strike; the royal colleges are too numerous and disagree too much.

There is also a strong counter-narrative of NHS inefficiency and waste. People who use the NHS sometimes encounter excellent, well-planned and well-signposted treatment: they also sometimes encounter unhelpful staff, inaccurate or missing records, non-use of cheap, effective technology like text message reminders of appointments, and badly coordinated care. And they notice it as waste and inefficiency.

Professor Tim Briggs’ comments about the NHS deserving no more money until it gets its house in order put a few noses out of joint, but it’s hard to argue with some of the emerging data. As many as 71 of the 142 orthopaedic units in England identified savings of between £20 million and £30 million after an initial GIRFT visit, with an additional £15 million to £20 million forecast for the succeeding 12 months.

How do you cut down on waste and inefficiency? You have good, well-trained and adequately resourced managers who can work with staff in all disciplines to drive out these twin wastes of public money. Or as dear old Lord Lansley used to call them, “bureaucrats”.

The Campaign for More NHS Management, anybody?

No, I thought not.