Where is the NHS equivalent of the strategic defence and security review?

The health service can be pretty insular so it is easy to forget that other public services are facing much large reductions of expenditure (relative to their current spend) than the NHS.

The scale of the cuts facing Britain’s armed forces is such that it has forced a reappraisal via the strategic defence and security review (SDSR) of what future capabilities the government can expect from the military. To be more precise it is reducing capability, as is obvious given the resultant physical reductions there will be in ships, planes and troops. 

In contrast, no such reappraisal of the role and extent of the NHS have been proposed, there is no NHS equivalent of the SDSR and there is no political, service, or public consensus as to what the consequences of the funding changes will be. Twenty billion pounds must be found, yet rationing remains a non word and politicians continue to tell the public that they not only deserve, but will get a higher quality (yet still comprehensive) NHS.

The experience of most readers will be that higher quality services normally require substantial investment, even if in theory higher quality might ultimately result in cheaper care.

To date the theory is stronger than the practice. Certainly bodies such as the CQC and the royal colleges set out requirements that take no account of the financial environment. Perhaps that is right and it is no concern of theirs, but the resulting financial pressure is real enough and a requirement to improve services combined with real reductions in funding will result in services from fewer locations.   

This is hardly news within the NHS although it tends to be viewed by staff with the same hostility and suspicion that sailors view the reduction of their fleet. The public’s reaction is even more unequivocal – they see the loss of hospitals as a manifest deterioration in services. Any headlines about job losses to doctors and nurses provoke a mixture of bafflement and anger. They haven’t seen anything yet.

Selling the notion that the NHS is improving whilst clinical staff are reducing will test the spin doctor’s skills (and the real doctors) as there is no Afghanistan to point to as an obvious unpopular area to reduce “overstretch”.

I am not arguing that there is no need to reduce the number of hospitals and undertake greater centralisation of specialist services. You can’t expect to meet increasingly exacting standards – especially for non elective care- with the existing workforce distributed across so many facilities.

However this isn’t just a problem to politicians - who seem to spend their time in opposition campaigning to keep hospitals open and generally demonstrate the fiscal resilience of a seven year old child in a sweet shop. It’s also an issue for those promoting a consumer driven health service. That is if patients are ultimately to take centre stage and not some ersatz proxy body - including clinical commissioning groups. The problem is that what the consumer may want may well be a long way removed from what central planners think they need.

However without any price signals to mediate demand where will this increased consumerism lead? It promises to be a strange world. You can be a successful consultant (as judged by referrals to you) and not only will you not get a penny more than your less popular colleagues, but your trust is set to get into trouble if your referrals lead to waiting time problems.

Perhaps those patients who choose popular consultants will not be counted against the wait time target because otherwise we will have to hope that the consultants in question increase their productivity. It would seem hope is all we have.

There have been acres of newsprint written about the “radical” Health Bill but to my mind it isn’t nearly as radical as its detractors and supporters purport.  As already noted it has done nothing to redefine the extent of the NHS, not has it introduced any measures to influence demand for services. In fact it sits squarely in the great – but distinctly non glorious - tradition of NHS administrative re-organisation dressed up as something more interesting.

Those who fear that it is the harbinger of privatisation of healthcare provision should reflect that it legislates little (and perhaps nothing) more than the previous Labour government had already set in place.

While some commentators get very excited about the capability or otherwise of GPs to commission services (while fair comment in itself I don’t know why they have such a high opinion of the people and organisations currently doing it) they might be better served criticising the absence of any reform of the entity that actually delivers service - the workforce.

Returning for a moment to the SDSR there were many problems it faced (a lot of them caused by incompetent procurements of extremely expensive pieces of military hardware-like the NHS’s national IT programme but on grander scale)  but one problem they did not have were concerns about the productivity of service personnel. Nor do you hear many people moaning about the pay of people in the forces (other than it is too low for the hardships and dangers faced).

The NHS has a massive problem with its workforce. The unholy trinity of Agenda for Change, the consultant and GP contracts have generally reduced productivity and been hugely inflationary. They are unsustainable and unless substantially reformed (for which you should read “torn up”) they will cost jobs and maybe the NHS its own future, because as it currently stands large swathes of the NHS workforce and its surrounding terms and conditions of employment are not fit for the job in hand. 

As a recent HSJ editorial has pointed out this “fact” is recognised by just about every board in the country and none of them are prepared to be the “first mover” in doing anything about it. They have their own good reasons not to do so and those who wish to see radical change in the NHS would do well to address what underpins such conservatism. Interestingly, it has nothing to do with 99 per cent of what is in the Health Bill.