The “NHS at breaking point” media furore has become a fixture on our winter calendar as regular as Christmas and New Year. Hospitals at full capacity, patients experiencing substandard care, the elderly and vulnerable hit the hardest. The basic story zooms in and out of media focus – the latest headlines will no doubt remain until the politicians return to Westminster and provide new intrigue for journalists.
The recurring coverage is frustrating because it never drills down beyond the surface of what’s going on. As we enter the 70th anniversary year of the NHS, it is surely time to look beyond the symptoms of the problem and try to diagnose the causes. The NHS is certainly struggling to meet demands. But the remedies cited by NHS chiefs and politicians willing to speak on the issue (both Tory backbenchers and Labour frontbenchers), simply amount to better planning and increased funding. This misses the point that the system we have today is largely unchanged from when it was first established in 1948.
A hospital-dominated system of healthcare was designed to meet the needs of a post-war population which had about 15 years lower life expectancy than today, and when ‘public health’ referred to the requirement for basic sanitary living conditions. 70 years later, our health needs have evolved: we are living longer (and many of us with long term, complex conditions) and there is now a prevalence of so-called ‘lifestyle-related’ conditions (indeed, the obesity epidemic would have inconceivable to those who designed the service during a period of rationing).
In the last 70 years our health needs have evolved, but the basic infrastructure of the health system is largely locked in time. The cumulative effect of this is that it is now struggling to cope with pressures it was fundamentally not designed to respond to. The lack of sufficient community-based care which could provide support for people to live independently means that too many end up in hospital and “bed-block”. And the lack of capacity in the system to do proper prevention means that too many “unmet needs” walk through the doors of A&Es when they should have had appropriate support before crisis hit.
As a result, the NHS is locked in a vicious cycle whereby the acute end of it picks up the consequences of a deeper failure to adapt. But by doing so it sucks in further resource and capacity which makes it harder to make the community-based, preventative shift that’s actually needed. Social care provision has been pared back to only the highest needs due to reduced council funding and just before Christmas the Government slipped out an announcement of another cut to already insufficient public health budgets. In the zero-sum public spending climate we continue to inhabit, these decisions will store up further problems for the services of last resort – hospitals.
In this regard, simply prescribing better planning and more funding is not going to cure an ailing service – we need deeper reform too. Channelling more capacity and resource into a system that is fundamentally not fit for purpose will only become more expensive over time and won’t reorient the system to address today’s health needs. The sorts of reforms required to make the shift were spelt out by the Place-based Health Commission, which argued that we need full scale transformation from a monolithic institutional service to person-centred health and care provided locally. This would constitute a more effective “system” which addresses not just clinical needs but also the wider determinants of health outcomes – the range of individual, social and environmental factors which impact our health.
As we enter the 70th anniversary year of the NHS, there is much to celebrate about the continued public affection and the political endurance of an institution with such noble aims as a universal health service free at the point of use. But if it is to last a further 70 years, we need a much more honest discussion about the scale of the reform needed to bring it up to speed with modern demands. Failure to do so risks continued erosion of the system – more stress for staff, deteriorating care for patients and more chunks of cash to plug hospital deficits.
This isn’t what anyone wants, so we have to start being more honest about the scale of the challenge the NHS faces. This involves prescribing remedies not just to the symptoms, but to the underlying causes of the patient’s recurring distress.