The way to save the NHS is to allow it to be changed
WHEN is a crisis not a crisis? When it happens every year. This is the tale of the National Health Service. It is never in crisis because it is always in crisis. November has become the month where we talk about the looming winter crisis in the NHS and, as sure as night follows day, we’ll do it next year, and the year after, and the year after that, too.
The reason for the annual NHS introspection is far from any of the factors which the politicians, of all parties, and the vested interests within the medical world will claim it to be. It is not Covid. It is not trade unions. It is not money.
Instead, the reason for the crisis is precisely the key characteristic which those politicians and vested interests do not want you to know about. It is the design and structure of the entire service. Our National Health Service is one which is custom-built to be in perpetual crisis.
It is a health service which, because its supply is so centralised, runs on a full-capacity model whereby patients can be moved from facilities in NHS boards where services are full, to facilities in other boards where there is spare capacity. Furthermore, many specialist services are, by design, located in only one board area, which eliminates the need to provide capacity for them elsewhere. This is the very concept of the NHS – it is designed to be a pooled and shared, equitable service. The problem arises when, like now, there is no spare capacity.
Some health services, of which there are many good examples across Europe, are run on a more decentralised basis where there are several suppliers of state-funded healthcare. This means that each supplier has to ensure, to the best of their ability, that they have capacity. This leads to more, overall, as the figures further down this column show, so there is usually capacity somewhere else for a patient to transfer to during busier times, like winter.
We are deliberately poor at exploring alternative ways to deliver healthcare, because we have made the unilateral national decision that our NHS is the world’s best healthcare system.
Indeed, we increasingly speak about it as though it is the world’s only healthcare system; as though we are the only country with hospitals and that sick people everywhere else in the world have to lie in the street and hope for the best.
Covid has exacerbated this hysterical fallacy, and has perpetuated the inability to critique the system without being accused of criticising the people who work in it. However, any objective analysis of the NHS would very rapidly reveal that the assertion of it being a top-tier health service, far less the world’s best, is mythical.
The NHS is now in a nearpermanent imbalance of supply and demand. At its most basic, some of this can be put down to population increases. The NHS was designed in 1948 when the UK had 50 million inhabitants. The country now has a population of 70 million, but the service is almost unchanged. This imbalance, and more, is dramatically exposed in the statistics provided by the Organisation for Economic Cooperation and Development, recognised as a gold-standard provider of globally comparable data.
Perhaps the most important of the myths which the OECD exposes is that Scotland and the UK under funds our health services. This is not objectively true, and indeed, the relationship between inputs (money) and outputs (results) over many years has shown that more funding does the NHS little good.
According to the OECD, the UK spends just over 10 per cent of its GDP on healthcare, compared to less than nine per cent for the average country. For sure, some countries are up in the teens, but others are significantly lower.
Despite this above-average spending, though – and here is the problem with a centrally-planned system – we have around half the number of hospital beds per head of population than the average OECD country. There are two-and-a-half beds per thousand people here, compared to nearly fourand-a-half beds in an average OECD country. Imagine, for a moment, the difference in waiting times this winter and beyond if, as in Germany, we had eight beds for every thousand people.
The same is true with doctors and nurses. The UK has proportionally fewer doctors and nurses, and less than half the proportion than some high-performing countries. This gap is, by design, going to widen; we are training fewer doctors and nurses than the average. Ireland is training twice the number of doctors per head of population than we are.
The outcomes are predictable. Our survival rate following a stroke is lower than average, as is our survival rate after major cancers such as cervical and oesophageal. Diagnosis for breast cancer takes place at a later stage than in other countries.
It would be fair to ask where the money is going. But, in fact, it’s a fairly hopeless exercise. Supertankers like the NHS cost a lot of money to run and have to build in a great deal more inefficiency than a larger fleet of smaller ships.
Supertankers are also extremely difficult to turn around. You cannot, in practice, get one of the world’s largest employers to move to a flexible 24/7 service or to stop using fax machines (really, they do) but you emphatically can make such changes to smaller, more malleable, more nimble units.
And so, this is really the heart of the debate. The future success of our health service depends on system change, not solely on money. It depends on us – all of us – leaving behind our emotional attachment to the NHS as a system, and focusing instead on building a better system which retains taxpayer-funded access to healthcare.
In other words, a system that honours the laudable intentions of the NHS, but works better. Those who claim to be the NHS’S high protectors – those politicians, doctors and academics who tell us we’re the envy of the world – are in fact the opposite.
There is a crisis in our health service. But it has been caused by a crisis in our heads; an emotional attachment to a failing system. The only way to save the NHS, now, is to allow it to be changed.
We are deliberately poor at exploring alternative ways to deliver healthcare, because we have made the national decision that our NHS is the world’s best