It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.
In the part 1 here, we looked at why the NHS budget must rise 3-4% per year just to stand still.
In part 2 here we saw exactly how this isn’t happening and the catastrophic effect it’s having on the National Health Service.
Now we examine why.
It’s clear the trend of rising demand and falling budget is not compatible with a sustainable health service, and after six years, the NHS is about to collapse. The question we have to ask is why would our leaders stand by and ignore, even exacerbate, the demise of the one of the safest, most efficient and equitable healthcare systems in the world?
Medicine is all about making choices: when you are faced with two courses of action, how do you decide which to take? What do I think the diagnosis is? What is the probability it is? What is the benefit of treatment? What is the risk if I don’t treat? What is the risk if I do? Standing by and allowing the collapse of the NHS is a choice, not a necessity.
The popular myth about the NHS, and the words certain elements are already chiselling into it’s tombstone, is that it is ‘inefficient’, ‘bloated’, ‘out-dated’, and we simply ‘cannot afford it anymore’.
The entirety of that belief is simply untrue. The NHS is ranked as one of the industrial world’s most efficient healthcare systems, and amongst the sleekest in terms of money spent/individual. Far from ‘out-dated’, NHS researchers and hospitals have pioneered some of the world’s greatest medical advances; Tuberculosis treatments and the first successful kidney transplant*, we invented surgical robots and participated in the world’s first lab grown organ transplant. Most recently we are the first country in the world to vaccinate against Meningitis B.
So the real question is “Can we afford it?”. The short answer is Yes.
The long answer is more complex. Every pound spent on a public system is a choice; it is an ideological choice, a financial choice and a political choice. When the NHS was first created in 1948, the political and financial situation was dire: the UK debt was twice the size of the economy (214% GDP), and politically Nye Bevan faced extreme opposition, including, shamefully, from the professional body of doctors at the time. Here a difficult financial and political choice was trumped by an ideological one; the idea healthcare provision should be available to all. Flash forward to 2008 and the global economic crash required another financial choice; to bail out the banks – at a total potential cost to the UK economy at the time of £1.162 trillion, which meant UK debt doubled from 39% of the economy in 2008 to 84% in 2016.
So the choice to fund the NHS today is actually three choices: political, financial and ideological.
Financially, if we compare 2016 to 1948 – our countries debt is a third of what it was when the NHS was created. Our international counterparts in similar financial circumstances have made a financial choice to spend more of their economy on healthcare. By 2020, that gap will be much more, and we will be spending amongst the lowest in Europe. And remember spending on healthcare isn’t an economic black hole – in areas such as public health every £1 spent to prevent disease saves as much as £5 on future health costs. More on this below.
Politically the NHS remains very well supported. It was even a part of the Olympic opening ceremony. However, the last government made a political choice to stake their reputation as leaders on reducing government spending, for no good financial or economic reason. Many economists and the IMF reject austerity as a means to increase growth in a country.
So what’s the issue?
It’s ideology. George Osbourne and Cameron believed in a small state, and that private competition is the most efficient means to achieve the best allocation of resources, a principle of economics that has no evidence base in healthcare. Despite politically promising no ‘top-down’ reorganisation of the NHS, in 2012 the largest ‘top-down’ reorganisation in the history of the NHS was pushed through in the guise of the Health and Social Care Act. This made it much, much easier for private companies to take publicly funded contracts away from public hospitals. Privatisation of services increased 500% last year.
As public services decline due to lack of public funding, further private companies will come in, and without intervention will eventually take over the entire service. Re-nationalising our hospitals and GP surgeries once this happens will be nigh impossible.
So what can be done?
Well the choice to maintain a publicly funded NHS isn’t as simple as “are we willing to keep spending more money on the NHS?”
There are many areas in the NHS where vast amounts of money could be saved and redistributed, without an extra pound from the Treasury. I’ve written about this before.
The two predominant areas of waste in the NHS are not how care is given, but where care is given. Currently private finance initiative deals provide £11 billion pounds of worth to the NHS, in the form of buildings and maintenance, but will end up costing the taxpayer £80 billion in interest. Hospitals like Barts Health in London pay £2.7 million a WEEK in interest on these deals. Why hasn’t this been addressed? Again it’s a choice not to. An alternative choice would be to nationalise this debt and renegotiate it – even restructuring it to paying 1/3 less would save the NHS £23 billion – enough to fund it fully for the next ten years.
Similarly the cost of administrating competing private companies and contracts in the NHS has a huge cost – estimated at around £5 billion/year. Reverting back to a purely state-funded and public model isn’t an ideological dream of left-wing liberals – it’s a sound money saving effort. Again, it’s a choice not to do this, because ideologically the government has chosen to create a system that prefers private competition, without any good financial, economic or scientific reason.
And if we don’t plan in the long-term to prevent diseases; diabetes, obesity, falls in the elderly, stroke and heart attacks – we are shooting ourselves in the collective foot. But a political choice was made to save short-term money on public health. Cutting social care costs us 2-3x much as it saves: I regularly have patients waiting for relatively cheap social care in highly expensive hospital beds, or contracting easily preventable conditions in inadequate social situations that develop into hugely expensive and life-threatening disease.
This is what happens when an unstoppable force meets an immovable object. Demand for healthcare is currently unstoppable; it rises 3-4%/yr, and without taking preventative measures, will continue to do so. The government is apparently immovable; they steadfastly refuse to meet this demand, which every year creates larger and larger problems as patients suffer in underfunded and understaffed hospitals. Between the two the strain on the NHS has reached critical mass – it will collapse without drastic intervention.
Neither of these forces are truly immutable; we can curb health inflation with proper prevention and better social care, and we can both fund the NHS to an equivalent level for a modern industrialised country, and save vast amounts of money through removing deals that are criminally expensive and wasteful.
I hope you now see the NHS is collapsing, and in dire need of help. This doesn’t have to happen. It is a choice.
What will you choose?
Read the other parts in this series: The NHS is Collapsing.