Tuesday, May 10, 2011

Why the NHS still needs reform

The debate about the NHS is frustratingly binary. Public vs Private. Managers versus Doctors. Front-line services versus bureaucracy. Planning versus chaos. Gosplan versus the Wild West Discussion on the Lansley Bill, even among the better Parliamentarians and commentators, seems to sink to this level.

Part of the problem is that the challenge of how we improve healthcare in the UK is fiendishly complex. Hardly anyone knows enough about all areas to really have a total grip on it. Furthermore, the issue of the NHS is related, as nowhere else, to larger ideas about national identity and the binding of our society.

Reforming it, therefore is a hellish task. Some basic truths about the health service cannot be escaped from. Firstly, it is, globally speaking, relatively cheap. Secondly, it is unusual in that it is provided through taxation and is free at point of use. Insurance or payment haven't, so far, entered the picture, unless you decide to opt-out altogether. Thirdly, as a system, the resources are allocated, for historic reasons largely, more to acute and hospital based services and less to community, primary and preventative services.

Despite big political disagreements about means, there is some consensus on ends. We need to make the health service better at helping people help themselves to stay healthy, less about treating them in hospital when they are sick. Resources need, over time, to shift from one to the other. We also need health and social care to be less rigidly separated as the two needs tend to come together, particularly with an ageing population.

There, however, it all breaks down and gets very binary. The way forward for the right is to create this change by splitting the purchase from provision of services and by opening up the market to any willing provide. Coupled with this, people should be allowed to both choose their provider and 'top-up' their service, like Fast Boarding, if they choose. This, goes the argument, drives efficiency, innovation and customer-focus. More bang for your buck.

The argument from the left is that all of this disrupts an ecology of co-operation, integration and professional and public involvement which has developed since the formation of the NHS. Competition, they say, puts people who need to work together e.g. GPs and community services or community services and Foundation Trusts, into competition with each other. The patient - who is guided down 'Pathways' between primary, community and hospital care, will suffer as agencies fight over the funding and, inevitably, act in organisational self-interest, rather than that of the patient. Furthermore, there is huge fear over the consequences of co-payment and the idea of a 'two-tier NHS'.

As a self-confessed wooly liberal, I see both sides of the debate. I also work closely with health and use health services quite a bit. I can see both cases. What I do not doubt, however, is that no-change, is as unacceptable as some of the more far-reaching aspects of the Lansley Bill.

I illustrate this with a personal story. One of my children is three and a half and has 20 words, about as many as a typical 18 month old baby. A year ago, he had none. We referred him to Speech Therapy. Apparently there is a waiting list. Then we got him seen. There was another delay. Then a couple of cancelled appointments. We get 1970s style letters telling us when we will be seen, inked in biro. No choice or quality of communication. The therapist herself is excellent but in the year since referring our child, he has been seen twice.

Had I not the commitment I have to the NHS, I would have taken my child private six months ago. A queue for speech therapy at this age is just going to compound the problem - creating more work down the road - and possible education/ SEN needs.
There is clearly a resource issue. But on top I sense a complacence too. This service is the only one funded by the NHS. Nobody else can do this and get NHS money. If I wanted my son's notional share of the budget of this service to take to the market to buy a service from a speech therapist or practice I couldn't have it. And there is no way I could augment this money with some of my own if I needed to, god forbid, because that would give my son some kind of bizarre advantage over some other child who may well also reach his fourth birthday unable to say more than a few words.

Clearly, there is a need for some system-change here. I would be deeply surprised if the budget for speech therapy was such that if was not possible to work harder. While we need more planning to ensure under-funded areas do get funded, we also need more freedom to ensure that the money works harder so that people who need services benefit from some of the things we take for granted in other areas of life e.g. choice and the freedom to use our own share of public sector resources in the way we choose, even if this means adding some of our own.

It is this kind of change that I am trying to encourage in my own work. I don't think the NHS should be a free market. There are real dangers in losing control of the system to a profit motive, as in the US where spending is out of control and outcomes extremely poor. We need system-planning. But this doesn't mean we can't have a lot of providers and it doesn't mean that users of the health service having to put up with a 1940s, nationalised industry approach to provision in which the forces which do drive forward innovation, quality and customer-services are systematically nullified.


Andrew Harding said...

Hi Craig, this really strikes a nerve. First, I hope your son makes good progress in communication beyond expressive speech. My eldest is about the same age and was slow to get started with speaking - nuturing his broader communication helped keep us properly focussed.
Second, speech therapy departments in my experience depend on the drive of their leaders. During my years at the British Stammering Association we worked closely with willing departments to develop a triage referral system to prioritise children (and crucially their parents) needing prompt intervention. Yes, we also campained on the deferred costs of delayed and/or ineffective treatment. The system has the scope to improve from within, although I am sure deeper changes could be good too.
Third, I wonder if I-Can have useful resources as they provide information for a broader range of communication needs.
Forth, there is a network of therapists in independent practise to whom we directed parents when faced with stonewall waiting lists: www.helpwithtalking.com

Just a few heartfelt thoughts, now from Toronto.


Craig Dearden-Phillips said...

Thanks for this Andrew, very kind. He's making better progress this last month or so, making us a bit less worried. I am hoping he gets there before he starts school. Thanks again. C