Let's be clear about the NHS
So said incoming PM Gordon Brown in his speech on becoming Labour Party leader this week, as he identified the NHS as his top priority:
"So I propose that as we approach the 60th anniversary of the NHS we discuss a new settlement for a modern NHS free at the point of need - clear about where accountability lies - clear where government should set overall objectives, clear where it should not interfere, and clear how independently local people should have their voice heard and acted upon in shaping the future of the NHS."
We are all for clarity and saying it four times in the same sentence must mean that Gordon is too. M-A-C would like to make a contribution to the search for NHS clarity asked for by our new PM. The most important thing to be clear about is what the NHS is actually for. That's different from what it does and how it does it. In other words, what we need to be clear about is the ends of the NHS, because everything else is just means to achieve the ends.
What is the NHS for?
Without clarity about ends, no organisation - and certainly not one that consumes close on £100bn of public resources annually - can hope to have efficient governance or be held accountable. This is about governance and not management, because they aren't the same thing. Governance is about who owns the organisation - literally or morally - and the responsibilities the organisation has to its owners. Management is about how the organisation is run and by whom. There has been governance muddle about the NHS since the beginning because it suits politicians. Surprisingly, there is a lot of good NHS management and good NHS managers around. We believe that if the country was clear about the governance of the NHS, its management could get even better.
With that in mind, we toss into the ring for consideration the following proposition:
The end of the NHS in England is: "The health of all people in England is maintained as fully as possible for a sustainable tax burden".
Balancing expectations with resources
Taking this view, the deciding factor about what the NHS does to achieve its end relates directly to what level of resources the people are willing for Parliament to spend in their name on the NHS. Scotland, Wales and Northern Ireland should be able to take their own devolved decisions on this. Determining the answer to the "how much is enough to spend on health?" question in turn depends on people's perception of what they are getting for "their" money balanced against their expectations and sense of value. Those expectations are radically different now than in 1948 or even 1988 and are changing rapidly.
The policy implication of this is that the new government led by Mr Brown should not waste time identifying some eternal and immutable principles for "a new settlement for a modern NHS". They should instead take a radical consensus building approach to identify realistic expectations. That would confirm that tax-supported healthcare spending is "worth it" to people because it meets their expectations and they perceive it to represent value for "their" money because they are the real owners of the NHS. Doing that doesn't imply that the NHS has to be - or should be - the same in all parts of England all of the time. That is already the case in the devolved administrations. There are other ways to grapple with inequalities rather than trying to divide out the cake into equal portions.
Resource limits and demand management are political issues which elected representatives must decide on the basis of the end of the NHS, i.e. "The health of all people in England is maintained as fully as possible for a sustainable tax burden". How available resources are then applied to this end is another matter and should be an open process resting on evidence-based clinical decisions, public health imperatives, and user and public views balanced with issues of local feasibility and achievement of value for money. Rationing decisions are inevitable and sometimes even desirable, but must always be explicit and contestable. This will involve "constructive discomfort" but that will happen covertly anyway. Making the discomfort overt will be a creative process in which people can be encouraged and supported to take a meaningful role.
Listening to the owners
Mr Brown's speech also stressed the need to listen to people. The NHS is largely unresponsive to the needs of patients because it doesn't understand that they are part of its ownership. That is mainly because they are not customers and in effect have little choice about alternative suppliers (unlike shoppers in supermarkets). It is also true that there is still a strong, though shrinking, deferential and submissive culture about healthcare and the NHS in particular – it is inherent in the word "patient". This needs changing without falling into a crass health consumerism ethic.
There is nothing fundamentally wrong with the Government's "choice" agenda, provided that people are helped to have the capacity to use it meaningfully. That capacity building element is generally overlooked and improving people's "health literacy" is the way to address it. A bottom up community development approach to help people control and consume public services is needed. Thereafter, it should not matter if exercising choice means that some less-favoured providers exit the market – that is real life.
User involvement in decision making is a lifeline for the NHS which it seems reluctant to grasp other than through rhetoric and half-gestures. We fear that the LINks (Local Improvement Networks) will be another manifestation of ill thought out process. If the NHS is to survive and even flourish in the coming leaner times, it must get better - much better and very quickly - at involving users of its services in decision making by understanding them as its owners. That's a key part of what Derek Wanless meant when he talked about the "fully engaged scenario", without which a centrally funded service would be not be sustainable. It is still beyond our grasp. Having more "choice" isn't the same as being fully engaged. As the Healthcare Commission recently concluded:
"many still feel left out of decisions about their care. Staff need to adopt a more open approach to decision making, the care of individuals, the future of services and how patients look after themselves."
The Health Select Committee's recent enquiry into patient and public involvement in the NHS asked the simple question "What is the purpose of patient and public involvement?" That's a no brainer really. The real point of engaging users of the NHS is shared power in decision-making and genuine user-provider partnerships that improve things for all concerned.
A clear message to the new PM
So to our new Prime Minister, we say: yes, let us be clear about the NHS. That means: being clear that the owners of the NHS are the people who pay for it and use it; being clear that the "p word" we should use more of is "power" not "patients"; and most importantly being clear that the end of the NHS is all about maintaining the health of all people in England as fully as possible for a sustainable tax burden. If we were clear about those things, then getting the work done through good management would be a great deal easier.
Andrew Craig
June 2007