There has been a lot going on in the news lately, events in Gaza, the Autumn Statement and the Covid inquiry. Although Sir Chris Whitty has been in the spotlight there, not much attention was given to his annual report, Health in an Ageing Society, which he recently published in his capacity as Chief Medical Officer for England. He highlights a problem that we prefer not to think about.
I am referring to the population ageing. By 2050 a quarter of those in the UK will be over 65, but he argues that it should not be accepted that these extra years will be spent in ill health. He then lists things that we can all do to improve our health. I shall return to that later. Firstly I want to look at the almost existential challenge facing the NHS.
A few facts first. People tend to use the NHS more when they are older. As the population ages fewer are working, and therefore contributing through taxation, but more will need its services. It has been estimated that the NHS needs a 2 to 3% increase in spending each year simply to stand still, because of the demands of an ageing population and the cost of newly invented drugs and equipment. Figures from the respected charity, the King’s Fund show that the annual increase in spending was 3.5% during the Conservative government between 1979 and 1997, and over 5% during the Blair and Brown one. When the Blair government took office it faced a “crisis” in the NHS but was able to move to a position before it lost office, of waiting lists reduced and far less use of the private sector. During the Cameron “austerity” years between 2010 to 2015 it dropped to less than 1% per year. To be fair it then increased to almost 2% increase per year with subsequent Tory governments up until the present day. Many attribute the current problems of the NHS to the parsimony of governments since 2010.
Fighting for life
In her new book Fighting for Life, Isabel Hardman gives an excellent account of how the NHS was set up and the problems facing it today. I recommend it to anyone interested in how the NHS has developed and politicians’ attitudes to it. Isabel is an independent commentator, not necessarily a Labour supporter, and she concludes that the Tories accepted the NHS because it was popular, “like an albatross round their neck” and were always concerned that the costs would run away. They were never very enthusiastic about it.
The “purchaser/provider split”
All parties, however, agree that the service has to be run efficiently. Kenneth Clarke, the cigar-smoking health secretary, (he had shares in tobacco companies) introduced the idea of the “purchaser/provider split,” in 1988. Health authorities were to tender for the most efficient provider, which was usually a hospital. At the time this meant within the NHS, and there was not an extensive use of the private sector, although many on the left prophesied this would happen. The system is still used, more or less, today.
The Conservatives have always had an obsession with bureaucracy, and are obsessed with the idea that there is excessive bureaucracy in the NHS, despite there being less in fact, than in other health systems, America in particular. They have quietly introduced a directive for NHS organisations to reduce bureaucracy by 30% which has caused NHS managers considerable headaches but is unlikely to increase efficiency.
Primary Care Trusts
The next attempt was by Alan Milburn, Labour Party secretary of health between 1999 and 2003 who introduced the idea of Primary Care Trusts (PCTs)to promote care in the community and public health. This reform required GPs and Community Health organisations to work together with public health to commission services from hospitals but also to promote better health in their communities. They also worked closely with local authorities. The PCTs were very successful, promoting all sorts of health initiatives and had notable successes such as reducing smoking and underage pregnancies. They also succeeded in involving communities in public health programmes.
Clinical Commissioning Groups
Unfortunately they did not last long. The new Conservative government after 2010 introduced Clinical Commissioning Groups (CCGs)with an obligation to tender for health services, including from the private sector, whom many Conservatives believed would be more efficient than the public sector.. Ironically the new system required the establishment of a large bureaucracy to run it.
The new system did not work very well because of a growing consensus in the NHS that it was better that older people be looked after in the community than in hospital, and this required cooperation between hospitals and community health organisations. Private providers were reluctant to disclose their information, or in some cases to have their accounts audited. The whole ethic of competition did not suit the NHS.
So where are we now? Back to Sir Chris Whitty. There must be a shift to preventative measures and good health habits so fewer people end up in hospital. This does not simply mean lectures by the likes of Sir Chris, but the reestablishment of organisations like the PCTs to encourage health professionals to work together by mobilising people to adopt healthier lifestyles and giving them the resources to do it. Preaching will not do it, but community initiatives will. This will not solve all the NHS’s problems, but it is a step in the right direction.