Compromise and Conceit

Recent revelations in the UK have shown that the UK government’s intended efficiency savings aren’t working (shock!) and it faces a huge funding shortfall. This is hardly unexpected, and probably the first of a range of such reports that are going to start filtering around Whitehall soon, but it has spawned a disappointing tirade from a Guardian opinion writer that I feel deserves a little attention because it contains so many egregious examples of the kind of woolly thinking that happens in the media when it attempts to discuss the serious problems facing the NHS. It also shows some of the collective doublethink that exists within a newspaper I get the impression was once great but has been reduced to cheer-leading labour from the sidelines, no matter how crap labour becomes. It also gives me a chance to hold forth at length on my opinion about the importance of mixed markets in healthcare, and why the NHS is a model out of step with modern life.

First of all, this tiradist, Jackie Ashley, offers a standard explanation for the NHS’s woes that I heard many times while in the UK:

The apparent mystery about NHS spending was partly answered on this morning’s front page in a separate story which revealed the average British man put on more than a stone between 1986 and 2000. The puzzle is why, given the big real-terms increase in health spending, the NHS isn’t hugely successful.

Now, these two sentences contain so much misinformation that it’s easy to see why commentators on the NHS get bogged down in misperceptions. For starters, the UK isn’t the only country to have experienced this increase in weight (of “a stone” – that’s a ridiculous measure of weight if ever there was one). Australia, Canada and the US have also experienced the problem of weight gain as, I think, have several European and South American countries. So presumably whatever problem the NHS is facing as a consequence of the fattening of the general population is something that other countries have also had to deal with, but those other countries aren’t necessarily suffering the same funding constraints and poor care that the British system has. And the clue is in the second sentence’s misperception. Yes, the NHS has experienced big real-terms increase in spending under labour, but after 10 years they were sufficient to get the NHS to nearly the EU average funding level. I’ve pointed out before the catastrophic effect this long-term underfunding will have on a health system, and it’s hardly to be expected that the NHS is going to do well when it’s vastly underfunded compared to its neighbours. I suppose you can’t make a hard-hitting article about the government’s political problems by recognizing that the NHS’s funding problems are caused by … underfunding.

Having presented this false “puzzle,” Ms. Ashley goes on to present us with a false set of answers:

The answer is a combination of our lifestyles, longevity and a cascade of new treatments which, together, pile up human and inflationary pressures that no other service faces. So despite the promise to ringfence the NHS from deep cuts, the inflation-level increases will feel like cuts.

So, the reason that the NHS is suffering funding problems is that it faces exactly the same set of problems that every other western health system is facing and dealing with. Perhaps the problem is that the NHS is under-funded? Or perhaps the problem is that it is poorly run and inefficient? Otherwise how can we explain the better performance of similarly-funded systems in Australia and Europe?

Our tiradist then goes on to observe that if these huge funding shortfalls do occur, this

translates into new super-drugs being refused to desperate patients (and the media campaigns that will follow); wards being closed; and a return to the waiting times scandals, sadly familiar to anyone who remembers the early years of New Labour.

Here it would be nice to imagine she would issue a poignant plea for the media to be a little more responsible than to just run silly campaigns about super-drugs being refused to desperate patients, but strangely enough for a journalist, she misses this opportunity to upbraid the journalistic profession on its transparent stupidity and lack of ethics. Do you think the Guardian will bow out of those “media campaigns that will follow,” Ms. Ashley? Ah the power of the passive voice when wielded by journalists trying to evade responsibility. Similarly, it never occurs to a journalist to think that a ward being closed might be a rational decision rather than madness; and it may not have occurred to a labour partisan like Jackie Ashley, but NHS waiting times remain a scandal from the point of view of the rest of the world, and were so at the end of New Labour’s reign. When 13 weeks’ wait is your target, you have scandalous waiting times.

Jackie then goes on to describe a big problem facing the NHS – its own bureaucratic inertia, and the difficulty of changing the system radically (whether for good or ill) in any kind of hurry:

Lansley wants to hand 80% of the NHS budget to GPs. This means the same primary care trusts tasked with making radical efficiencies now, also have to prepare for their own administrative suicide by helping set up mini-bureaucracies all over England

Now in the fantasy mind of your average Telegraph reader Ms. Ashley is a communist, as are all NHS managers, so you’d think they’d welcome the withering away of the state, but here we see a tacit admission that government departments don’t like to do themselves out of a job. Now, I happen to agree with her that the devolution of the NHS budget to GPs is purest madness, but blaming it on the current health minister is a bit rich, as is her subsequent feat of describing this process as “hardcore Tory thinking.” This process of handing PCT budgets to GPs is in plain English (for the non-UK readers) the process of handing the funding for area health services to ordinary family doctors (General Practitioners, aka GPs) who then decide how it should be spent on local priorities. It was originally called “Practice Based Commissioning” and was trialled extensively under the previous Labour government. It’s exactly the opposite of “hardcore tory thinking” because it tries to localize funding and spending decisions without actually exposing them to a proper free market. It’s the bastard child of politics, focus groups, right-wing health funding ideology, and a bankrupt “left wing” party led by a Vampire (Tony Blair). In essence it just makes the area health services smaller and less competent, in the interests of a free market ideology that is too scared to out itself and show its fangs. But a Tory idea it is not – the Tories just see it as an excellent way of achieving their wet dream of localism (which, by the way, why is this so important in a country smaller than an average Australian cattle farm?) and funding cuts simultaneously, and blaming doctors for the resultant fuck up. If the Tories are really the bastards that the Guardian makes them out to be, they’ll (rightly) blame the subsequent clusterfuck on the policy’s originators – the Labour party. But I bet you they don’t.

And, by the way, it’s funny to see a pro-labour party hack like Ms. Ashley suddenly waxing lyrical about these organizational details when they were just too, well, boring, for her to bring her critical (ha!) gaze to bear on back when Labour were in power and talking about them continuously.

Of course there is a way that devolving funding to GPs could work – make them properly private enterprises, competing with each other on quality, breadth and depth of service for payment from a single, government-run insurer. Make the hospitals a mix of private and public, with basic funding provided on a (semi-) fee-for-service basis, with private hospitals topping this funding up through private payments and public hospitals getting block grants for capital investment, research and public health work. i.e. introduce a system similar to the Australian, German and Japanese systems. Then GPs get to continue being doctors, area health services shrink to become managers of public health work and overseeing of hospital standards, and the hospitals get punished for poor quality work. However, introducing such a system in the UK would mean admitting that the NHS model, even though revolutionary and of profound importance in 1948, doesn’t actually work anymore and needs an overhaul. No party, Tory or “labour,” is going to do this, especially in an environment of cowardly conservatism and rampant budget cutting.

And this leads us to Jackie Ashley’s final paragraphs, where she describes the real consquences of a system on the edge of administrative and financial ruin, and fails to even really get angry about how bad it is in the average NHS hospital. It just doesn’t seem to occur to the average British commentator on the NHS that having “elderly patients not being fed” is not a passing matter to be commented on near the end of a discussion of political priorities, but is in fact a massive fucking failing of your whole system that any reasonable healthcare system would stamp out fast and with extreme prejudice. Why is the NHS unable to do this? Because it’s a runaway behemoth which is simultaneously beyond punishment for individual failings, and yet incapable of the kind of central planning and intelligent management that would stop these things from happening. No one has the political will to discuss, let alone tackle its obvious, huge failings, and no-one is willing to discuss the serious increase in funding that it needs, let alone to link these to the improvements in efficiency and outcome which a modern health system demands. So instead everyone, Tory and “left wing” alike, looks for distractions and mentions abominations in care and service quality that would be a matter of national urgency in any other public health system in the developed world as if they were just another simple reality of any modern system. Which just goes to show how much the British have lost perspective on how healthcare should work, and how much they need to start looking overseas, to new models, for an insight into what they need to do to fix the 30 year recurring problem of their decrepit health system.