Outside the marginals

a commentary on the politics that followed the UK 2010 & 2015 elections

The N in NHS

The BBC’s Health correspondent, Nick Triggle, has written a blog post titled “Dropping the ‘N’ in NHS” in which he ponders:

… could the new boss of the NHS in England, Simon Stevens, be set to break the mould? Over the course of the past week – firstly in his interview with the Daily Telegraph and then in his speech to the NHS Confederation conference – one thing has stood out above everything else: his emphasis on the local.

Then this week he set out his vision in a little more detail to the conference of health managers. This is what he told the meeting in Liverpool: “We need different solutions for diverse communities. Horses for courses, not one-size fits all.”
BBC News Website: Dropping the ‘N’ in NHS

From this he questions the “N” in NHS – and fundamentally misunderstands what the N means.

He cites two examples where “local” solutions have “proved” his case:

  • Stroke treatment in London where, by centralising services in a region with a lot of hospitals for its physical area, stroke death rates have been cut by 12%.
  • Elderly care in Torbay where services have been designed around the predominantly elderly population.

He says there will have to be two changes to make a “local HS” work:

  • A change from the current top down mindset
  • Public acceptance of diversification

However he quotes Labour polling that shows the greatest concern about the NHS is the “postcode lottery”

People do not like the idea of variation from one place to another, it seems. They want the “N” in NHS to stay.
ibid

National does not mean uniform “top down”. National has to mean something to do with operating across and for the nation and owned and paid for by the nation. The postcode lottery (in terms of outcomes) does not have to apply if you localise the NHS. Health is an “end” and it is totally reasonable that the “means” to that end is local and varies from place to place.

It is entirely reasonable that all NHS stoke patients should expect the NHS to try to achieve “London levels” of stroke recovery, but outside a high population density metropolis the “London solution” will not work. Local solutions should seek to achieve national outcomes.

The “top down” should be what is necessary to ensure the national level of outcomes; solutions have to be managed locally.

The NHS is a National Health Insurance Scheme. This means that we, the “policy holders”, spread and share the risk. It is a social scheme in that our premiums are not based on factors such as where we live. Delivering almost any health outcome in the remote Pennines is going to cost more than delivering the same outcome to someone in Newcastle – but we do not believe that people in the Pennines should pay more than those in Newcastle. It’s called social solidarity.

Local Health Services challenge this spreading of risk and this social solidarity. As Nick Triggle admits elsewhere in his article you want to “put the local” in the NHS – you don’t want to remove the “N”.

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4 thoughts on “The N in NHS

  1. Peter on said:

    Perhaps he should change it to IHS or International health service, as it seems to be for the benefit of the world, sometimes at the expense of the UK.

    People struggle to get a GP appointment, yet ‘health tourism’ is rife, and we always seem to be inviting overseas nationals to have complex and expensive operations ‘on the house’.

  2. I suspect that this is a “local” phenomenon – albeit paid for “nationally”. I can get a GP appointment within a day and my mother (in the same region – well away from major ports of entry) in a nursing home can have a GP visit her in the afternoon after waking and feeling a “bit off”.

    When she lived elsewhere she could not get the doctor to visit (neither could my father) – but this was not obviously due to “health tourism” nor for that matter due to immigration (the area was “remarkably” white with standard accents) – I think it was more to do with local attitudes to “care” in GP surgeries.

    If you live in an area close to Heathrow or say the channel ports, I accept that there may be issues. But are these NHS issues or immigration issues? Airlines should understand that they will be liable for care costs if they “permit to fly” someone who is so ill that immigration officials feel obliged to permit entry for urgent health care.

    The absolute amount of “leakage” is probably eye-wateringly high if we knew the full scale. In relative terms it is probably a very small amount. Splitting up the health service into a number of smaller (regional?) services would probably not make much difference to this issue – the larger regions around major airports / ports of entry will probably still have the problem at the same absolute levels.

    As a nation, I would hope that we would not have a problem with the occasional planned “pro bono” operation from an overseas national who cannot get a particular operation in their own country. It is probably good “foreign policy”.

    Likewise, I would hope that we would respect reciprocal agreements (such as the EHIC):

    Your EHIC lets you get state healthcare at a reduced cost or sometimes for free. It will cover you for treatment that is needed to allow you to continue your stay until your planned return. It also covers you for treatment of pre-existing medical conditions and for routine maternity care, as long as you’re not going abroad to give birth.

    • Peter on said:

      Sometimes I despair at the willingness of some unrelated people to set up appeals, especially on behalf of children, to send an entire family to another country (usually the USA) for months on end to have an operation, when that same money would be far better being donated to children’s hospitals throughout the UK (except Gt Ormond St, as it gets far too large a slice of charitable donations already), in order to provide those facilities in this country.

      If this was done, then far more children could benefit across all social groups, instead of a handful of cases where they have the ability and network of contacts to finance and organise the overseas trip. I would guess that for every high profile ‘appeal’ there will be another 10 who due to less publicity will just die or vegetate, with the public oblivious to their plight.

      • This of course raises the point that health tourism is two-way (although if you go to the USA the chances are you are going to pay and pay heavily). Often these appeals (“to send little johnny to the USA for life-saving surgery as it is his only hope”) pull at our heart-strings and are a response to parents’ understandable desire “to do everything possible”. Sometimes these stories have a “happy ending” in which case we tend to hear about them, otherwise an “unhappy ending” may make 10 seconds on the local TV news.

        It is worrying that sometimes these appeals (for overseas treatment) seem to be for distinctly experimental, unproven – or even quack – treatments with the parents complaining that they are subject to a sort of “national flag lottery”. It underlines the fact that we do not have a decent understanding / agreement on what the NHS should and should not cover – and because the “lives of loved ones” are involved I do not think we as individuals can get an agreement. (Except one that is ruinously expensive – but then an agreement that treatment should be offered should be matched by an agreement that it will be paid for – which takes us into the “fair taxation debate“.)

        I am worried about the move to get more direct “people involvement” in NHS strategic planning through initiatives like NHS Citizen. It will mean that he who shouts loudest will be the one who is heard. If only we had people who could represent us:

        • in Parliament and hold the Department of Health to account
        • in councils and hold public health and wellbeing boards to account.

        We can’t (and should not) stop people going abroad for treatment – but should be wary of paying to tidy up afterwards when the patient returns home with new problems or complications. This particularly applies to overseas cosmetic and dental treatment.

        Likewise we can’t stop people fund-raising for NHS hospitals even though the result can distort outcomes (Great Ormond Street Hospital almost appearing to be a private hospital from its corporate advertising). I can understand for instance fund-raising to build and run family hostels to house and support families when a close relative has to travel significant distances for complex specialist treatment. Although such hostels might be financially precarious, I suspect the quality of support of families from a dedicated voluntary team will be different from the more medicalised support offered by hospital staff.

        Fund raising can also let the NHS (and by definition the Government and the taxpayer) “off the hook”. A clear example of this is hospice care – which is distinctly “non national” and varies locally. Why should you get NHS funded care when dying through trauma but not when dying from a progressive incurable disease?

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