Tangled - a modern tale about the NHS Crisis

by David Gilbert

January 6, 2018

It would be wise to keep a cool eye on current debate about the ‘NHS crisis’. All is not as it seems.


There are different issues to be disentangled.

Firstly, purpose and vision. What matters to people who use services and to those that pay for them? And how does the NHS keep focused on that? We will come back to this one.

Secondly, how services are delivered. Or, in the jargon, what sort of model of care or what sort of services should or can be provided. This hinges nowadays on another power battle - whether a traditional ‘hospital-centric’ and ‘illness-focused’ model of care should be sustained and/or how healthcare services can be better joined up (‘integrated’), prevent people getting ill in the first place or better to support them to look after themselves in the community.

Thirdly, who should provide services. This is about money and accountability - including the role of the private sector.

In any decent strategic mind, the above steps are taken in the order above: purpose and vision comes first. Form follows function.

However, given the ideological heat around the iconic NHS, it is inevitable that the third issue – who provides services (rather than what or how) drives the debate as people hold such strong ideological assumptions. This fire is fanned because ‘sustainability and transformation plans’ (STPs) that could change how the NHS operates have been going on largely in secret.

The operation to change the NHS has been driven and riven by secrecy and, in turn, fear. Fear of a dialogue around ‘privatisation’ and/or ‘restructuring’ (and decisions to close local hospitals, for example). Conspiracy theories abound, particularly about ‘marketisation’ and ‘putting profits before patients’ (these theories may be true). I have blogged about both these issues here and here.

Powerful medical and institutional interests are piling in. Medical representative organisations arraigned against privatisation though have a mixed approach usually to private practice. And the patient movement, such that it is, would be wise to sometimes treat the BMA's arguments (for example) with a pinch of salt. At least, that's my opinion.

And acute hospital chief executives are very much part of the decision making structures around different models of care (e.g. In STPs) and battling for their own vested interests.

It's also intriguing to read articles by policy leaders I respect (though don't necessarily agree with) arguing that STPs are the best way towards less competition and more collaboration - that it is only in those spaces that the Thatcherite purchaser-provider split is being re-considered wholesale. It remains ironic though if they are not practicing what they preach - advocating better relationships with the rest of us, while huddling together in secret.

This is not black and white. The entanglement is getting more and more knotty.

Meanwhile, media and public debate has been hijacked by the A&E crisis. Because of the ongoing hubbub about accountability, any alternative dialogue about what to do (e.g. Patient-led solutions, see here) is drowned. See here

Back To Basics

As someone who uses mental health services, it concerns me that the noise surrounding the NHS crisis ignores my voice and any debate on what matters to me. For example, I don’t believe more and more beds will fix anything. It may be a short term solution but it could prop up the acute sector and leave people like me, and other people who require better social care, housing and community care on the streets (literally).

Money is not infinite, and has to come from somewhere. Yes, it is to do with austerity, but all health economises face constraints and decisions on where to steer limited resources. Let's not be naive in saying there are no hard choices to make.

Most people who have had life changing illness, injury or disability or with LTCs or who are carers know that change is needed - more holistic, consistent and coordinated care, often closest to where they live. And many are engaged in work to shift models of care. We don't want to end up in A&E because primary care is inaccessible.

As a citizen and tax-payer, I want to know where my money is spent. I also want leaders to be accountable. And I would much prefer that money that goes into health services stays in the NHS for the benefit of patients rather than shareholders.

The heat of the debate though derails better engagement and solutions. It also masks the need for patient and citizen power in board rooms – something I do not see either ‘side’ making with any true force. All parties assume they know what is best for ‘us’.

If NHS leaders were truly strategic, they would first be asking - 'what matters?' - the vision and purpose question. The one that kicked off this blog. And, how can you answer that without involving people as true partners and patient and citizen leaders being in positions of power.

Let's cut the crap: You would not have a women-centred organisation run solely by men. Why do we have a 'patient-centred' NHS that is run by clinical, managerial and policy leaders? Not a patient in sight. And, no, professionals are not patients (though they can be), and professional leaders are (mostly) not patient leaders - see here for a debunk of that framing.

I have long argued that we are only at the foothills of local patient and citizen leadership. In terms of influence in policy making, we aren’t out of the jungle hut.

Personally, I think we could have truly accountable models and systems of care and sustain the NHS and restrict the role of the private sector – but ONLY IF people are true partners in current dialogue and change.

Me and loads of patients, community folk and good citizens could help. We could if clinical, managerial and policy leaders want us to have some power. Do they? Hmmmm...

Meanwhile, let's continue to take it as best we can.


(c) 2018 David Gilbert

Read my blogs on patient-led healthcare at: http://www.futurepatientblog.com

Follow me on Twitter @DavidGilbert43


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