The survival of the NHS is again being questioned. As the service reels from cuts and the wreckage caused by the latest political masterplan, doubts are being raised about how long the NHS can survive in its current form, offering free care for all at the point of use. So what does the future look like for healthcare?
The Dilnot commission on social care funding has this week opened up two debates – where the boundary should lie between healthcare and social care, and their relative funding.
Lord Warner, former Labour health minister and now a member of the Dilnot commission, warns that NHS funding can’t keep growing while the social care system is having to choke off demand through ever-tougher eligibility criteria. “If the commission puts in place a solution to social care funding, then healthcare funding continues to grow much faster. In 10 years’ time we will need another Dilnot commission,” says Warner.
“The NHS needs to stop stuffing shed-loads of its money into inefficient hospitals. The more we take large sums of public money to fund that model, the more difficult it is to keep social care funded.”
Stephen Thornton, chief executive of the Health Foundation charity, is adamant that the principle of free healthcare will survive: “I do not think there is a crisis. Every time we have a recession people pop up and say free healthcare is unsustainable. Well, no. A civilised, wealthy society should be able to provide healthcare free at the point of use. There are a few crackpots on the extreme right but they don’t know what they are talking about.”
But Jeremy Taylor, chief executive of care charity coalition National Voices, worries that the principle of free care may be preserved at the cost of quality: “If we treasure those principles we may paint ourselves into a corner.”
He believes the debate about paying for some care will resurface: “The more we try to integrate health and social care the more we will have to grapple with the weird dichotomy of free at the point of use NHS care and means-tested social care. The issue will not go away.”
Thornton believes there is another reason to change the way the NHS delivers care: high-cost healthcare could hobble the economy.
“There is a real issue about our global competitiveness if intermediate economies such as China introduce approaches to healthcare which cost a fraction of ours.”
They are more willing to steal ideas from industry and exploit technology: “How many GPs will still not give you test results by text? And using industrial scale quality improvement – not in the tiptoeing way we do it here. Arguing for decades about what nurses are allowed to prescribe is an example of the glacial pace of change in our system compared with the ‘let’s just do it’ approach.”
One of the arguments against free healthcare is that “demand is infinite”. Patient groups are now turning that on its head, demonstrating that involving patients in decisions drives down costs as long-term conditions are managed without expensive repeated emergency admissions.
Penny Woods, chief executive of patient organisation the Picker Institute, believes the potential for working with patients to cut demand is huge. For instance, simply by encouraging people to live healthy lifestyles could drastically reduce the number of patients being treated for heart conditions, diabetes, cancers and mental health problems such as depression.
John Appleby, chief economist at the King’s Fund thinktank, cautions not to overstate the case against hospitals. “There are good reasons to have hospitals – they can be efficient ways of gathering together expensive resources such as consultants and machines. I can see hospitals being less bounded by their bricks and mortar, running services through primary care, but there will still be wards with nurses and bedpans.”
The NHS Confederation chief executive, Mike Farrar, wants the public to think about how much healthcare they consume, learning from the environmental movement: “How do you transform the way people use the health service and view their own health? You could introduce the concept of a care footprint, so in future people would think more about the pressures on the service.”
He believes that over the next 20 years technology will shift the power relationship between the patient and the clinicians. Taylor agrees: “The information revolution will have a huge impact, but it will not be stuff that government has planned. We might hit upon a different way of doing diagnosis and referral – why depend on GPs to do that? People want immediate access to the expertise they need. We can probably cut out much of the GPs’ present role, give more power to community nurses, patient navigators who may be volunteers, allow patients to make some decisions for themselves using decision aids and responding to real-term feedback from chips inside them monitoring vital signs – this is all going to change healthcare much more than politicians.”
The technological revolution must be accompanied by more information about the quality and safety of any new diagnostic and treatment aids. Stephen Dorrell, former health secretary and now Conservative chair of the Commons’ health select committee, calls for “glasnost” around healthcare – honesty about services that need to close because they are no good.
The one existential threat to the NHS is short-term political thinking – ministers failing to allow outdated, unaffordable, unsafe services to shut. Warner explains the problem: “You have a political class who are afraid. It is a perfectly reasonable lesson to learn that being brave on the NHS is political suicide. It’s difficult because the British have a love affair with the hospital.”
Thornton believes politicians trying to preserve the NHS could end up destroying it: “If politicians put a stop to organic changes in healthcare then the system will be running inefficiently and unsafely. That’s when its opponents will stand up and say ‘what do you expect from a state-run healthcare system?’”