As an example of engagement and participation, last night’s “leaders debate” failed. If MAC tried to organise a public participation meeting with these rules – “please sit there like dummies and say nothing unless you are asked” – we would be lynched. Our only hope of escape would lie in the fact that nobody would have bothered to come to such a rule-bound event. Going through the transcript and watching the live action (thanks BBC IPlayer) what stands out is the lack of interaction with the studio audience.
The first – and only -question relating to health didn’t come until very near the end, so perhaps the NHS is not such a burning election issue after all? From a nurse, it focused on our ageing population, new technology and drug costs. Did the aspiring PMs answer the question? Of course not. Once the platitudes about loving the NHS and wanting to keep more people in their own homes not care homes and pay for all new drugs were out of the way, the fairly well mannered exchanges were not about health at all but about hospitals and numbers of nurses and cancer drugs. That’s confusing healthcare services (the means) with health itself (the ends). The public deserves better than this.
We can have whatever level of healthcare services we like, provided that people through their elected representatives are willing to pay for them (and assuming we are willing to forgo paying for things like Trident, schools and motorways). But just spending money on services does not mean health will be improved or protected or, more importantly, that the yawning gap of health inequalities between sections of the country and groups within the community will be reduced. Doing that needs shrewd public health driven strategies linked to skillful disinvestment and reinvestment to achieve savings and service changes. The public rarely is included in those debates, but it cannot be left out this time. We are the owners of the NHS after all – the NHS Constitution says as much. The state is just the custodian of our resources and owes us the duty of good stewardship.
To do what needs to be done, the level of health literacy must rise. The linkages between health, employment, education and overall social and environmental well being must be clearly understood and reflected in policy and action. Locally MAC is working with our commissioners to deliver a “Training to Make A Difference” programme to a diverse range of people with long term conditions so they can make effective contributions to decisions about the services they use. This can work but it needs sustained investment and is not a quick fix.
“Never let a good crisis go to waste” should spur us to think about ends rather than squabbling over how to pay for the means. Pause and consider this: what would we do if we had to create a national health service “under canvas” from the 7th of May without the existing infrastrucure? A good place to start would be with “zero planning” assumptions as well as zero budgeting and then see what is really important in terms of making a positive difference to health (health gain) and wellbeing and identifying the resources to apply to that objective. Our present NHS was not created for that purpose and its inadequacies make that obvious.
NHS and social care expenditure is bound to be very much less very soon regardless of what politicians say. All English commissioners are agreeing eye-wateringly challenging savings plans as I write this. These will not be achievable without public and stakeholder consent. Engagement in the process must precede implementation, not follow it. The “Save Our XXX” placards will soon be waving. Waiting in the condemned cell until the money tap is simply turned off and the savings are made by crude cuts is not an attractive option. Ask the Greeks what this feels like. They are about to have the IMF walk through the door axe in hand.
There’s no silver bullet to stop the money going down the drain – but there is lots of “silver buckshot” that’s worth firing. It would help to start by doing these things:
- pool the budgets between health and local government (Section 75 shows the way)
- focus on a “total place” approach that means what it says
- merge the staff teams and managements
- eliminate the duplicated overheads and rationalise the estate
- share the back office functions
- integrate the strategies and manage demand through primary care
- give people with long term needs realistic integrated budgets to do things for themselves
- and across the board emphasise a preventive approach that is straight with people about individual actions having consequences and entitlements going hand in hand with responsibilities.
That’s not nannying, far from it. That’s laying down a social contract for wellbeing that local people can understand and will want to influence because it is about what happens where they live and what happens to them and their families. Health literacy and active citizenship can be scaled up, but they must start at the local level. If we and our leaders don’t learn that lesson, the hard choices we have to make will not be addressed and the next PM may be ringing the IMF sooner rather than later.