You know it’s serious when the BBC starts its feature on the challenges ahead for the NHS with this ominous sentence: “The NHS is arguably facing its most challenging period since it was created in 1948.” Why are they cranking up the NHS Doomsday Machine? What they are trying to do is get our attention – and about time too – to make a simple point. Unless we as a nation do something fast about issues such as demands of an ageing and increasingly dependent population; the impact of obesity, inactivity and rising metabolic disease rates; the expectations and costs of medical and pharmaceutical developments; and last but certainly not least the consequences of our less than inspiring lifestyle choices around food and drink, then we can kiss the NHS as we’ve known it a fond farewell. It will have crumpled under the strain and no amount of reforms and efficiencies – must less cuts dressed up as “savings” – will save it. Decoded, quite a lot of this reads like “it’s all our own fault.” And a lot of it is.
There’s another slant on NHS Doomsday which says, more or less, that “it’s all their fault.” We know how to engage with patients, carers and communities and build support for radical change. But there is a powerful impediment preventing those in power – clinicians, bureaucrats, politicians – from working like this. It’s really about fear. Not fear of patients and constituents themselves, so much as fear of losing some of their own power. Shared decision making – at whatever level – means shared power and that’s really uncomfortable. That version of doom-saying is pretty true too.
Those who know what’s going on with NHS finances, like the estimable John Appleby at the Kings Fund, realise that the NHS in England is not very likely to achieve the Nicholson challenge by 2015, but less the “Nicholson 2” challenge to 2020. But its also obvious that trying to achieve it will bring in its wake much disruption, dislocation of existing services, patient and public anxiety and outrage and professional exhaustion and retaliation. Health and care professionals turning on their customers out of exhaustion and frustration is not a pretty sight. The Patients Association has already noted an increase in calls to their helpline about concerning ‘dismissive’ or ‘disrespectful’ GPs.
All in all, this amounts to a Doom-saying contagion that looks unstoppable.
Face the facts time
Just look at the Kings Fund report Transforming the Delivery of Health and Social Care to see the full horror. The cover has the strap line “time to think differently”. And how! So why didn’t they publish this (actually they have been saying most of it for a long time) before the ill-fated Mr Lansley launched the most disruptive English health reforms ever?
That astute observer of the health scene Roy Lilley was uncharacteristically doomy about the KF report, dubbing it “a gazetteer of grief facing the NHS. A glance at the summary is enough to make you reach for the breadknife. It’s stuff we know but it’s a tour-de-force, all in one place. A repository of the really awful!” (NHSManagers.net 10 Sept). And he’s not the only one. And this is even before the Francis report on Mid Staffordshire hits. The prognostications around that are the most terrifying version of the Doom Contagion – the ‘A Plague on all your houses’ version where hope is finally and completely abandoned. We are paralysed in anticipation.
Think beyond delivery – it’s about “ends” not “means”
As well as dire predictions of what will happen if we don’t do things better, Chris Ham and Co say some good things that get beyond Doomsday messages and the feeling of helplessness that affects both users and health and social care practitioners. Here’s an assessment we particularly like.
As well as involvement in decisions about the care they receive, patients have a key role to play in looking after their health and managing their health conditions, and yet health professionals do little to encourage patients in this role.
Patient and public expectations are rising. Increasingly, patients and service users expect health and social care services to be like other service industries and are willing to do more for themselves and interact with services via technology. They expect to be offered choice and variety and to experience services that are convenient, personalised and provided in modern buildings and healing environments.
Few would argue against better – radically better – delivery of services. But that’s not enough. It stops short of the real issue: agreeing on health itself and what we, as citizens, should decide about what our health and care system is for – its ends. Only when we are clear about what it is for and what we are willing to pay through taxation to achieve those ends can we can discuss the means for achieving what we want.
Until we get our thinking in the right order, we will go on agonising about delivery (means) and the problems with resources. The doom-saying will get us in the end.
But at bottom this is NOT about money – it never was. It is and will always be about “what is the NHS in England for?”
A way out of the thought loop
There’s a way out of this “means before ends” thought loop if we have the courage to take it. Certainly politicians up to now haven’t shown much understanding of it, despite a rising tide of “engagement rhetoric” and a veritable “involvement industry”. Put simply, it is that we have to engage citizens – that means all of us – who use and pay for the NHS in England in deciding what it should do and at what level of expenditure. Anything else is just hand-wringing while the noose tightens around our necks.
The mandarins, politicos and professionals may decry this as “populism”. Far from it. I see it as an exercise in informed democracy, responsible decision making and accountability for our own decisions. NHS doomsaying is a debilitating disorder that needs strong medicine if we are not all to succumb to the contagion.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.