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Rude health?

The NHS was founded in 1948.

It was founded on the principle that good healthcare should be available to all regardless of wealth. And apart from in a few areas it remains free to everyone at the point of care.

While in 1948 good healthcare was about giving the nation access to healthcare and avoiding unacceptable premature death, the world has moved on but it could be argued healthcare has not kept up – we can do so much now, for ‘free’, that as patients and providers we have perhaps forgotten what is important in ensuring ‘good healthcare’.

‘Free’ means people don’t always treat the available care with respect or use it wisely. As a result the NHS has perhaps evolved to become one of the world’s best systems keeping sick people alive for a very long time, and at great expense, rather than improving the health of the nation as was intended.

So what could ‘good healthcare’ look like as we head to 2020?

It certainly needn’t be the dystopian future in stories like ‘Logan’s Run’…where ageing people were euthanased when they reached an age where they no longer positively contributed to ‘the greater good’ – even if some of the more extreme views in our society might demand this.

Neither, however, should it be entirely a version of what it is today, just kicked down the road for a few years… Yes there will be more older people (over 65’s rising from 18% to 26% by 2060) but that demographic needn’t be a ‘timebomb’ and can be managed with minor impact on good healthcare…if we have the vision to act now.

We need to go ‘back to the future’ and look at what we all deem to be ‘good healthcare’:

–            It should remain free – so we need to look at the cost side with great scrutiny (and remember that everyone who pays tax and NI really is paying for it!)

–            It should be available to all. It should neither be patrician nor provide a ‘religious’ template for how we should all lead our lives (we have no truc with lifestyle apartheid in health)

–             It should address the moral dilemma of extending lives vs. improving the health of people (are we ready to move from in large-part a ‘national sickeness service’ to a true national health service?

–            At it’s heart it should be evolved to provide ‘good healthcare’ – nothing more and nothing less.

Enough on principles for ‘good healthcare’– now for some practical measures…

 

Good healthcare and consumables:

We all know the stories about NHS procurement the different costs of latex gloves across different hospitals (the different prices each hospital pays for the same items). We need to knock heads together at the highest level in each part of the health service and find ways to simplify procurement and drive down price. In simplifying we should not be afraid of driving competition out of the market – in the unlikely event that we end up with too few suppliers for a particular good/service we should create a ‘good healthcare’ version for ourselves and compete under the NHS brand. Changes made in supply must be approved by healthcare professionals and only done where there is a benefit to the patient and a reduction in costs.

Good healthcare and medicines:

There are too many medicines which cost too much. We need to help the pharmaceutical industry provide better medicine more cost effectively. We also need to look at what we do with existing medicines. We need to think beyond just the ‘patent’. Investors in pharma companies need to understand that ‘good healthcare’ will deliver profits in different ways – the lazy option of investing in big pharma no longer works (in fact it is failing now – look at how M&A is driving the market in the absence of widespread innovation and future growth opportunities). Blockbuster medicines are a thing of the past. Instead investors will need to hunt out innovation and continuous improvement from the arsenal of medicines we already have. Regulators will need to be better equiped to support innovation which delivers ‘good healthcare’ i.e. better outcomes for patients available for all. ‘Innovate or shorten your patent protection’ might need to become the mantra by which global medicine harmonisation is achieved.

In addition there are a few simple steps which could be taken to drive down medicine wastage. For example there are c.13million GP visits from patients concerned that their medicine has changed when it is only the box because the supplier of that medicine has changed…but the solution to this can wait for another day.

Good healthcare and professionals:

–            A ‘no-overhead’ model for filling locums is needed – locum agencies charging £££’s for staff need to be abolished. A single or standard diary system across the NHS is probably the key…it allows shifts to be planned but more importantly it would provide an ecosystem in which one or several locum agencies could connect open slots with doctors, nurses and other workers digitally and link them up to online ‘ratings’. Together with capping locum rates and enabling more flexible working to be adopted for individuals who don’t want to work full time or have odd availability patterns (quite often, I have found, due to those staff also caring for relatives) then much cost can be removed here and invested in ‘good healthcare’

–            The NHS is apparently the 5th biggest employer on earth with 1.7m employees – recruiting more people to ‘care’ as the population ages won’t solve things without a significant and targeted shift in immigration policy. Rather than looking at the cost of people to the NHS we need to look at their value in delivering ‘good healthcare’. Going forward decisions need to be made not on getting more people in or cutting headcount but on getting the best out of people and ‘the best’ should mean getting more ‘good healthcare’ with improved job satisfaction.

Good healthcare and death:

In the USA 50% of people die on the operating table with healthcare professionals doing everything (expensively) to extend the life of a very sick person – this is not good healthcare. We need to grow up a little and talk more about death and plan for it better with our loved ones…perhaps death and ageing could form more of a part of the national curriculum?

 

Good healthcare and patients:

–            Apparently as patients we miss 1 in 7 hospital appointments. No wonder it costs a lot – what a waste of time and resource which gets all the more tied up in re-booking appointments. Perhaps we should charge for people who miss appointments and invest the charges in ‘good healthcare’. Or if not we need, at least, to find a positive manner to allow people to be more considerate in the first place.

–            As patients and accompanying carers we often forget to be nice to those trying to help us– we all know that kindness spreads (just like anger). Perhaps you are in pain or worried but you’ve come to get fixed so don’t take it out on the doctor, nurse, porter or receptionist – they are all there to try go get you sorted out…

Good healthcare and vice:

There must be no healthcare apartheid. And indeed in many areas it is quite the reverse. Smokers pay many £’s in taxes on cigarettes. Some say they pay too much for their treatment others say they pay too little, for now let’s just assume they about cover their costs. However when we look at their pension pots (if they are lucky enough to have one) we find it will pay out at about 11% more than a similar non smoker (see impaired life annuities). These higher payments are made on the assumption that the smoker will live less long. But what if we didn’t positively discriminate on the basis of smoking? What if we all got the lower pension? What if the unspent money from the pension pots of smokers (who’ve died earlier) was then invested in good healthcare? Would it be worth it? Well ask yourself – what would you do with approximately £3-30 billion a year (depending on how you calculate it)? How about 100,000 nurses in the community encouraging good health (non-smoking included?) and building 150 new hospitals every year?

People naturally take shortcuts with their health because it takes more effort to be virtuous. So the big opportunity here is to think how ‘good healthcare’ can benefit from from vice and laziness/an ‘it’ll be alright’ mentality rather than fight against it.

Good healthcare in isolation

Often patching up an unwell elderly person leads to be blocking or a repeat visit because the social care infrastructure around that patient is inadequate. With moves to integrate health and social care budgets by government do hospitals need to consider creating their own social care system (nursing home / sheltered housing) when/if no good cost effective provider can be found locally? Beds unblocked and fewer recurring visits could ensue.

Conculsion

There are lots of things we can do. We must all be honest with ourselves and decide what good healthcare should be and then lobby politicians, prime ministers, healthcare leaders on the things we want to change. We need to take an active part in the ‘good healthcare’ debate if we want to avoid a bad outcome for ourselves in the future. Finally we must be willing to accept that ‘good healthcare’ can and should be done with less money and not more. ‘Continuous improvement’ does not always need to cost more!

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