A sustainable future for the NHS

With the General Election campaign underway, it is perhaps no surprise to see politicians blame each other for the pressures the health service is under. 

But while arguments rage about interpretation of statistics, meanwhile delayed discharge, or ‘bed-blocking’ caused by a lack of social care capacity, and long-term vacancies for nurses and doctors demonstrate the NHS doesn’t have the resource or capacity to deal with demand. GPs, too, are stretched. “What’s important is not who ‘caused’ the problem but who can show leadership to overcome these challenges,”says Dr Peter Bennie, chairman of the BMA in Scotland, “tinkering with one small part of the system will not solve the problem. Instead we need to look at the whole system and consider what needs to change for it to become sustainable in the long term,” 

Dr Miles Mack, Chair of the Royal College of General Practitioners (Scotland), says while in Scotland the talk has been of nurses, the UK political parties have made commitments to investing in general practice. The commitments, made at the UK party conferences, followed a campaign by the RCGP called ‘Put patients first: Back general practice’, which highlighted “devastating underfunding of general practice as a whole”.

“While in England the major party conferences offered commitments to 5,000 or 8,000 extra GPs, in Scotland there has, as yet, been no such pledge. One promise has been given to increase numbers of nurses as a direct consequence of success in May’s election. It would be a grave error if our Scottish parties, in seeking to differentiate themselves from Westminster concerns, failed to face up to the need to properly resource GPs – the hub of the NHS. This should be a key battleground in order to achieve the 2020 vision of providing care at home or in a homely setting.”

A recent report by the Scottish Parliament’s Health and Sport Committee found the poor health of the nation was rooted in inequality, and public health initiatives had not helped address the gap.

Theresa Fyffe, director of the Royal College of Nursing in Scotland, said: “While the NHS isn’t set up to reduce poverty directly, it can target its resources more effectively and work with social work, education, the justice system and others to make a difference at an individual level.” She said the committee’s report illustrated the need for sustainable investment in community projects working with the most vulnerable in society. “However, this type of project is often the victim of short-term funding and cuts, and benefits can be short-lived as a result,” she said.

"The SNP Government have made a political decision to dump all the austerity cuts on local government, not on the health service"

UNISON Scotland's Head of Bargaining & Campaigns, Dave Watson says financial pressure on local government has been an issue. “Ninety-five per cent of the solution to those inequalities is not in the NHS, but the preventative spend agenda has, frankly, been abandoned because the SNP Government have made a political decision to dump all the austerity cuts on local government, not on the health service. I understand they’re reflecting public perception they’re two things, but the reality is four out of five job losses in the public sector in Scotland have been in local government, and it’s local government that has to face up to social care. All the rows you see at the moment, whether it’s in Glasgow about GAMH or media stuff about cuts in the budget, the fact is commissioning staff are going around trying to squeeze more and more out of a declining pot, and the maths just don’t do it.”

In the NHS itself, Dr Bennie believes strong political leadership is needed. “The most serious decision politicians have to make is “what needs to change for our NHS to be sustainable in the long term”.  The choice is whether or not they have the conviction to actually take the difficult decisions that will inevitably follow,” he says.

Do those difficult decisions include a reassessment of the NHS’s universal commitment to free healthcare at the point of need? A recent survey by Lord Ashcroft found most people across the UK thought the service was deteriorating, and half thought it should start considering charging for some services. Nearly half of Scots would consider the reintroduction of prescription charges. Lord Ashcroft said the parties were avoiding “real discussion” on health. “Talking about potential reforms, even when aimed at ensuring the sustainability of the service in the long term feels, to many, like an affront and makes them defensive. That is why a proper conversation about the NHS is so important. It’s a shame there is no sign we’re going to get one,” he said.

Dr Bennie agrees: “The NHS should remain fixed on its founding principles: that it is available to all and free at the point of access. However, we have to be realistic. The financial environment is particularly challenging and we have an ageing population which has more complex care needs. We, the BMA, believe now is the time to have a public debate about the future sustainability of the NHS and that may well require our politicians to be prepared to make some difficult decisions that may not be universally popular. I hope we will be able to convince politicians that the long-term survival of the NHS is more important than the short-term electoral cycles,” he says.

"Now is the time to have a public debate about the future sustainability of the NHS"

However, Dr Mack warns against reform away from general practice. “The NHS is the most cost-effective health service in Europe. June’s well publicised Commonwealth Fund study put the UK health service at the top of the international pile. Anything else would cost the UK taxpayer more for a lesser service. The key feature of the NHS, which sustains it, is the strength of generalism through primary care, as delivered by GPs. That service saves the NHS billions, year on year. The NHS is worth investing in and must stay universal,” he says.

Health think-tank the King’s Fund issued a report recently which was fiercely critical of reorganisation of the NHS in England, and warned against further top-down reforms. The Health and Social Care Act 2012, it says, left the NHS weaker, structurally “incomprehensible” and less able to improve care for patients.

Chris Ham, King’s Fund Chief Executive, said: “Historians will not be kind in their assessment of the Coalition Government's record on NHS reform. The first three years were wasted on major organisational changes when the NHS should have been concentrating on growing financial and service pressures – this was a strategic error. Only latterly has the government adopted a more positive focus on improving patient care and achieving closer integration of services. Politicians should be wary of ever again embarking on such a sweeping and complicated reorganisation of the NHS.”