Along with many of my colleagues, I have been arguing for years that the current structure of the NHS cannot survive. Giving the health service endless money won’t make a significant difference, unless its core structures are changed.
It is therefore very interesting to see that Matt Hancock, in the middle of the pandemic, has unveiled a package of major changes to healthcare, the essence of which is to reverse the Lansley reforms.
One of the reforms the health secretary is taking aim at is the purchaser/provider split, which I have identified in the past as one of the ‘four crumbling pillars of the NHS’. The split involves regional panels commissioning various services, with hospitals and providers competing for ‘contracts’. But the system does not work and is inefficient in practice, leading to very poor provision for services such as mental health, which are not seen as sufficiently profitable.
Many of the Lansley reforms, such as the purchaser/provider split, had plenty of potential benefits, but they have ended up as a disaster. Hancock’s aim is to reverse these changes and remove the burden of bureaucracy from the NHS in order to give patients more flexibility.
The government’s change of heart is to be welcomed but it will not be enough unless the management of the delivery of healthcare is totally changed so that it becomes clinically led with administrative support. At the moment the NHS is a remotely managed system with doctors and nurses treated like cogs in a machine which are dispensable if they ever try to be helpful (this attitude partly explains why we are short of 40,000 nurses and thousands of consultants, even though these posts are funded). I am aware of one large hospital where the managers virtually disappeared at the beginning of lockdown, leaving doctors to make major decisions themselves. This led to a much more effective and efficient service. Removing a couple of layers of management at the hospital greatly improved outcomes and productivity and, most importantly of all, morale, which has been completely eroded and which is the major cause of unfilled positions, sick leave and early retirement.
According to Matt Hancock’s White Paper, NHS services will increasingly be moved out of hospitals into the community in a bid to prevent poor health in the first place – although this kind of work is taking place in many major hospitals already. The department for health’s goal is to join up all local services, scrapping the need for internal competition within the NHS. I, for one, completely welcome this change and cannot understand why it has been taken so long to be noticed. As usual, it has taken a crisis such as the Covid pandemic to highlight these problems.
Finally, ministers now understand that GP groups acting as customers, buying services from hospitals and private firms on behalf of patients, mires the system in an extremely expensive bureaucracy and unnecessary red tape. It is worth pointing out that the NHS is often referred to as a single entity when in fact it is at least four separate organisations, with NHS Wales and NHS Scotland consistently doing worse than NHS England. This is in spite of NHS Scotland receiving considerably more money per head.
As well as the scrapping of the single market, ministers want to improve the prevention of bad health. This kind of approach can be very successful, as seen in the reduction of deaths caused by smoking. The challenge now is to improve obesity, which is currently a bigger cause of cancer than tobacco. There will be some challenges. One of my colleagues was recently reported to the GMC for calling his patient fat when trying to get her to lose weight (she claimed that he had humiliated her and caused her to have low self-esteem).
But the Covid crisis has shown the importance of tackling obesity. As a clinician, it is clear that the wards are full of Covid-positive patients who are very overweight, regardless of their race, gender or background. We also know now that those with diabetes, blood pressure and cardiac conditions are more susceptible to becoming ill following Covid infection. Most of these conditions are lifestyle related and could be improved by weight loss and increased exercise.
Another factor that has been brought to light by Covid is the importance of Vitamin D. Once again, the pandemic has highlighted what many of clinicians have been shouting about for years, which is that if you have low Vitamin D levels your health will be considerably worse. It is about time the government addressed the appalling low levels of vitamin D in this country, which in turn are associated with a dreadful burden of chronic disease and early death.
When it comes to NHS administrative reform there are greater challenges. It is a relief that Matt Hancock is rectifying the first of the NHS’s crumbling pillars. But it will make little difference if the NHS’s current management structure and shackling of clinical staff, which inhibits their creativity and initiative, is not reversed.
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