Saturday, September 11, 2021

WEEKENDER: The Compounding Of The NHS's Failure, by Wiggia

The statement from Boris Johnson on social care and NHS funding this week was yet another failure to even try to reform the NHS and the way it performs. I can’t say I was surprised; after all, no one has had the guts to to make any meaningful reforms to the NHS since it was launched in 1948.

The original NHS was based on the concept brokered by Aneurin Bevan, Clement Attlee’s health minister from ‘45-46.

It was based on this…….

“This project was said to be based on three ideas which Bevan expressed in the launch on 5th July 1948. These essential values were, firstly, that the services helped everyone; secondly, healthcare was free and finally, that care would be provided based on need rather than ability to pay.”

At the time it was a welcome addition as health care had been a hit and miss objective for many and paying for care restricted it to the better off.

Almost from the beginning it was spending more than its budget and soon prescription charges came into being.

It’s been through various periods of change, mainly as technology, drugs and increased demand for procedures that before were unheard of; all of course cost more money and the NHS adapted and grew.

Even in the Eighties, a time of wealth growth before the crash, we could not have foreseen what the NHS would become. It was already eating resources and expanding both in terms of personnel and what was expected of it, all a long way from that original concept.

This quote sums up where we are today….

“ Today, the NHS is facing a greater crisis still. The issues of funding and demand continue to rise and the ability to provide free healthcare to all is a continuous topic of debate for many. “


"Tight spending in recent years and increasing demand for services have been “taking a mounting toll on patient care”. They add that there is “growing evidence that access to some treatments is being rationed and that quality of care in some services is being diluted.”

This of course came about after the financial crash in several years ago. It cannot be looked at in isolation to the rest of industry and commerce all had to make savings and wages were suppressed; what didn’t happen, being a public utility, was that jobs were not lost as in the private sector so like-for-like comparisons are not entirely valid.

The front line shortages only highlight a system that has failed to train our own nurses and doctors over a long period and rely on the expediency of bringing in ready trained staff from overseas. Many are coming from countries that can ill afford to lose such staff. The front line shortages also highlight the fact that an organisation employing 1.3-1.5 million people has got a gross imbalance somewhere in who it employs.

When pay rises are discussed especially for nurses it has to be remembered that whatever one thinks about nurses pay many of the claims are slightly disingenuous. Why? Because what is never mentioned is this…

Many staff saw a 1.5% rise immediately in April this year (with payments backdated to then). They will only see the full increase when they go up a pay band, which can happen at any time throughout the year (their own ‘pay anniversary’).

There is an automatic raise in salary, something that does not happen in the private sector and that is regardless of any justification; claims of low entry wages don’t really stack up as it should be viewed in the same way as an apprenticeship, i.e. you are learning your trade and will be paid accordingly. No one should expect staff still learning on the job to be paid the same as experienced qualified staff, yet many of the nursing unions believe they should on a special case basis; this is unrealistic, or should be.

After the 2018 pay deal this is what it actually meant to nursing staff - not exactly bread line pay rises:

“Pay will rise for some staff by between 4.5% and 29% over the next three years. This includes the increases in salaries staff will get by progressing through their pay band over time, and pay rises would still occur without a new deal. It doesn’t cover doctors, dentists, or very senior managers.“

With many in the private sector not having in real terms a pay rise for ten year but contributing for the above it must be quite galling, though few realise how the points based pay rises work.

Health tourism is something that rightly raises the hackles of those who pay for it but is mainly ignored by those who treat the same abusers. The moral indignation of those in the medical profession who believe we should treat all and sundry is typical of those who use other people's money and have no accountability.

The figures for health tourism are so vague that one suspects they are are not really known. The figure of ‘just’ 0.03% of the total budget is trotted out as a reason to ignore the claims as being ‘insignificant’, but £1.8 billion is not insignificant and the reality is it is just a rough guess, whatever it is it is wrong and would pay for many treatments for those who contribute.

What you won't find anywhere is the figure for treating those who arrive every year as immigrants and who are entitled to the full range of products despite never having put a single penny in the pot; this sum with the huge numbers coming here every here must be enormous and a drain on services.

Even those who have no status in this country now use the A&E as their go-to GP surgery, having been barred from the latter as they cannot sign on. What must be the figures for that? They don’t know; they never seem to know those facts that are inconvenient.

What we don’t need is an NHS run along the lines it is today. Any organisation that is in dire straits as the NHS is and begging for yet more money does not advertise for community cohesion advisors in a big way at £70k a year and all the office staff etc. that go with it. Something is very wrong with their priorities.

Even outside the non-jobs they have no problem paying six figure salaries for ever more layers of management. This ad is just literally plucked out of the internet after minimal effort:

The number of senior management posts haS risen from around 500 in the 70’s to 43,000. At first glance that is a staggering increase , but it does not take into account the overall rise in staff levels and the extra areas of management needed for sectors such as IT; in many areas the NHS does not have as many managers as the private sector. Despite this fact many jobs advertised with very high salaries appear to be non-jobs.

A more recent guide to the increase is this one from 1999:

“As a proportion of NHS staff, the number of managers rose from 2.7 per cent in 1999 to 3.6 per cent in 2009 2009, just ten years." Was that rise in numbers justified? It is difficult to find where the extra jobs were created and why.

Will the money now being pledged actually go to the right areas to help alleviate the problems of its and the government's own creation? Somehow I doubt it. All the time the basic services are being withheld from those who not only have paid for it but will be paying the extra money needed.

(Said by Tony Benn in 1995)

Nothing in Johnson's statement gave any reason to believe any meaningful changes will be coming along anytime soon. The money pledged will not supply any more front line staff for some time and the bed shortage in comparison with our European neighbours remains. When you take into account that hospitals are still working under virus regulations and are not nearly near the procedure rates pre-Covid the waiting lists will grow, as has already been intimated.

The divvying up of this money is as usual just a back of the envelope job. The social care authorities are already worried most will go to the health care side ahead of any social care needs. What was not said is as usual often more interesting: even on the assumption this will help social care, is it enough? and what about the council tax levy all councils applied and will continue to do so, that is for social care? What is indeed the total being allocated and what is needed? That is not set out.

So with the new NI contribution social care will be in effect be in receipt of three revenue streams. None of this was mentioned by Bozo in his saving the world speech; nor was one of the big reasons for the needed funds: the growth in our population because of immigration. All these millions extra who have never contributed to the tax pot for health are all allowed to partake in using it; as I have said before, we are edging ever nearer the time when it all becomes unaffordable. In the meantime whoever is in power will soak the tax payer for all they can. The virus may be a get out of jail card in the HoC but doesn’t stand up to a problem that has been growing for years.

Aneurin Bevan said on the birth of the NHS that it would be funded from general taxation, but escalating costs soon had governments alarmed as this quote explains…

“A free and universally available service on this scale was highly unusual. The provisional estimates of costs for the first year were based on past hospital accounts, some of which were sketchy in the extreme. They were rapidly exceeded. In 1946, when the NHS Bill went to Parliament, the estimate of the total net cost annually was £110 million. At the end of 1947 it was £179 million. At the beginning of 1949 a supplementary estimate of £79 million was added and the figures turned out to be £248 million. The actual cost in 1949/50 was £305 million. The following year it was £384 million. The government became alarmed.”

To show how the health service has grown completely out of proportion to other areas needing funding from the public purse, that £305 million in ‘49 is the equivalent of just over £11 billion today and yet the NHS is now running at £159 billion without costs for Covid and will obviously be even more in the next few years. Whatever the reasons, it is like a runaway train.

Naturally all the new procedures drugs etc. all cost more as does the inflated employment quota, but on the other side all prescriptions were free, all dentistry and all eye tests and spectacles.

Another item that is difficult to pin down is the amount included in annual costs relating to the ongoing payment for PFI projects so trumpeted by the Blair government and still costing us billions. Many articles have been written on the rip-off nature of these PFI projects but whatever the actual figures it is something else, alongside failed IT projects that would have had the money involved put to better use. The sums are eye-watering.

The ‘free’ word was used even in those early days despite the fact it was never free, but the word gave the NHS an edge when comparing with like organisations world wide, hence the ‘envy of the world’ phrase so often bandied about in such a misguided way.

Going back to these early days shows that many saw the problems ahead. Even as early as 1949 this was published and how very true it all became and still it applies:

“Dr Ffrangcon Roberts, a radiologist at Addenbrooke’s, was an early and perceptive commentator.275 Early in 1949, he drew attention to the unreliability of the predictions because of three factors:

they ignored the effect of the ageing population

they ignored the intrinsically expansile nature of hospital practice; previous government experience had been of chronic care and general practice, not the activities of the voluntary hospitals where the application of science resulted in expansion with accelerating velocity in every branch of medicine

they were based on a false conception of health and disease. ‘Positive health’ was neither easily nor permanently achieved. The fight against disease was a continual struggle which was ever more difficult, promoting the survival of the unfit. We were cured of simpler and cheaper diseases to fall victim later on to the more complex and expensive.“

And ever since, the costs in line with that statement have escalated. The failure has been the neglect to act on any of these early predictions and any that came later; instead the NHS has become a bloated leviathan just hoovering up ever more resources without any accountability to the tax payer and paying ever more lip service to those that run it for their own ideologies.

Decades have passed with the cries in the background that it cannot go on this way, but on and on it does go. It is now the biggest employer in Europe yet one of the poorest providers of health care judged by the results; something is seriously out of kilter.

I repeat, this has reached the 'rinse and repeat' stage: nothing ever is done about the inner workings and whether the layers of management are justified and the 'treat-all mantra' - even those who have no right to the service, though a few at the top of the organisation believe we should be treating the world for nothing. The whole edifice needs stripping down and re-assembling in such a way that we get value for money and a decent health service. At the moment there is no hope for that and it is costing a fortune we really don’t have.

In 1911 Lawson Dodd wrote:

"The economy of organisation, the greatly lessened cost of illness due to the increase in sanitary control, and the immense amount saved in the reduced number of working days lost through illness, would make the health tax seem light, and it would be regarded as a profitable form of insurance."

Pure socialist rhetoric; wonderful if true but open to abuse and the facility for people to use the health service for everything from aspirin to a grazed knee; and that was only the start.

What was also overlooked was the fact that universal health care on this scale would result in increased longevity; a good thing, but an expensive result of having an NHS it was never factored into the original costs.

Basic diseases were easily cured for the first time but more complicated and more expensive issues replaced those and again the costs soared.

The advances in medicine became a treadmill for ever increasing costs. None of this is wrong but a public used to the notion of a free health service expected for the same price ever-expanding services and they got them. In the end though like all things there is a reckoning. It could be that reckoning is here at last because I see no way back from the present situation, the costs alone to rectify the total mess we are in now caused by a completely misguided ‘save the NHS’ from being overrun by the effects of the Covid virus have created a situation that I believe is not completely retrievable.

The argument that all would be well if we stopped foreign aid, HS2, ditched much of the climate change scam and put that money into health care are missing the point: while all those things have merit in being culled, diverting that money into the NHS would achieve nothing unless changes to the organisation were made; it would just be swallowed up as I fear this latest ’gift’ from the tax payer will be.

If a government given a golden opportunity to overhaul the NHS in the way it is run and the way it is financed, i.e. an insurance content, cannot put in place any long-term planning as to manning the front line staff, cannot deal with the inner ideologies at work, cannot stop the stepping outside the NHS's remit to deliver health care and ditch such woke projects as running parks, cannot stop adding layers of unnecessary management positions such as the much-quoted diversity officers, cannot get a grip of the joke GPs masquerading as health providers on their well-paid part-time positions... then it is never going to happen and we are stuck with an expensive second-rate health service as it largely is now. I am not holding my breath.

This by the way was the Conservative Party's manifesto pledge, for what it is worth, in 2015.

“The Conservative party manifesto for the 2015 general election committed “to increase spending on the NHS, provide seven-day a week access to your GP and deliver a truly seven-day NHS—so you know you will always have access to a free and high quality health service when you need it most.”

That must look to most of us now as one of the sickest jokes ever committed to a political manifesto and there have been many.

Being at this moment in time still partially incapacitated, I turned on the TV this morning (Thursday) and one of the awful breakfast programs was on. Before I switched off again I noticed a doctor (from the BMA?( was being interviewed about the clamour from GPs to retain the strategy of appointment by phone at a high percentage rather than go back to face-to-face appointments. There was the usual guff about ‘pressure,’ lack of doctors (true), and that many were retiring or working part time working, all causing a shortfall in the staffing of surgeries; the gist of the message was about poor GPs not being able to cope.

At no time in the interview was the question asked: "How could they be under pressure, having hardly worked at all for the last sixteen months, and seeing that today the majority of surgeries have empty waiting rooms and the doctors (in some cases as I know) are only there one day a week?"

Even when told by a patient that not being seen in a face to face interview can create life-threatening situations the doctor put on that stressed look and said being short-handed made these things inevitable; hmmmmm, on occasions like that one could happily put a brick through the screen. The thought that in these difficult times that they perhaps could put a weekend shift in to help and make up for the year spent at home never crossed his mind.

My own underused surgery even has the gall to state that appointments, if you should be ever lucky enough to get one, are rationed to a ten-minute slot for one problem. What happens if the one problem has involved other problems, or you have more than one ongoing problem, they don’t explain. One can in the case of places like this be forgiven for thinking they are taking the proverbial.

They are currently not even trying to give the service we have paid for. A relatively small number of surgeries are actually trying to give that service. I have a friend in another county who can still phone and get an appointment the next day and even a house call; if they can manage it in a busy city, one asks the question why ours and many others remain closed.

Even blood test and x-ray results are taking up to two weeks to come back with a result? Why? The same items pre-Covid came back sometimes in 24 hours, staffing levels in the labs have not changed, so what is going on. The whole thing is a mess.

No one can come up with an easy answer to all this. Different health providers world wide have different set ups and different results: the French system is still largely lauded as the best 'but they spend more' is the cry from those here that want a better NHS;  'we are starved of funds' they cry. Yet the French spend more in part because of the sheer amount of bureaucracy involved in getting anything done; strip that out and it is a better service that the NHS for a similar outlay. Japan spends less than us but clinical results are better. There is no 'one size fits all' in this, that is not not an excuse for the NHS to do nothing about its structure which is broken in nearly all front-line areas.

Bojo’s much trailered hosing of the NHS with money, repeats what governments in the past have done. Will this turn out to be just another sticking plaster? Probably.


(Ed.) See also this story in today's DM:

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