Health: protestors can be part of the problem
From inception it has been regarded as a genuine national treasure, a source of great pride. Today it is in deep crisis. Without radical change its condition may even be terminal.
There are many obstacles to overcome; one of the most important is a lack of understanding about the nature of the crisis and its causes. This seemed to be encapsulated by the fact that the demonstration was organised to protest against perceived inadequate support for the NHS - an organisation that doesn’t even exist in Northern Ireland. Nobody seemed to notice, not the politicians who attended nor the media who reported on the event.
The difference between the NHS and the Health and Social Care service we have here is critically important and to ignore it, or to treat it as if it doesn’t matter, is a fundamental error.
To understand the problems of today it is important to examine the extraordinary achievements of the health service over time.
In 1948 life expectancy was 66 for men and 71 for women. Today those figures are 83.4 and 86.2. In the intervening decades, and contributing to this amazing change, more and more sophisticated and expensive treatments have been developed and deployed. In 1948, the annual cost of the health service per head of population in GB was just £200 – a figure that seems scarcely credible today.
The net result is that we have a population that is living longer and, as a consequence, more and more of the population suffer from chronic conditions. The cost of care for people rises as they get older, peaking in the last few months of life.
As the population ages the demand for care inevitably increases. Under the current system it is misleading to talk about health budgets in terms of cuts because, as demands increase, so too does the required budget. We therefore have to spend more and more every year just to maintain services as they are. Latest estimates suggest that this should be between 5% and 6% per annum, meaning that health spending would double over 12 years just to stand still.
The ageing population doesn’t just affect the cost of care, but also how it is funded. As the proportion of the population at and above retirement age increases, so does the tax burden on those still in work. Fertility rates are falling, so there are proportionately fewer younger people. And as government policy now discourages immigration it is hard to see the tax take being increased through that route.
We are therefore on a trajectory that will ultimately lead to a system which can no longer be paid for, unless we make changes. This may be unpalatable but it is inevitable, and it is high time politicians others recognised this.
This does not have to be bad news. It just creates the burning platform for necessary reform. And what is needed is a system just as revolutionary and exciting as the original health service. It was designed for the treatment of illness, making sick and injured people better. A 21st Century system would be focused on keeping people well.
That is essentially what the Bengoa proposals are all about. It means prevention of illness, treatment in the home wherever possible, and a system that empowers citizens to make decisions about their care. There would be a need for a significant initial investment but, over time, properly funding social and primary care would relieve the strain on acute hospitals and permit their reconfiguration.
If our politicians were genuinely concerned about patient safety, for example, they would be far more bothered about the quality of the care that they received in hospital rather than the building they are treated in.
The future focus of health should be on helping people live longer, better, more fulfilled independent lives in their own homes - where they want to be.
A system focused on prevention and early intervention not only produces better outcomes for society, it also costs less to run. By adopting such we would end up with a service that would be easier to sustain in the long term.
We also need to be honest about productivity in health care. This is an area which has slipped behind other sectors. Health productivity is still comparable to how it was in the 1960s. This is not the fault of health workers. Technology is available to make a significant difference. It must be invested in. There are many ways it can help.
Japan is the global leader in this area, hardly surprising as it is the oldest population on earth and is further down the ageing population trajectory than we are. Some may object to the widespread use of robots, automation and artificial intelligence, but the area needs to be studied and best practice adopted.
Finally we have to grasp the fact that good health is not purely the preserve of the health service.
It is not generally realised that only about 20% of health outcomes are related to clinical care, as opposed to: 10% to physical environment (air quality, housing and built environment); 40% to socio economic factors (education, employment, family and social support, community safety); and 30% is related to behaviours (smoking use, diet exercise, alcohol and drug use and sexual activity).
Therefore in order to improve health we have to ensure that all government departments work together to deliver the outcomes we need. That in turn means redefining how we invest for better health outcomes.
One of the biggest obstacles to health reform is the sheer size of health bodies. The National Health Service is the fourth biggest employer in the world at 1.7 million.
However (and this is why the distinction is so important) Northern Ireland’s health and social care system is separate from the NHS. It employs considerably less people (64,575) and is governed by a devolved administration which has signed up to a Programme for Government and which has, as a founding principle, the notion that all government departments have to work together in order to achieve agreed outcomes.
In addition we have, at least in theory, an integrated health and social care service, meaning that health and social care ultimately come under the same management and therefore can be co-ordinated. In England and Wales social care is the responsibility of local authorities whose budgets have been cut to ribbons. Efforts are ongoing to integrate these services but the fact that this is not already the case, and that both the health service and social care sector are struggling, makes this extremely tough. Northern Ireland is, by comparison, in an advantageous position.
These facts - that HSC is separate from the NHS, and is smaller, and that we have integrated health and social care - mean that with political will, a working administration, and political understanding and buy in we have the ability to effect the necessary reforms, a structure manageable enough to work with, and every prospect of making the necessary change. All that is required is a little understanding.
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