I posted this video on YouTube this morning.
In it I argue that the NHS is a mess, created by meddling politicians who have broken it into hundreds of organisations that they pretend trade with each other. The result is not efficiency or productivity. The result is an admin mess and a failure to meet needs.
The only reform the NHS needs is to get rid of this mess by consolidating the NHS into regional and national care services that treat us as whole human beings. Then we, and it, might get better.
The transcript is:
I want to put the N back in the NHS. By which I mean, I want it to be a national health service again.
The trouble with the NHS right now is that it is fragmented into vast numbers of supposedly independent organisations.
Every hospital is run by a trust.
Every ambulance service is run by another trust.
Mental health services are run by different organisations from physical health services.
GPs are of course, independent of hospitals, and many of them are are privately owned in effect either by the people who run them or by consortiums who are now buying up GP practices.
We have a whole range of organisations working together who, however, do not deliver an N - a National Health Service - and I believe that's wrong.
We are integrated human beings. We're holistic. We have to be treated as a whole. Our needs are not to do with our thumb, or our ear, or whatever else it might be. They're actually about the whole person. Because when we're ill, in whatever way it might be, it isn't just the symptom that is affected - the particular limb or whatever else it might be. It is our whole well-being that is affected, and the NHS needs to reflect that in its organisation. So I believe that we actually need a national health services.
Now that would be a national health service for Scotland - they've already got one, but it needs to be properly funded.
And for Wales, but it needs to be properly funded.
And in England it might mean regional health services. So I'm not pretending that health services in Kent should be run by the same organisation as health services in Lancashire, because I suspect that makes no sense.
But there could be a South-East England health service, a South-West England, an East Anglian one, and a Midlands one. You get my sense. We'll go up the country until we get to a North of England health service. What follows is that those regional authorities, coupled with those for Wales and Scotland and Northern Ireland, would be responsible for delivering integrated care.
We wouldn't have the stupid situation that you might phone 111, which is one agency, who then refer you to an ambulance, which is another agency, who take you to hospital, which is a third organisation, who then discharge you to your GP, which is the fourth organisation, all of whom are billing and charging and arranging with each other in inconsistent ways.
We would have one integrated service.
I believe that is the only reform that the National Health Service requires.
The people in the NHS know this.
They know what they want to supply.
They know they want to get rid of the red tape.
They know they want to get rid of the admin.
They could do that if only we gave them the power to concentrate on health and remove all the layers of organisation which are the impediments to progress now and deliver instead integrated care for everyone.
Nationally, which would put the N back in the NHS.
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1st rate suggestions. The conclusion to draw from this is that fragmentation of the service, lends itself to creeping privatisation, “it’s bloody useless lets pass it to the privaet sector which will be more efficienct” – style of.
Given LINO won’t support any of the suggestions – one wonders which party will?
Why not more local set-up based on old counties? Closer to the population. Also need some form of democratic (non-party) accountability at that level.
Too small in too many cases…
We cannopt have that many major hospitals
I can see the merits of the regional structure you propose but current arrangements rely on cars. CO2 emissions must, must, must be cut a lot and soon. Smaller areas may require some smaller hospitals. Some operations may no longer be viable but with fewer traffic accidents and cleaner air there will be some medical compensations as well as, hopefully, stronger communities.
That’s fine
But not all counties can offer a hospital offering all expertise
@Peter Wills
You may recall that there used to be such organisations as RHA’s, or Regional Health Authorities, which were sufficiently large to overcome Richard’s objection about size.
There also used to be local CHC’s, or Community Health Councils, which WERE very local – I sat on the Barnet CHC – which offered a powerful local voice on the delivery of NHS services in a region. The Barnet CHC was sufficiently powerful to stop Virginia Bottomley, at least temporarily, from closing Edgware General Hospital.
I’m not sure who abolished the RHA’s, but the CHC’s were definitely abolished by Blair, so maybe he got rid of the RHA’s to, as a means of enabling the laughably inefficient internal market beloved of neoliberal fanatical supporters of market-based solutions. I’d welcome clarification from someone who knows!
CHC’s were too democratic for Blair’s taste, while, if he did abolish the RHA’s it would probably because viewed them as too bureaucratic – a bitter irony, given the sclerotic nature of the internal market.
One final point, of course, is that Corbyn’s 2017 Manifesto (and perhaps his 2019 one) argued for a renationalisation of the NHS (in the sense of bringing it back together as a single organisation, as well, of course, of bringing privatised services back in house) to be matched by an integrated National Care Service.
If only, is all I can say!!
With some 5.5m people, we had our Scottish Police Service centralised, ostensibly on the grounds of economies of scale, managing costs and providing more efficient centralised services, but it hasn’t gone that well as local links have been well and truly severed.
Instead of my being able to ring our local Police station for relatively simple issues, and speaking with the same person more than once, I am now diverted to a centralised call answering facility some 120m away. This is much less public facing, and offers a much inferior service.
An alternative option, and one which was recommended by many in the Police service, of having 5-7 area based autonomous police services, delivering a range of policing, but then sharing both a central database and cost sharing specialised services that would be commissioned on an ‘as needed basis’, was simply ignored.
Of course strategic co-ordination is needed, but there is no reason to have very large regional NHS services and administrations that end up distant from the people they serve, especially if these are only achieved by rigidly applying a population threshold criterion, which might work in more densely populated metropolitan areas, but then don’t fit large rural areas, with dispersed populations.
For example, I believe there have been proposals for a new “centralised” Pembrokeshire A&E unit which could mean an ambulance journey of up to 60miles.
In the holiday season that is about an hour and half on blue light..
This will mean closing down local services.
In my youth the A&E service provided for the county, in several local hospitals, served some 95,000 people.
The population now is about 125,000 people, yet this is deemed only sufficient for a single centralised A&E service. Values seem to have changed.
I think the principle of maintaining devolved services as far as is possible, and then only upscaling to regional services for more specialised requirements, which can be co-ordinated, has to be more effective for patients, and service delivery has to be the key criterion.
That is closer to what we have here in Scotland, though I do face a 250m return drive for a 15min basic clinic appointment this next week, as local clinics were severely cut under austerity, so there are downsides for us patient patients, however it is structured.
Thanks
The destruction of NHS Dentistry, the breaking up of districts into into Trusts, the removal of RHA’s, the massively increased admin of the internal market, all came about because of ‘Working for Patients’ in 1989. It was designed to make the NHS ready for privatisation.
My wife told me -I haven’t read myself-that during the pandemic, the medics in Croydon got together and organised services in a different way and it was very successful.
We need to do more of this and trust the professionals-in education and social work as well as the NHS.
The awful 2012 Health and Social Care Act has been replaced by the 2022 Health and Care Act which put more emphasis on integrated services but the private sector has still been given a part in decision making and some think too much.
What annoys me is that before 2012 we had a system which worked and could have been developed. I think you are right and it is what Labour should be advocating.
this is the 2022 BMA view. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/integration/the-health-and-care-act
If the private sector is so efficient, why is healthcare in the US so expensive and health outcomes for the population as a whole so poor.
Which is not to say that the NHS is perfect, although it has a reputation for producing good health outcomes from its limited resources. We should be learning lessons from how other countries organise their socialised health systems and seeing what could work better. Artificial markets are not always the answer.
“why is healthcare in the US so expensive”
PROFIT
This is so so right – I have been trying to explore bottom up ‘whole person’ public services off and on.
There are other examples from child protection disasters where 40 or 50 professionals from several agencies had personal contact with a family but noone had the whole picture. Victoria Climbie, Baby P etc etc – Lord self serving Lameing’s inquires recommended yet more top down hierarcy , more and more layers of communication.
The confusion is spread when BBC get NHS head of ‘providers’ or ‘chief medical officer’ to speak , so people have no real idea what the NHS is
The real dread is that politicians love restructuring the NHS – and have done it time and time again – right up to the Lansley ‘ internal competition’ disaster and now the ICC supposed collaborative system.
Hi Richard,
Ths is the reult of thinking about the NHS from top down, profit point of view. I they were to think of providing a service, from the bottom up, the conclusions you come to, are inevitable.
Sadly, many people now only think of profit and money, rather than quality. It is why many of our private businesses are considered ‘crap’, for want of a better word.
Regards
England NHS has the best outcomes, better than Wales or Scotland, so that is not consistent with your proposal.
Basically your answer is more spending on the NHS and hence more tax, as always.
But you’ve not explained where their money will be spent and where it will come from.
England is wealthier. The outcome is always going ti be that way unless there is levelling up.
The Taxing Wealth Report explains where money can come from.
I actually proposed cutting spending on admin. You were so keen to be rude you did not notice.
Measuring NHS outcomes is not the same as measuring health outcomes. I am not clear what measurements you are relying on. Until you provide a clearer evidence base I am a little sceptical of your prime assertion. On some measures of NHS performance I think you may be quite wrong, but I do not know what evidence you are relying on. Health outcomes and NHS outcomes are not the sma thing.
I’d be interested in where you get information suggesting that health outcomes are better in England than in Scotland.
Not a criticism, but I read both Scottish and English news and I understand we, in Scotland, may be doing better if direct comparisons are made?
Trolls do not use facts
This person is definitely a troll
My comment above was based on (far too much) reading of the national press and The National in Scotland.
Merely an observation which I’d like to believe is true but would quickly change my view if proved wrong.
On dentistry, yes, an absolute mess.
As my dentist and friend said to me years ago “If you don’t believe the NHS is being privatised, take a look at dentistry”.
Prof John Robertson has written several articles comparing health services in U.K.
https://talkingupscotlandtwo.com/?s=NHS
Richard, less than week in and it already becoming exceedingly tiresome. Is anyone interested in facts, or do they all prefer this madhouse where nothing but barefaced lying matters?
It seems the lies and the liars are winning the day
It is also intended to confuse, which is an effective way of deflecting attention. I suspect both Mr Lawson and I were a little confused by the comments here.
Prem Sikka pointing to private equity buying up GP’s
https://x.com/premnsikka/status/1794688667111579702
NHS dentistry has been steadily privatised by attrition. Why would we think that exactly the same end has not been planned for the whole NHS when precisely the same process of attrition has been in place since 2010?
Thanks Mr Broadbent. I have used the link to feed the indy campaign.
At the very least we need Richard’s regulation of Companies, if this idea isn’t implemented or in the interim before it is.
https://calderdaleandkirklees999callforthenhs.wordpress.com/2024/04/18/private-equity-gp-company-in-serious-nhs-contract-breach/
https://calderdaleandkirklees999callforthenhs.wordpress.com/2024/05/22/25520/
Thanks
as well as the N not really being National I would suggest the H is not Health but more about illness and reacting to conditions not maintaining hood physical and mental health.
The S is not really a Service as too often it seems to be run for the convenience ( or profit) of those in charge.
That said I fully agree with Richards comments about the increase in transaction charges and staff employed since the internal market and commissioner/provider splits.
Richard,
There is nominally a national health service for each of the countries of the UK.
There are also Integrated care systems/Boards responsible for the NHS in quasi-Regions of the country -although these could be reduced a bit.
So it would be easy to respond that what you want already exists.
The thrust of your commentary however suggests that you would abolish the NHS internal market which treats care as a commodity to be costed, priced , packaged and contracted for.
This would take the NHS back to what it was pre 1990.
I worked for the NHS at the time. It was worse than it is today.
There was little accountability , no one knew what was being done, professionals did as they liked to further their self interests. It was starved of resources by politicians who had other priorities- whether Labour or Tory. The chaos and dysfunctionality was used by the right wing to push for NHS privatisation. The Left wing merely liked to hold up the NHS as an example of Tory incompetence and malevolence. Labour in power turned to Mackinsey to tell them what to do….which was and is to create organisations that will ape the managed care systems of the USA.
I hear what you say Richard and your heart is in the right place but there is much more to it than presented here. Be careful of what you wish for.
Nothing I said suggested we go backwards
I suggested new integrated care systems. That would not be the early 90s again.
I think you are misreading me, big time.
Roy Lilley’s nhsmanagers.net is very well worth following.
see https://roylilleysnhsmanagersneteletterpodcasts.buzzsprout.com/
He is an experienced NHS manager, who tells it like it is.
We chat occassionally and have declared outselves a mutual fan club
Interesting – not sure that I agree that larger organisations are necessarily bigger but the point about cross-charging and additional administration between trusts is a valid point.
But would this be improved by having bigger regional groupings? They would still have to have admin – payrolls need to be paid, equipment needs to be procured, buildings maintained.
The main driver behind having lots of local trusts was to allow people to make decisions locally and to reduce the bureaucracy that inevitably accompanies huge organisations (both private and public sector).
Really interesting addition to the debate though .
Of course there would be admin – but whole rafts of accounting would disappear and the focus would be on health care and not financial issues in local management