Cllr Stuart Carroll is the Cabinet Member for Children Services, Education & Health on Windsor and Maidenhead Council.

Nurse strikes, prolonged waiting lists, pandemic backlogs, unchartered winter pressures, and mass public discontent. That’s just for starters.  It is no exaggeration that the NHS is crisis-laden across England, Wales, Scotland, and Northern Ireland. This article majors on England, but the context is equally grim UK-wide and this is no ordinary crisis. It is fundamental and existential.  For fans of space history, Apollo 13 and the iconic phrase “Houston, we have a problem” are legendary as synonymous with crisis, emergency, and doing whatever it takes to survive.  For NASA, that meant getting three stranded astronauts back from an aborted moonshot to planet Earth using unprecedented techniques before rising CO2 levels proved fatal. Sadly, the NHS is a contemporary Apollo 13, risking implosion with irreparable repercussions barring similarly drastic action.

To borrow a sporting analogy, the NHS is firmly in the relegation zone and alas, without changes, going down. There are inescapable natural causes partly explaining this peril, particularly the overwhelming pandemic impact on population health causing delayed operations and screenings, primary care meltdown, and a pummelled A+E landscape.  These challenges are not NHS exclusive with all international healthcare systems suffering.  Moreover, peer systems like France, Italy and Spain got knocked out with severe collapse during the height of the pandemic.  The NHS remarkably stayed on its feet albeit with gelatinous knees and wobbly legs. Yet the NHS’s political prominence, extraordinary public investment and status as the sacred institution arguably render this Apollo 13 crisis worse.

Indeed, NHS FC has played three long seasons since 2020 without any summer or winter breaks absorbing serious injuries (big backlogs), long suspensions (cancelled operations/appointments) and haemorrhaging players (staff departures and leadership changes). Budgets and spending reviews have delivered spending increases, but rampant inflation is wiping those dry. No wonder the NHS has, per a recent King’s Fund survey, lost the public terrace.  It has also lost the dressing room characterised by nurses strikes and staff shortages. The crisis is serious and deep, yet still NHS FC is playing like it can win every game and cup competition rather than focusing on top-tier survival.

However dismaying, being in the relegation zone critically demands a different strategy, tactics, and way of operating to secure survival as a premier healthcare system. Otherwise, Einstein’s definition of insanity – doing the same thing over and over again and expecting different results – strikes through. A new drumbeat and mission is urgently needed. The NHS needs to “park the bus”, defend before attacking, and dig in to win and get over the line. That means focusing on core imperatives and basics only. Winning 1-0 should be the target rather than seeking unattainable 5-0 victories. A relegated NHS is an unpalatably painful prospect and, unlike the footballing world, there are no parachute payments or easy ways back. An Operation Apollo 13 strategy is therefore needed prioritising five major areas:

  1. Primary care and GP consultations strategically using other healthcare professionals, namely pharmacists, to enable quick, effective and safe appointments.
  2. A&E and ambulances with emphasis on speed and safety.
  3. Elective operations with a 12-month backlog plan and continued emphasis on paediatrics and early years.
  4. Vaccinations, screening and diagnostics with greater use of technology, personalised healthcare and genomics.
  5. Mental health services including an emergency plan to tackle the enormous pandemic crisis and persistent killers like suicide.

However hard and tempting, anything else needs deferring as “nice to do” until relegation is avoided and a stable mid-table status secured.

The NHS is doing too much, whether that’s fertility treatment, non-urgent plastic surgery, and transgender operations. Having reviewed NHS Tariffs and utilisation indices, staggeringly, procedures like breast prosthesis removal, male gynecomastia reduction, liposuction and penile circumcision are routine. Unless deemed seriously life-death, such “healthcare” should not be the NHS’s ask nor business.

Other vital functions, e.g. performing clinical trials, data analytics and negotiating pharmaceutical prices through the notoriously complex Voluntary Scheme on Branded Medicines, should be transferred to a new Department of Science, combining the National Institute for Health and Care Research, Office of Life Sciences, legacy parts of the Vaccines Taskforce and miscellaneous functions in the Business Department for powerhouse integration. This would free the NHS load whilst providing serious UK leadership in life sciences and economic growth. Over-prescribing of medicines demands a saving taskforce as does the better use of health technologies to dampen service demand. A crisis needs a crisis plan, meaning the deployment of Occam’s Razor to strip the NHS to what is absolutely necessary for lucid day-to-day focus.

There are three other loud and noisy elephants rampaging around the NHS room, which government must grip for next season’s forward planning. First, the NHS today is manifestly different to its 1948 birth. Societal plates have changed: the population is substantially bigger, people are living longer with a greater chronicity and complexity of condition, and NHS services have ballooned.  For the NHS to mirror its inception is folly and inimical to its longevity. The NHS is not immune to evolution and must focus on a modern core and tighter scope of what it does and doesn’t do, and what is affordable. After all, nothing is really “free at the point of need” and never has been: the NHS has never been funded via a magic money tree, but real taxpayer hard cash and in England that equals £180 billion annually. Politicians must stop parroting these misleading, vacuous phrases which create a sense of entitlement and no public reference point. Moreover, increased funding alone won’t solve this endemic basic health economic problem and the debate must move on. There has been mission creep, requiring the NHS to now reset to basics and criticalities with a ruthless dashboard of streamlined priorities.

Second, the NHS has long been a National Illness Service, or worse a National Hospital Service. The Health, which must mean prevention, public health and healthcare management, remains a poor relation and afterthought. Regrettably, the UK population, as a collective squad, lacks match fitness and disproportionately uses the NHS in unsustainable ways. The pandemic has amplified health inequalities and ill-health, which seismically drain government resources, especially across the welfare state.  The largely reactive Department of Health and Social Care needs stripping back to minimum size releasing precious expert resources to invest in frontline staff and world-leading agencies like the MHRA and UKHSA, whilst NHS England needs reviewing amidst the current relegation zone dogfight.

Third, Adult Social Care (ASC), which successive governments have bottled or lacked stability to implement proper reform, is titanically pressurised, draining NHS resources through a lack of coordination, capacity, and forward planning on essential basics – namely hospital discharge and community care. Not only is ASC bursting, the two systems are reinforcing a hospital merry-go-round.  ASC also operates antithetical principles to the NHS: ability-to-pay and means testing. Thus, to constantly ask local authorities to grab last minute winners with inadequate resources and botched reform proposals is lamentable. The ASC policy medicine is a tough pill to swallow, but the UK needs a pis aller.  Critically, any reform package must deal with system divergence, delivering fairness and affordability via a co-payment regime to exempt the most impoverished, whilst recognising precepts are merely costly bandages amidst shattered local government finances.

Gene Kranz, Director of Apollo 13 Flight Operations, once famously said “failure is not an option”. The NHS needs the same drumbeat, purpose, and mission for all our sakes. The stakes are high and the crisis is life-threatening; not just to patients but the NHS itself. Bold changes are needed now; not the same old 4-4-2 formation. For now, winning equals survival and with it confronting the reality of what the NHS has to be to win. The public terrace will only support for so long. Just like failure is not an option, it is now or never.

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