Like many others no doubt, I’m convinced that Aneurin Bevan is turning in his grave right now; perhaps even more than has been usual in recent years. The events in our national response to the coronavirus pandemic must have prevented any restful peace for Bevan. As he looks down on the unfolding covid-19 debacles there will be a face-palm or two.
Those who know anything about British history will acknowledge that Bevan’s most significant legacy was our National Health Service. But, despite Bevan’s visionary foresight – “This service must always be changing, growing and improving; it must always appear to be inadequate” (to drive improvements) – it appears that the last word in this visionary statement is proving to be his most prophetic observation, as ‘inadequate’ becomes the new state normal.
The NHS is Broken
Many have said – “the NHS is broken” – but is it? With the amazing effort that has been expended during the pandemic, I’m not sure that ‘broken’ is the reality, at least not amongst the ethos of most clinical and care providers on the front-line. That expert care, delivered by professional people with empathy and skill is thankfully, still something that is undoubtedly truly valued by our society.
However; it’s really not that difficult to see that something is still sadly wrong. When the NHS, which we have all funded from our taxation, becomes ever more dependent upon the laudable efforts of people like Captain Tom Moore wearing out his shoe leather, one can only conclude; despite the best efforts of all the clinicians, supported by the entrepreneurial work of individuals like Tom, our health-care system is damaged, if not broken. But why? What is wrong with the system?
Systems & Services
As with many other public services, tasked to ‘deliver more with less‘ by the Government in recent years; the NHS has suffered from the ravages of austerity and become in many ways, just another victim of political ideology. Be that accidentally or intentionally, it doesn’t really matter, we have lost sight of the specific raison d’être and expected service delivery outcomes that underpin the public services we desire and demand.
Writing about the impacts on Policing back in 2017, Simon Guilfoyle examined how systems failures tend to impede the work of those organisations who provide public services. The NHS, policing, public-health and social-care have all been impacted by similar issues.
Within his seminal text on public services management structures (Intelligent Policing: How Systems Thinking Methods Eclipse Conventional Management Practice), Guilfoyle highlighted that; “Conventional management practices are often at odds with systems principles.”
People within the constituent departments of many organisation tend to forget (or ignore) their reason for being. The outcomes they are actually tasked with delivering, get lost in the fog of bureaucratic administration and small-p political thinking. Either from the perspective of ignorance or elements of silo-thinking, all applied with high levels of individual and departmental self-interest and protectionism.
Systems in organisations begin to collapse if one or more components act in a self-interested way, such as maximising their own outputs (or profit, test scores, vehicle fleet, budgetary savings, etc.), and they become directionless and ineffective when management methods interfere with or obscure the system’s aim or purpose. (Simon Guilfoyle)
I suspect that like me, Simon (see below) has also been frustrated by the constant manipulation of statistics by the media, non of which is helpful. This distortion of those statistics, delivered under sensationalised headlines for commercial gain (sell more ‘news’) is problematic. Most of what is being churned out is, in many ways, counterproductive and mostly only loosely based upon the realities of the situation.
Despite the need to challenge actions/inaction of governments and their provision of public services, under ‘poor’ leadership; the NHS is an organisation already facing significant difficulties and struggling to meet demands. It can’t be conducive for their efficacy when limited resources get embroiled in mitigation against media misinformation. To my mind, I find it somewhat puerile that; when the system is already in difficulty, when the clinicians and nurses are currently battling the pandemic but yet, the NHS is also obliged to mitigate against the sensationalism and misinformation peddled by the MSM.
The Cygnus Effect
Irrespective of the Government coming ‘under fire’ (see here) about alleged failings, that have now become clear after the preparedness Exercise Cygnus in 2016. Many news reports have (as expected) compared the predictions of Cygnus with the subsequent 2020 coronavirus pandemic.
It should however be remembered that this exercise examined ‘hypothetical’ circumstances and, regardless of any ironic prophesy becoming reality, the identified issues which have subsequently come to fruition, were still hypothetical. They had both time and cost implications behind any eventual provisions (or not).
The massively bureaucratic decision making machine, of Government, the Department of Health, Public Health England and the NHS (with all the quangos), could only ever have delivered what was suggested, with the appropriate risk-assessment, sufficient funds and political will… all difficult under constrained and finite public funds. Is the constant 20:20 hindsight really very helpful, particularly in the midst of the crisis? Probably not, despite still being worthy of later scrutiny.
Anybody who suggests that four years (between Cygnus and Covid-19) is ample time for the NHS (and Govt) “to get their act together” probably haven’t experienced the slow churning cogs of the public administration bureaucratic machine!
An update to the NHS Emergency Preparedness, Resilience and Response Board (EPRR) in 2017 (see here) highlighted;
- the statutory requirements placed upon NHS England by the Civil Contingencies Act (2004) and the NHS Act (2006) as amended by the Health and Social Care Act
- provide the Board with assurance that NHS England and the NHS in England is prepared to respond to an emergency.
Clearly, the NHS needs to “plan for, respond to and recover from a wide range of incidents and emergencies.” With such wide ranging issues, from extreme weather conditions to outbreak of infectious diseases, or major transport accidents or terrorist incidents, there are some significant issues that could impact on NHS services.
The NHS in England are prepared to respond to an emergency, and have resilience in relation to the continued provision of safe patient care. (2017 EPRR paper)
To be fair, there was some progress made with the EPRR work programme, post Ex Cygnus however; covid-19 has sadly shown the ‘summary comments’ within the 2017 document were premature. They were not only presumptuous but also perhaps a little too ambitious.
To my mind, many of the situations we currently face, irrespective of any appropriate preparedness planning in the past, are tied-up within the bureaucratic structures of all NHS process. Yes, suggestions and resources to mitigate against any possible/probable outcomes could/should have been acted upon however; given the processes involved, it isn’t hard to understand the impacts of what I’ve called – The Cygnus Effect – something that shows absolutely no sign of abating, at least not any time soon.
The NHS was born out of the ideal that… ‘good healthcare should be available to all, regardless of wealth’ and (for most) that still rings true today. Bevan’s visionary principles also stated that: health-care should meet the needs of everyone and should be free at the point of delivery. A simple idea?
Yes but, the clarity of water contained in that small pool of purpose has been muddied during the passage of 70+yrs. Bevan’s original ‘three basic principles’ – which most would agree are easy to understand and comprehend – have expanded exponentially.
What are the NHS core values – Even a simple Google search, on that specific question, provides numerous and varied answers. There is anything between 3 and 8 principles, that despite minor changes over varying timescales, broadly all say something similar to;
- Working together for patients.
- Respect and dignity.
- Commitment to quality of care.
- Improving lives.
- Everyone counts.
Today, every core part of the NHS structure now have their own particular set of guidance. Those – ‘core values’ – ‘guiding principles’ – ‘care values’ and ‘visions’ within that abound within corporate ‘mission statements’ but sadly, not all of them appear to be totally aligned, except in the written word but often not as part of day-to-day application. As Dr Ben Goldacre would no doubt point out; I Think You’ll Find It’s a Bit More Complicated Than That.
When attempting to explain and illustrate their structure, even the NHS themselves acknowledge the fact… The NHS is a complex system…
…which can sometimes make it difficult to understand – especially working out who is responsible for what. It’s made up of a wide range of different organisations with different roles, responsibilities and specialities. These organisations provide a variety of services and support to patients and carers. (NHS England)
When asking – How does the health and care system work? – not even the experts can provide us with a simple answer. Yet – as ‘non-experts’ – we all have our own personal opinions or visions. We have hold expectations about what the NHS is, what it should provide and how it should be doing what it was designed for… our NHS is important to us.
Even the renowned King’s Fund, an independent ‘think-tank’ on improved health-care in England, can sometimes struggle to keep abreast of the constant changes across our NHS. and health-care systems.
The NHS (2013)
The NHS (2017)
If you consider that the King’s Fund see a need to provide a four week course, to help people understand the NHS and it’s structure, you can start to understand that the simplicity of Bevan’s original idea has been clouded.
The NHS (now)
Over recent years the system has also been in a constant state of flux. However, many of the ‘much-needed’ changes and/or important ‘improvements’ are often born in little more than political ideology, like the financial constraints of austerity. Sadly, a good deal of that constant churn seems to result from departmental and individual parochialism within the constituent organisations of what we see as our NHS.
But all these changes are unsurprisingly self-lauded and constantly ‘valued’ by their developers and departmental leadership. The aspirations of many subordinates tend to perpetuate and protect what is often evidence of poor systems application within most public service bureaucratic machines.
Counting NHS staff isn’t as simple as you might think. The NHS counts its staff in two main ways: ‘headcount’ and ‘full time equivalent’.(fullfact.org)
As of 2017, there were roughly 1.5 million people employed by the NHS across the UK, which includes around 1.2 million staff directly employed by the NHS in England (fullfact.org). In May 2018 it was suggested that there were “100,000 vacancies in our NHS” (also challenged as inaccurate (see here). But, as with all headline numbers, the context and structure behind those figures often paints a significantly different picture.
In 2018/19 around £115 billion was spent on the NHS England budget. The rest was spent by the Department of Health on things like public health initiatives, education, training, and infrastructure projects (including IT and estates).
…even based on the government’s current spending plans there is likely to be a spending gap of over £20 billion by 2022/23 (fullfact.org)
The fullfact.org website also confirmed that NHS funding is in a poor state of affairs. When NHS trusts collectively; “finished 2018/19 with a deficit of around £571 million” things don’t look that promising for the future, even without the impacts presented by covid-19.
- The average growth between 2009/10 and 2014/15 under the Coalition government was 1.1% and from then to 2016/17 under the Conservative government was 2.3%.
- As at July 2019, UK public health spending was the equivalent of about 7% of GDP, similar to what it was back in 2010 and higher than in previous years. Back in 1955, it was worth about 3% of GDP.
Again, the exact figures for NHS funding are always… at the best variable and mostly subject to political direction, rather than being commensurate with actual or perceived clinical requirements. And don’t forget, there are often strong elements of artistic licence involved when differing artists display their interpretation of any intricacies in the overall picture!
In so many ways, and for all manner of reasons some of which are valid and/or required but many of which probably are not, we have sadly lost sight of the fundamental and simple principles that ‘our’ health-care system was built upon.
I’m not sure there will ever be a solution for many of the issues that have been raised in recent years. I’m not sure we will ever enjoy or benefit from the type of health-care we expect or desire. I know the system will never return to what they once were… always assuming that is what we (and Bevan) really want, or still desire. I’m am however relatively confident that we will see the best outcome we could (probably) expect from the NHS, during the covid-19 pandemic (and resource ‘crisis’)… if we all play our part. Should we be trying to change things (for the benefit of all, irrespective of status and wealth)? Undoubtedly. Will we see the ultimate results and quality of service delivery that we (mostly) aspire to realise? Possibly.
The (political) quote below was wrongly attributed to Bevan by Jeremy Corbyn during the 2017 General Election campaign (see here). It’s probably been used by several (mostly left-leaning) politicians and activists since then. However; the following words, which actually came from Food for Ravens, a TV play by Trevor Griffiths [about Bevan] are no less succinct, relevant and poignant today, irrespective of personal political allegiances..
“The NHS will last as long as there are folk left with faith to fight for it”