We love the NHS because we value the concepts of equality of care and equity of access. But hospitals are overloaded, access to care varies across the UK, there is little emphasis on preventive health and we have a workforce that feels so undervalued and overworked that thousands of staff are leaving. Can the NHS – which will celebrate its 75th anniversary on 5 July – be saved?
There is much to be proud of. The people in the service – medics, nurses, physiotherapists, dieticians, pharmacists, occupational therapists – are all routinely involved in a multidisciplinary approach to caring. Not many countries come close to this. We could have a health service that is internationally acknowledged as excellent, given a concerted effort. But change needs to be devised by clinicians, validated by patients, and facilitated by politicians and administrators – rather than the failed model of change devised by politicians and imposed on staff and patients.
Here are six steps that would transform performance and public perception of the NHS.
Link primary care to social care and clarify the role of GPs
We need to improve primary care and link it to a revamped social care system. How about a new institution – NHS-C (for NHS Community) – with its own budget? GPs could facilitate discharges from hospital as well as leading care in the community, including community hospital beds.
GPs are choosing to work part-time and often are not able to fulfil the role of both family doctor and secondary-care gatekeeper. The boundaries of GP work need redefining: GPs could lead on the community management of complex illness, medication decisions and coordinating care in the community, and not carry out screening (see no 4) or administration tasks that routinely take 50-70% of their time, and should be devolved to others or minimised with better IT.
Whether GPs are contracted by the NHS or are NHS employees, they must be involved in revising their job description. They won’t accept major change if it is imposed top down. This re-evaluation should be led by the profession rather than endless initiatives by a series of politicians with differing agendas. Enticing and encouraging retired GPs back to work will be more productive, cheaper, and quicker than training a new cohort from scratch or trying to fast-track medical training by ill-thought-out shortcuts.
Agreeing national standards: a real levelling up
Remember Thérèse Coffey’s proposition that patients should hope to be seen by a GP in two weeks? I think we should aim much higher: what would you want for a member of your family? I suggest a few national healthcare guarantees or standards:
a) A maximum 48-hour wait to be seen in primary care by a health care practitioner (not necessarily a GP).
b) Maximum four-hour waits in A&E.
c) A few days at most – not the several weeks it can take at present – between the medical decision to discharge from hospital and community placement. Make the new NHS-Community accountable if this discharge target is not met.
There is a postcode lottery. What is delivered in Tonbridge may not be in Teeside (better leave Scotland, Wales and Northern Ireland out of this; although agreeing UK-wide standards would be a positive and a marker of a United Kingdom). To equalise access to healthcare will need a triage system run by trained staff (not GP receptionists) and prioritisation of calls – the ambulance service does this already. This may involve redistributing people and resources away from secondary care and towards primary care.
Change attitudes to the care profession
We need to make being a carer a respected and sought-after occupation. How? Tax advantages or a free carer’s travel pass would be a good start, coupled with improving continuous professional development, training and career progression.
Improve preventive health
We do this poorly, apart from national screening programmes for breast, cervical and bowel cancer. Sajid Javid recently proposed patients paying for each visit to their GP: this would lead to inequalities in terms of people unwilling or unable to pay. Compulsory contributions reduce demand but decrease equity of access. But screening centres, possibly funded in part by soliciting public contributions, would make an enormous difference: one place providing blood pressure testing, cholesterol testing and prostate screening for men; and one for cervical screening, breast cancer and osteoporosis screening for women.
An effective obesity strategy – starting with education at school
Tackling obesity is the key to reducing cardiovascular or cancer mortality. We should set up a programme of diet education in schools with a new (compulsory) GCSE on personal health. Within a few years the public health benefits would be enormous.
Tackling the gap in mental health services
We should provide better access to therapy for mentally distressed people, removing the stigma of mental illness and most importantly tackling critical early life events such as school exclusions, a significant cause of mental health problems.
These six steps would catalyse major reform of the NHS. But there are other larger possible measures that are more contentious: in 1997, New Labour made an instant impact by granting independence to the Bank of England; what about ringfencing the NHS’s budget and granting independence to the health service? A fixed percentage of GDP, subject to revision and with safeguards in case of economic catastrophe, would allow funding to be managed by an independent NHS. Some areas may not be immediately funded because we cannot afford the cost: but then we can talk about fundraising mechanisms for high-cost contentious areas. Stopping the NHS from being a political football would enable long-term planning.
Many agree that the NHS needs fundamental reform: coherent proposals are thin on the ground because those who are best qualified to propose, debate, test and implement them are furthest from being in a position of power.
There is no point in insulting, denigrating or undervaluing the role of politicians in this process: but in something as important as the NHS they should be tasked with carrying out the will of a coalition of clinical and patient representatives. Then we can honour the achievements of the NHS by moving to a new scheme that is more suited to our needs over the next 75 years.
Stuart Bloom is a consultant physician and gastroenterologist at University College hospital London
