Sunday, 15 January 2017

The NHS: no easy solutions but lets stop the shouting and start talking

Stories of the NHS have been hard to ignore this past week. There was the British Red Cross perhaps ill-judged description of the NHS facing a ‘humanitarian crisis’; the May/Corbyn ‘tit for tat’ funding polemic; alongside stories of blame involving health tourism, older people and angry, tired doctors. Borrowing a term from psychology, it’s clear that there is great deal of ‘high expressed emotion’ in many of the narratives used by people to describe the state of our NHS. In clinical practice, there are 3 dimensions of high expressed emotion: hostility, emotional over-involvement and critical comments. It is possible to see these dimensions played out in some of the recent commentaries on the NHS, and perhaps its easy to see why.

The NHS remains a precious feature of British life. Every 36 hours the NHS sees 1m people. Most people in the UK have grown up knowing only the comprehensive health service we have today. In most instances the care, treatment and support we receive is completely free at the point we access it. For many it is the envy of the world. The US based Commonwealth Fund, founded by the philanthropist, Anna Harkness in 1918, and which carries out independent research on health care issues and how to improve health care services, declared the NHS to be the most impressive health care system in comparison to services in 10 other countries (Australia, Canada, Germany, France, New Zealand, Netherlands, Norway, Sweden, Switzerland and the US). In 2014, the system was number 1 in terms of efficiency, effective care, safe care, co-ordinated care, patient centred care and cost related problem.

Such a high quality service doesn’t come cheap. It costs some £120bn a year to provide health care to the 66 million people living in the UK. This is a population that is set to increase to 69m by 2024 and to 73m by 2035, but is also expected to continue aging. The average age across the population in 2104 was 40, by 2039 it will be nearly 43. The number of people aged 60 and over has already reached 15m and of those, 1.8m are aged over 85. It’s worth noting that some commentators have claimed we don’t spend as much on health care as a percentage of our GDP as other countries, which is true in comparison with the US, but less so with some European countries for example.

However, I’m not sure that simply providing more money would solve some of our current pressures. Of course it would help, but as economist’s at the Health Foundation noted in 2015 (see their report here) the means of raising additional funding (through increased taxation) is unlikely to be a long term sustainable solution. I think that in addition to thinking about how more money can be provided, as a society we need to also consider what we could do (perhaps need to do) around health care expectations and health education.

Over the last 20 years I have been privileged to travel to many parts of the world as part of my job as an academic. Often I have been able to fit in a visit to the local health services. I have seen vulnerable children locked up alongside dangerous patients in forensic mental health units in Kenya; health care provided in crumbling buildings in Hungary, Slovakia, Lithuania, and the Czech Republic; special care baby units in Uganda where the incubators were stacked 2 high; remote care in Finland and Australia; and emergency care in Brazil that brought to mind what I imagined 14th century Bedlam to be like.   

What I’ve noticed in all these examples, so often far removed from what we in the UK have grown to understand to be modern health care services, has been the desire to support and care for those in need of care and help. For me this was exemplified in one visit in particular. It was a visit to the Sindh Institute of Urology and Transplantation (SIUT), a hospital in Karachi, Pakistan. Leaving aside the fact that I was accompanied everywhere by a security man complete with a Kalashnikov rifle, it was a humbling and informative experience.

Patients were offered a comprehensive service, from first assessment, diagnosis, and treatment and where appropriate aftercare – it was a one stop shop service and all provided for free. All the care was provided by healthcare professionals who were enthusiastic, talented and extremely hard working, many for nothing other than the opportunity to work at the hospital. The conditions in parts of the service were awful. There were often patients queuing for many hours to be seen, and many more being cared for in corridors due to bed shortages. The buildings and equipment was either state of the art or rather past its best. You can see their wonderful ground breaking work here.

They provided a health and care service. People travelled to SIUT from all over Pakistan because they knew they would be seen, and helped. As with the NHS, the demand was unrelenting.  Whilst in the UK there has been a 30% increase in people pitching up at A&E departments, 30% of all attendees don’t present with an immediate need for emergency care. If people’s expectations are that’s where primary care can be found, then service providers and commissioners need to respond to that. Does this mean we need more GPS? maybe - is a different kind of primary care required? absolutely - should this include hospitals? probably.

We also need to increase what is done in providing Personal, Social, Health and Economic (PSHE) education. In various forms and to different levels, this is currently provided in schools in an attempt to equip young people with the knowledge, understanding, attitudes and practical skills to live healthily, safely, productively and responsibly. Much more could and should be done at other points of peoples life journey to reinforce the start well, live well age well approach to health promotion and the need to reduce demand for health care. It won’t make a difference tomorrow, but that shouldn’t stop us from trying.