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Future fortunes

The fate of the NHS hangs in the balance as the election season gets under way

mainHeadlines for the NHS in April made grim reading. The consultant contract came under fire from a committee in Parliament, which claimed that our esteemed doctors had a 20 per cent pay hike with little increase in productivity. Yet, despite an increase in consultant numbers, their actual clinical output only went up by around 4 per cent. The media had a field day with ëfat-catí consultant stories. The GP contract also attracted attention, claiming that the average GP is now on over £110,000 a year and does not have to do any out of hours work for the new cash. It then transpired that the nurses were revolting!

At their annual bash in Harrogate the Royal College of Nursing (RCN) was incensed by the governmentís decision to stage nursesí paltry pay award in two phases and voted in principle for industrial action. It is pretty rare for the RCN to back industrial guerrilla tactics, so one must assume that the nurses are pretty miffed. It is also apparent that the much heralded new pay system for the bulk of non-doctors in the NHS has also gone belly up. Agenda for Change was meant to improve NHS pay and conditions, linking pay to skills and competencies, and lift morale. The opposite has happened and many nurses and therapists complain that with financial pressures there is simply no training available to progress through the new pay structures.

As if all this was not bad enough, a group of doctors for reform claim that the NHS is no longer free for many patients. They allege that millions of people are paying top-up monies to access elective treatments and diagnostic interventions to avoid waiting. The doctors argue that this is leading to greater inequalities as the poorer citizens do not have the capacity to pay any top-up to improve basic health service packages. This is all happening against the run up to local council elections in England, elections in Wales and Scotland, and an expected Blair departure in June followed, most probably, by Gordon Brown as Prime Minister. What are voters going to make of the April NHS headlines?

Satisfaction
This government has thrown record amounts of cash at the NHS, with the annual budget rising to £100bn by 2008. With record numbers of staff allied to extra cash, the public might reasonably expect the health service to show signs of real progress. There is scant evidence of this in the media headlines and a constant flow of negative NHS copy does little to build public confidence in services. The NHS is a curious institution in the public psyche. When people actually use the service their levels of satisfaction are very high, particularly when experiencing major illness like cancer or a heart attack. If you need serious clinical attention through accident and emergency into an acute bed the NHS track record is pretty good. Even in softer areas of care, patient surveys tell us that the punters are pretty satisfied with the health service when they need it. We also have a better regulated NHS than ever. The Healthcare Commission now reviews the clinical performance of all health providers and, despite pressures, the health service does not have many failing Trusts. Monitor regulates the robustness of business plans for NHS Foundation Trusts and would-be Foundation Trusts, and it is interesting that the two top hospitals in the Health Commission league tables were both Foundation Trusts; the Royal Marsden and Harrogate Hospital. Yes, the NHS is under immense pressure to better manage its money and shape reform, but on the whole it does well. However, the staff in the health service seem to feel pretty negative about it.

In the mire
The NHS employs around 1.2 million people and, despite headlines, the majority have a clinical background as a doctor, nurse or therapist. The service has experienced rapid growth, probably not well managed, and the pay bill has steadily risen. A recent report from the Kings Fund, an independent health think tank, suggests that the bulk of new NHS monies has actually been spent on pay, leaving modest amounts for services to grow and improve. Yet, although pay and conditions have improved clinical professionals and other NHS staff suggest that morale is at rock bottom and the health service is a ghastly place to work. Despite this overtly negative perception peddled by various health unions, they also protest vehemently when Blair suggests greater involvement from independent sector providers in primary care and other services. For politicians the NHS is a classic no-win scenario. How is it that a government spending record amounts on the health service, with more and better paid staff than ever before, is in a mire over the state of the NHS?

The forces at work are complex. There can be no doubt that the central command of the NHS, at a time of rapid financial growth, has been poor. Witness the rapid demise and departure of Sir Nigel Crisp, former CEO of the service. Since his departure we have seen another cull at the Department of Health, with many senior figures jumping ship. Will front line NHS clinical staff lament the loss of such people? Will these departures dramatically impact upon the quality of patient experiences and the morale of doctors and nurses? I very much doubt it. But if the Department of Health can get its act together under David Nicholson, the new CEO, and the 10 Strategic Health Authorities in England actually get some clinical buy-in for reform and change, then the NHS could turn into a success story.

Election time
As we head towards a period of elections and we witness the end of the Blair years, the media will play the NHS as a key issue. As Brown potentially becomes the next Prime Minister, the media focus on him and all his work has been intense, particularly in the conservative print media. Negative NHS stories will also play well among those who wish to see the demise of the health service and shift UK healthcare to a European model, funded through social insurance, not general taxation and allowing a far greater public and private mix in both funding and provision. In short, we could, over the next few years, see a real debate about the essence of health funding and provision for the UK, which is likely to have huge implications for every citizen and all who work in the health sector ñ the stakes will be high indeed.

As a nurse and health manager, I have been lucky enough to see health systems all over the world, from the US, where money can buy the best care on the planet, to China, where collectivism rules, to India, where the poor get little or nothing. I am always thankful for the NHS when I return from some of these trips. The health service is not perfect and it may feel like it creaks at the seams occasionally, but we sometimes forget the value we gain in pooling our health resources through general taxation. Having health services available to all, based on clinical need and not the ability to pay, and essentially free at the point of need, remains an element of the welfare state from the post-war period worth keeping. The NHS cannot stand still: it cannot remain a monolithic monopoly provider. The NHS, despite protests from professionals with vested interests, must become more patient-focused and support greater choice and more even quality of services. If this means breaking up the monopoly in general practice and primary care with greater independent sector providers, then so be it.

As society ages and the fast pace of change driven by technology continues, the way in which the NHS is shaped and delivered must also change. However, the underlying principles underpinning the governance and provision of health services should be cherished and valued. It is ironic sometimes that the obvious ambassadors for the NHS, the 1.2 million people who work in it, actually damage it with their negativity. If staff who bemoan the state of the NHS really believe there is some utopia to face current challenges that will give them some certainty around their salaries, investment in their education through the public purse and a pension plan that is gold plated, they are mistaken. The NHS in Scotland and Wales is markedly different to England and the imminent elections in those parts of the UK will undoubtedly show that the people of Wales and Scotland fully understand and appreciate the value of the core principles and values of the NHS. I hope voters in England are as clear in their vision regarding the future of the NHS

11th May 2007

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