Some of our readers have been showing signs of impatience. They ask questions like, “Where are you two going with all this forensic examination of the fate of our hard-earned cash?” “You have something in mind, tell us,” or words to that effect.
We sympathise, but you have to believe us (like all physicians, we never lie): it is very difficult to get to the bottom of this particular Russian Doll.
We found it difficult to focus as each new day brought a clutch of unknown functions, groups, bodies, and so on.
We have summed up what we have found so far in the spreadsheet, which we urge readers to go through.
The sheer complexity of systems and overlapping aims we have encountered means that no one seems to have an overview of the service and control over it, and no one can be held accountable. Organisations under the NHS have competing priorities and different aims. This can’t be correct, as the ultimate objective is ensuring patients get effective, timely care.
The NHS system now needs to be focused on only four aims. Anything that does not contribute to these aims should be shelved or, even better, disestablished.
Equitable longer healthy life expectancy.
Excellent quality, safety and outcomes.
Excellent access and experience.
Value for taxpayers’ money.
You will notice in our sheet how, for example, NHS England has miserably failed to achieve any of these aims and seems mired in IT as the solution to all ills. Three out of its four responsibilities are related to IT. Yet, healthy life expectancy at birth in England from 2020 to 2022 was 9.3 months lower for males than from 2011 to 2013 when NHS England was established and 14 months lower for females. - Therefore, IT needs a servant to the NHS, not its director.
Each aim should be broken down into a series of inputs, processes, and outcomes with which the public agrees—the public funds the system, which is there for the public’s benefit.
A few further considerations fall out of all this.
First, we suspect anything related to “economic development” is shorthand for pharma input. It should be eliminated from the NHS structure and functions. What is public is public, and what is private is private. Besides, we have difficulties reconciling all the various funding streams, so who knows what goes where?
We badly need a bottom-up structure. The concept is simple. For a while, we thought of calling it “back to basics.” However, those old enough to remember the Major government might feel a chill creep down their spine, so we can call it bottom-up.
Who does the majority of the coal face work in the health sector? Primary and community services, including rehab centres and hospitals.
So, the first block is the retention and upgrade of the Integrated Care System and Boards (ICS and ICBs), and trusts run not by bureaucrats but by those with at least five years of experience at the sharp end.
The current system takes 90% of the funding—ICBs get 10%—which is difficult to justify given the generalised public discontent.
We have been unable to examine Northern Ireland, Scotland, or Wales because of a lack of resources, but we rely on our readers to comment on what is happening in the devolved nations.
Ambulance and Emergency services should also be upgraded and integrated into emergency care. The current system is falling; therefore, trusts should ensure that the horrendous waits entrenched in service are a thing of the past. At the very least, the NHS needs joined-up care.
The ICBs would maintain the current structure but slim down on bureaucrats and hangers-on. Some considerable funds would go into revitalising both practical and academic primary care, offering breaks and rest to operators with the possibility of swapping with colleagues in other countries on a one-to-one basis or even taking a six-month paid sabbatical every 5 of service.
Remuneration would be up to independent bodies for which there is plenty of precedent.
Next, public health is integrated into primary, secondary and tertiary care with only a representation and coordination function at the ministerial body level.
We have not yet included the regulator MHRA, which appears to be understaffed and run by the pharmaceutical industry. They should be separate and independent. The MHRA should be publicly funded, with no pharmaceutical cash allowed. To realise economies of scale, maximum use of the centralised procedure for registration and greater collaboration with EMA should be reverted to. The rules of the mutual recognition procedure should not be changed for the same reason.
The UKHSA, whose role and accounts are mysterious, should be disbanded as all other duplication structures that advocate evidence-free interventions and refuse to fill the gaps with good quality evidence. Look in vain for an assessment of measures to tackle hospital-acquired infections (HAIs), probably the biggest killer during the Covid pandemic. No, “antimicrobial resistance” is not the same as HAIs. That gives you an idea of the chaos or subterfuge going on.
NHS England should be disbanded, with the exception of the NHS Fraud Squad, which should be amalgamated with its police counterpart, its budget doubled, and enhanced with an incentive mechanism. If you get a court conviction for, say, £500M worth of fraud, you get to keep 5%, which will be divided amongst the officers who secured the conviction.
Finally, yes, finally, as this is a bottom-up proposal, there is a need for a small representation at the ministerial level—so a slimmed-down DHSC that functions as a system coordinator and interacts with politicians.
Recruitment and contract allocation would follow Civil Service rules, with a 3-year time bar on revolving doors between any part of the private/public divide. So no friends, lovers, family, and, least of all, freebies would be allowed. Financial probity must be ensured for those who pay or have paid taxes. The party is over.
We are currently missing NICE, MHRA, and NIHR, so this is a partial summary of the chaos the system is experiencing. Their time will come.
Some of the proposed changes may require legislation, but none need a constitutional change as there is no written constitution. As they are all in the taxpayers’ interest, it should be difficult to argue against them—perhaps.
So, dear subscribers, we await your comments. You get a chance to redesign a system as you would like or at least agree on a proposal to address the current broken mess. Please support us by becoming a paid subscriber. We try to provide a public service, and any bit of support is very welcome.
Two confused old geezers wrote this post.
In my ignorance, all I can offer is a show of support and indeed I am a paid subscriber and encourage anyone I know to do the same. You guys are wrestling with a Gordian knot and unfortunately there is no Alexander to cut to the chase. Thank you for laboriously and analytically making the effort to unpack the maelstrom of NHS funding. Who else would attempt such madness? Two (not so confused) and I suspect, weary old geezers :-) It’s certainly not an easy undertaking but with your determination to apply logic, evidence and impartial analysis (with no skin in the game), is worthy of praise. I am not experienced enough to be able to add anything tangible in terms of economic analysis, sadly above my pay grade and certainly above my ability :-). Nevertheless you are prepared to take on the unpalatable task of questioning where our money is going, so I salute and thank you both.
So far so good - but the real ' medical grassroots' are the GP surgeries where a root-and-branch reform is imperative. Since 2020 and the deplorable closure of surgeries 'because: covid!', together with the daily misery of trying to get an appointment - face-to-face or telephone - is the main reason why so many patients go straight to A & E, with the results we're all familiar with.
Let's also add the closure of many small surgery-dependences which were part of a large one with multiple GPs. This isn't due to the Lockdown years - this started in the late 1990/early 20002. There were two such surgeries in my area, within walking distance of five or ten minutes: both gone. Now, being a somewhat frail old geezerette, I need taxis to see a - not my - GP ...
But never fear: according to a report in today's Times, Madame Reeves will present the NHS with loads of more money, even though there's no plan on how best to spend it, except for 'increasing productivity', according to Madame Pritchard ... See: more money and all will be well with our NHS in all its entities and manifestations!