TEN things that could be done to improve our NHS

TEN things that could be done to improve our NHS

by Jonathan Stanley
article from Thursday 6, September, 2018

CRISIS, CRISIS, oh the humanity, it's unprecedented I tell you, the roof is caving in, urgent care is broken... actually none of this is true. 

The NHS is doing its job as a state monopsony; reducing spending to the absolute minimum as defined by outrage that builds to the point of the government losing power at the next election. Crisis is the sensor of monopsony in a democracy and those who rail against the government are just another cog in the machine. 

That Labour is so useless and that we increasingly see bonds between the old and young in our society fragment means the "crisis" just has to be a lot worse than normal. We need to hear more screams, more pain, more disaster to care enough to demand something is done. Or the machine has to be made more sensitive to the noise of the crowd.

This does not mean that urgent care cannot be far better than it already is. There is much that can be done but it specifically needs to move away from using crisis as a sensor for government and speak directly to those senior levels of management and work with them to have a machine that is fit for purpose: making the sensors more sensitive.

We need to accept we are seeing a creditor/debtor stand-off of a very focal kind: those with property who are gaining without labouring and those without property who are labouring without gaining. Dealing with this problem used to be at the heart of both Labour and Conservative policy. In place of labour taxation, we must return to the contributory principle, where those able to pay will, and in times of immense capital gains made possible through the credit system we have to do things a little different.

We now see the same narrow perspective and clever accounting that saw branch lines and little stations closed to save cash during the Beeching Axe being applied to remote and rural A&Es, as well as to some in the capital where services are deemed "condensable". Instead of branch line closure, simply cut passenger flows to large stations. So too does closing smaller A&Es mean patients move to other centres already struggling, and they do so using ambulances.

So here is my ten-point plan to desl with someof the problems of the NHS. There will be many mooted of course, but none look specifically at the sensors. 

1. Maintain free personal care only for those who can’t afford any contribution. 

The Govan Widow paradox must be consigned to the past. Instead, restoring the contribution system Beveridge proposed in the 1940s would mean an asset-based contribution like the Dilnot Cap passed by Westminster. We at the Bow Group have proposed a total cap on costs after five years with an increased contribution for the first three years in residential or nursing home care. 

The left wing free personal policy is actually a sop to wealthy home owners and is ripping a fortune out of our overall NHS budget. 

2.Abolish the four-hour wait, at least during winter. 

We know now quite conclusively that this can only at best be a three season a year target so why try and prove the point otherwise? It's over, really.

3. Transfer at least £500 million pounds to NHS billing directly from the DfID.

All unpaid medical bills from foreigners should be recovered to their countries' aid programmes and the details sent back to those governments to collect their aid back from their citizens. They are not our citizens and frankly not our problem. Start with that aid portion not yet even spent but sitting in bank accounts. We know from various estimates at least £500M goes unpaid every year. So just pay up. 

This will have Barnett consequentials, so that's £50 million the SNP could and should spend on A&E.

4.Split all urgent care providers away from regional health boards and A&Es. 

Merge the Scottish Ambulance Board with these direct contact centres and establish a special board that covers all of Scotland. This would be the one stop shop for all unplanned care and could be integrated. It would also take over all GP out-of-hours services and be run regionally, as ambulances are now. Crucially and perhaps most controversially, this new board should be headed by a cabinet minister that may or may not be the cabinet secretary for Health as it is now but would nonetheless chair Gold Command meetings and be directly responsible for resilience of emergency healthcare. This amplifies the sensor as it focuses the minister on this sector of healthcare.

This proposes making unplanned care operationally independent of the NHS and treating it as, literally, the third emergency service.

5. Stop blaming foreigners quite so much. 

That DfID money mentioned above will cover this population anyway and the main issue afterwards for clinical staff is actually how good a patient’s English is. This is an immigration issue not a health issue. We should not be allowing people residence who cannot speak English unless they have a robust means of communication. Interpreters in A&E are extremely disruptive and telephone interpretations are no substitute to direct elicitation of patient history. I've been there and done it and it results in a poor service and creates delays. 

This does mean that Scotland's participation in the Compass dispersal programme for asylum seekers should be stopped or significantly reduced unless capacity to cope can be proven. Glasgow took 3,000 in 2017, far too many. 

6. Senior specialty registrars in their final two years of training can have their training extended by six months and then serve two three month Urgent Care secondments. 

So they would do nine months on training, 3 months on urgent care twice. This would ease stresses on registrars whose current on calls result in arduous and a highly variable workload. Many more could be non-resident on call if a senior registrar was based in A&E. The same registrars could then be removed from A&E if urgent surgery or procedures were required. Given how precious these training places are there is no reason these secondments could not be written into training contracts to make them NHS Winter Warriors.

7.Redefine the boundaries of health boards with local authorities and have councillors (NOT MSPs) appointed onto health boards so that all commissioning is run by local authorities. 

That is the only credible way health and social care can now be merged, with one local authority budget for social care and for healthcare commissioning. This would prevent local authorities gaming the system by not providing cheaper social care beds to decant patients from hospital. 

8.Initiatives proven to reduce admissions such as improvements to domestic heating to cut admissions for chest problems need funding through these combined health and social care authorities. 

This is not social prescribing and GPs should be left alone to be ordinary attendant physicians in the community rather than dilute their role with social administration. We have been doing this the wrong way round for a long time.

9. Be honest about our tax system and how property owners have enjoyed incredible capital gains at the expense of young people. 

If we are not prepared to care about this we cannot expect young people to care about the state of public services. Many countries from Denmark to Hong Kong have property value taxation as part of raising overall revenues and in a globalised world ever higher taxes on income does not seem wise. That tax could be applied only to say the equity of the property and not to the mortgaged portion.

10. Establish an independent body to ensure we train a MINIMUM number of docs, nurses, midwives, et cetera in Scotland.

We cannot be capping uni funding while giving free tuition to EU nationals and then not train enough Scottish doctors. The overall effect currently is reducing the UK pool and the Scotland Office could fund a symbolic ten places at medical school to highlight the dire shortage. 10 places would cost about 250k a year tops assuming non-EU fees.

…and finally here’s one for free…

11. Deal with antisocial behaviour from drunks in A&E as in any other public building.Patients can be easily treated under arrest, I've done so many times. The ritual of boozing, losing and crashing into A&E to abuse very polite public servants is a vile one acquired over too many years. Plain clothes officers in major A&Es would be a very welcome addition to the service. We cannot bring back the high-pressure hoses to wake them up but a night in the cells and a fine can be very sobering!

There are many more ideas of course, too many to list. This is not a crisis we are seeing but simply a choice we have as a nation chosen to make. 

We don't want to pay anymore in income taxes. We cherish government targets, or seem to. We refuse to accept that an ageing population requires almost as much social and medical input over time.

We haven't even touched on how no-default divorce has left us with a legacy of silver singles and single parents who have no back up when they struggle. That's an article all by itself. 

This is perfectly soluble if we wish it to be, most other countries seem to cope very well. Better is possible.

Dr. Jonathan Stanley is Health Research Fellow at the Bow Group, a Junior Doctor and a Member of the Royal College of Surgeons

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