Yes: Dr Michael Weeks
On 23rd October 2014 the NHS England Chief Executive, Simon Stevens, launched the NHS’s ‘Five Year Forward View’, a plan which consisted of a forecast of future pressures and the proposed solutions set out to alleviate them. I am arguing that these steps are the correct priorities to save the NHS.
First of all I shall discuss the aim: ‘to save the NHS’. For me this is ensuring a system where both quality and performance in constantly improving, be it access to new equipment and drugs or shortening NHS and GP waiting lines. Behind the scenes, however, there are other standards; such as keeping the country’s bacterial resistance to antibiotics low and keeping the next generation of doctors fully prepared for the challenges they may face when fully trained.
The lefties out there don’t seem to understand the rocky economic situation the world has found itself in recently, and wish to break austerity by throwing money at every problem before thinking of an optimal solution. This was Gordon Brown and Ed Miliband’s entire health policy – one of their great failures, of course, being Labour’s failed IT system, which ramped up unnecessary costs of £9.8 billion. That’s thirty times the price of building a new hospital, in specification and detail, as the blueprints laid down for the new Royal Liverpool Hospital.
The NHS ‘forward view’ represents the well thought out Conservative, and Lib Dem, organised analysis of current and future problems. It identified the most important stressors on the delicate NHS and set out nationwide tactics to challenge them.
The number of people over the age of 80 is set to double to 6.2 million over the next 25 years. The elderly are more likely to have multiple organ disease, requiring longer stays in hospital, more medication, more rehabilitation and more social care in the community. Under-delivery at any stage of this process leads to a backing up of patients where the hospitals beds are all full, A&E becomes backlogged and elective admissions become cancelled, all resulting in an overall failure of the system. A constipated NHS is a useless NHS.
Now to relieve this horrid constipation, treatment is often an enema at the back end, such as: high capacity home care packages; hospital at home; district nurses as well as dedicated discharge lounges where if a patient is not acutely unwell they are not in the hospital taking up a bed and catching pneumonias. We need a healthy gut in the form of high quality hospital wards with specialist physicians dedicated to managing the diseases of the elderly. We need a picky mouth where GP’s and A&E services only accept patients who are indeed sick. We need rapid diagnostics to exclude the sick from the worried well. Proposed arrangements for such improvements are the bread and butter of the ‘forward view.’
The second great wave of patients, previously rarities – exceptions to the rule – are the obese and overweight. It is an epidemic that is sweeping our country partially due to the availability of cheap high calorie meals well beyond what is necessary and the increased sedation provided by our electronic lifestyles. A mind-boggling 61% of adults in the UK are overweight or obese. Diabetes, heart disease, liver failure, depression, arthritis and pressure sores are a few of the many diseases this overindulgence has added to the burden of the NHS. We must pay for supersize hospital beds, toilets, operating tables and even mini cranes (we nicely call hoists in the industry). Again, these patients take longer to recover: putting more pressure on bed availability and increasing the need for carers at home. Obesity, along with other avoidable burdens such as tobacco and alcohol abuse, have been targeted as a priority in the NHS ‘forward view.’ One measure is to develop workplace incentives for employers to promote better employee health; another is the introduction of a nationwide sugar tax to reduce the affordability of a highly refined sugar diet and to raise money to be ring-fenced for bariatric services.
This plan represents an age of change, no longer can money be spent on all fronts simultaneously, and there just isn’t the cash. Instead, careful identification of the choke points in the system and optimising them maximally to keep the patient throughput high. A little money can go far if well-spent. The second great change is increased responsibility; the NHS cannot afford to pay for everything for everyone with the self-infliction of avoidable diseases. So, if users need to contribute, it seems fairest that avoidable disease bearers are the first to be raided for cash. We can keep our liberties and eat doughnuts till we burst, but those doughnut-buyers have to pay, like cigarette users, into our NHS kitty to contribute to the expensive treatment they will require 10-15 years down the line. Every right we are so lucky to have in the West should come with responsibility to prevent abuse. If this line of thinking can catch on and become implemented by the government then, and only then, will we have a fighting chance to save the NHS.
No: Marco Fullon Narajos
It sounds logical, doesn’t it? Increasing the public health focus on primary care and social care, the ‘Five Year Forward View’ (5YFV) promotes prevention over cure, moves funding from acute to community services, and closes down smaller district general hospitals that are not equipped to handle complex acute cases. The rationale is this: everyone is getting older, but not necessarily living a better quality of life and many (if not most) of today’s health issues are so-called ‘of our own making’. In its foreword, 5YFV guilt trips us, ‘One in five adults still smoke. A third of us drink too much alcohol. Just under two thirds of us are overweight or obese.’ But it’s fine because the 5YFV will offer more preventative services.
It would be easy if people and health behaved like that. The social model of health proposes the simple and hardly revolutionary idea that people’s health is determined primarily by societal factors. It asks why people smoke, misuse drugs, drink alcohol excessively, eat unhealthily, undertake risky sexual behaviour, and do not get enough exercise. Is it because people are lazy, impulsive, and hedonistic, or is it that higher unemployment, poor education, poverty, crime, and lack of evidence-based, good parenting practices promote unhealthy behaviour? I would love to say that I came up with this myself, but I didn’t. It’s not contrived; it’s evidence-based.
‘Mental health’ may have been the buzzword of 2015, but the tenets of public mental health strategy remain true in 2016 and will remain so at least for the next five years. The idea is that if we placed a focus on good mental health, then the underlying causes of risk behaviours (smoking, excessive alcohol, lack of exercise and a poor diet) will resolve over time. The problem is that people are impatient and want solutions that give rise to finished products now. But cardiovascular disease wasn’t built in a day.
So how do we shift the focus to improving public mental health? There are some evidence-based strategies that the Royal College of Psychiatrists have published, but these are not discussed in 5YFV, as these strategies aren’t seen as having a health agenda, rather, a social one. Besides, the current government would be quick to reject many of these ‘social strategies’ – faster than you can say ‘false dichotomy’.
Let’s take alcohol, for instance. 5YFV states that the NHS will actively support ‘comprehensive, hard-hitting and broad-based national action’. But what does this mean? The Royal College of Psychiatrists have spoken out about minimum unit pricing as an evidence-based method to reduce alcohol consumption back in 2012. The rationale behind this is that it would be cheaper to buy booze with lower alcohol content, so it doesn’t disadvantage those who are already poor. The government initially agreed but then took a U-turn and instead pushed to have a ban on alcohol sold below a certain price (below-cost selling); this would have the complete opposite effect, instead pushing alcoholics to fork out more for the cheapest drinks, which often has higher alcohol levels.
And let’s not forget why some people drink alcohol in the first place. Women are nearly twice as likely to be diagnosed with major depression than men are; yet men are far more likely to be dependent on alcohol and substances of abuse. Is that because women are more likely to get depressed or are men more likely to turn to alcohol and drugs to self-medicate emotional struggles? This is why there needs to be greater mental health awareness in the public alongside increasing funding of psychological therapies like CBT. More men and women aged 20 to 34 die of suicide than of cancer, and yet the NHS promises all patients two weeks to see a cancer specialist in a hospital if the GP suspects cancer, but the NHS only promises that three-quarters of patients will receive psychological therapy in six weeks if you get referred to the new Improving Access to Psychological Therapies (IAPT) programme. I heard that English people love queuing, but I doubt they’d want to queue for that long!
Don’t get me wrong, 5YFV is not a bad thing; it is wonderful that this document exists to formalise a strategy that will sustain the NHS. But it’s neither revolutionary nor brand new, and it won’t save the NHS. The principles underlying 5YFV have been around for decades and instead of repeating the same old chat, the NHS needs to make demands for more money, and rebalance the funding towards mental health services. It needs to advocate for change in public sectors that do not immediately seem related to health like better education in schools (did you know that the higher your educational attainment is, the lower your risk of dementia?), funding for parenting programmes, and research and development. Try that one on your GP the next time they ask you to come back in two weeks if you’re not feeling any better.
