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                                                                BRITAIN
As #politicians squabble over England’s ailing health service, the bureaucrats have offered some promising medicine.


A SENIOR Conservative politician once described England’s beloved National Health Service (NHS) as “the closest thing the English have to a religion” (Scotland, Wales and Northern Ireland run their own services). Yet, as with many religions, passionate devotion can often stand in the way of serious analysis. Public discussion is too often reduced to an absurd competition about who can express support for the institutions of the NHS in the most unqualified terms, says Stephen Dorrell, a former Conservative health secretary. Anyone who tries to introduce nuance “quickly finds out what it must have felt like to be regarded as a heretic in a more religious age”.

With a general election looming, all parties want to look righteous, and are not thinking critically. The Labour Party, most trusted by voters to run the NHS, wants to make it the primary issue. The Tories, though supportive of the service, don’t want to talk about it. Whichever party succeeds stands a better chance of winning in May. But the result is an unholy mess.
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Tight budgets and increasing demand from Britain’s greying population have put the NHS under huge strain.

But unlike other departments, forced to cut and reform, it lacks a clear consensus and firm direction on how it should adjust to straitened times. National targets for waiting times and length of stay in hospital do not necessarily lead to better care. Emergency wards are clogged and the money is about to run out.
Yet
the
NHS
wastes
over
£2
billion
($3.3 billion)
a year on expensive or unnecessary treatments, like overprescribed drugs and pointless X-rays, according to the Academy of Medical Royal Colleges.

While politicians, afraid of being accused of heresy, make timid suggestions, Simon Stevens, the NHS’s innovative new boss, has offered his own ideas for reform.
NHS spending is up 3.6% in real terms since the Conservative-Liberal Democrat coalition government came to power in 2010, according to the King’s Fund, a think-tank. Even so, the service is struggling to hold itself together.

Occasional cash injections have helped it cope with an increase in patients. But with 3m people still waiting for care, the highest total in six years, more is needed. Even if spending keeps up with inflation, the NHS claims its budget may fall short by £30 billion a year by 2021.

The Conservatives’ main move has been to back away from their own reforms, passed in 2012, which increased competition, gave health officials more autonomy and handed control over the purchase of care to groups of local doctors. Never understood by voters, these are now seen as a political disaster. But some aspects—like experiments in integrating services and moving care out of hospitals—deserve support. Labour, meanwhile, wants to merge the NHS with “social care”—looking after the elderly, disabled and mentally ill—which is run by local authorities and is also cash-strapped. That is a laudable goal, but it would probably involve another reorganisation and huge cost. So would a plan by Andy Burnham, the shadow health secretary, to take the service back in time by favouring NHS providers over private competitors for contracts.

Spending on non-NHS services ticked up slightly, to 9.5% of net NHS expenditure in the last financial year, according to Reform, a think-tank.
Otherwise, the parties have simply promised to throw more money at the problem.



Labour says it would boost the NHS’s budget, which sits at £110 billion, by £2.5 billion a year if it wins the election.

The Conservatives say they would continue with real-term increases, which have averaged £1 billion a year under this government. The trouble is neither of these pledges would come near to closing the funding gap, nor would they maintain the current rate of spending when accounting for the ageing population (see chart). The longer-term trend is yet more worrying. England spends just over 6% of national income on the NHS. If this continues the share would rise to 20% and account for half of government spending by 2061.

Defenders of the NHS have had suspicions about Mr Stevens ever since he started work in April. He arrived from UnitedHealth, a private American health-care firm. Before that, he worked on Tony Blair’s pro-market health reforms.

Recognising that advocating change to the NHS is inevitably political, he has stepped carefully. Nevertheless the five-year plan he published last month looks to change the service in a big way.
Mr Stevens reckons he can save £22 billion a year by 2021 through curbing hospital admissions and limiting demand for services. This would involve better public-health efforts, but also a major restructuring of existing institutions to break down barriers between family doctors and hospitals, physical and mental health, and health and social care.

For this he will rely on local efforts, but he has given officials a menu of models from which they could choose. These include allowing hospitals more freedom to provide primary care and helping them to support care homes to prevent emergency admissions. Others involve allowing local doctors to provide some services normally done in hospital and getting smaller hospitals to team up and share administrative costs.
The plan is politically astute. It does not mention competition or privatisation, which raise hackles. But many of its ambitions can be achieved only through greater use of the private sector, says Thomas Cawston of Policy Exchange, a centre-right think-tank.

Mr Stevens also calls for consolidating services, pointing to how 32 stroke units in London were reduced to eight, with positive results. He does not suggest closing facilities, though officials may have to. Nor does he propose ending favourable contracts for staff, or consider controversial user charges and higher taxes to make up the remaining £8 billion gap.
Mr Stevens has so far avoided any big fights, but he will face resistance from entrenched interests.


Take the situation in Bedfordshire, where the group responsible for purchasing services has bundled 20 contracts for musculoskeletal care into one that was won by Circle, a commercial health group. Mr Stevens is supportive of such agreements to integrate services. But the local NHS hospital has so far refused to work with Circle, lest it lose customers (ie, patients) and upset its balance-sheet, on which hospitals are, in part, judged.
For now, though, it is perhaps enough that Mr Stevens has pleased the politicians. Labour and the Tories continue to spar over the NHS, but both parties have expressed support for his plan. He will need it.
Past
attempts
to
reform
the
system
have
failed.

The difference this time, says Mr Stevens, is that the NHS has little choice.
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