My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

Saving the NHS: – A health care system free at the point of need with equal access for all…

Filed Under (Health Policy, Reform of the NHS) by Paul on 17-04-2012

…but first achieve the equality that you want to save.

Let me be clear about my personal position.

What Save the NHS means to me is this. This is a payment system which takes the financial anxiety out of accessing the health service and means that if you need to either go and see your GP or need a major heart operation, you don’t have to worry about how much money you have in your bank account.

This is not an abstract principle but concretely impacts the lives of everyone in the country. I am about 3 months older than the NHS. My brother is over five years older than me. My mum used to talk to me about the time – before the NHS – when she tried to keep half a crown (12.5p) on the mantelpiece just in case she had to take my brother to the GP. Throughout her life she said how lucky I had been to never need to worry about having that money to see the doctor.

Throughout the last two thirds of her own life she too did not have to worry about how much money she had before going to see a doctor. But in the first third she did. These are real experiences from an older generation.

Nye Bevan used a great word to describe how he wanted people to feel about access to the NHS. Not that it provided security, but that it provided serenity. He wanted people to feel serenely confident about access.

So this basic principle is what I mean by wanting to save the NHS. There are other things that I think flow from this, but to defend this principle I would man the barricades.

But in wanting to save this concrete principle, I have a big problem. Whilst there may not be charges and co-payments for access to the doctor and hospital at the moment, during the 64 years the NHS has existed it has not created equal access for all.

There are a range of important differentiators of money, culture, location and ethnicity, which demonstrate very unequal access.

So my passion for saving this fundamental part of the NHS co-exists with a passion to change the way in which the NHS operates – in order to deliver the equality of access the principle promises.

This has led to some very strong arguments between myself and others who want to save the NHS.

There are some who believe that the crucial part of the NHS that needs saving is the organisational locus which sees that it is clearly being run from the centre by the state. This belief is that the accountability to the Secretary of State and to a central government department in Whitehall is the only way to guarantee equality of access in every part of the country.

Adherents believe that ‘command and control’ is an integral part of the way in which that principle of equal access can be guaranteed.

(Next week I will be developing some of the ideas that the founder of the NHS Nye Bevan had about central control and its problems).

The problem is that the command and control of such a large organisation simply does not and cannot ensure equality of access. The 50 years during which Whitehall tried to ‘run’ this very large institution were characterised by its failure to do so.

The problem with command and control was that there was a lot of command and very little control. The old NHS was characterised by a lot of shouting from the top and a lot of ducking and diving in the areas where the service was actually being delivered.

So my problem is that whilst I believe in equality of access I am disappointed in how the old style centralised NHS has failed to deliver it.

I know that there are many people wanting to save the NHS who really believe that its principles can only be delivered through a central system of command and control. Many of the last decade of rows about NHS reform have been about this belief.

But these are arguments about an organisational form that is or is not best suited to achieve a principle, NOT about the principle itself.

Much of the argument over the past year has been passionate about the need for a strong centre. The Bill itself was amended in May 2011 in such a way as to provide one of the strongest central organisations ever – the National Commissioning Body.

For the first time a national organisation with no local governance at all will decide in which road in my locality a new GP service will be provided.

I am sure they will aim to do this in such a way as to ensure the equality of access enshrined in the NHS.

I am equally sure they will fail.

For much of the last decade people genuinely believed that they were arguing about the fundamental basis of the NHS. But in fact much of the debate centred around the organisational form rather than the principles of the NHS.

Some of the arguments in which I have been engaged over this period have been to try and reform the NHS in such a way as to develop greater equality by taking power away from the centre.

Others have concluded that because I want to change the central nature of power in the NHS I must be against equal access. Not true. What I am against is a particular form of state organisation which has failed to create equality and will do so in the future.

However much power the central state has, it cannot make equality of access.

And in this way, for some people, when they say they want to save the NHS  they are concerned about saving a form of state organisation, not a set of principles about payment and access.

Comments:

7 Responses to “Saving the NHS: – A health care system free at the point of need with equal access for all…”


  1. The OECD has looked specifically at the issue of access to a GP or a specialist and shown that the NHS leads the world. You may dislike central planning on principle, but as perhaps as Churchill said of democracy, “it’s the worst of all systems apart from all the others that have been tried” http://www.oecd-ilibrary.org/sites/health_glance-2009-en/06/06/index.html?contentType=&itemId=/content/chapter/health_glance-2009-64-en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2009-en&mimeType=text/html


  2. You state that “There are a range of important differentiators of money, culture, location and ethnicity, which demonstrate very unequal access.” How does central planning contribute to unequal access on these grounds and how will its reduction improve equality of access? I’m not against what you suggest per se but I’m completely unclear as to how your point of view answers my questions.

    Thanks for the post and a thoroughly interesting blog.


  3. To argue for equality of access by means of local control seems a bit odd to me. Won’t that reinforce the differences between, say, Kingston and Hartlepool? Don’t we need some measure of central control to address the inverse care law? Wasn’t Paul part of a Government which, rather successfully, had the biggest NHS Plan ever, and upped standards and access nationally through National Service Frameworks (for example)?


  4. Interesting that you don’t use the full name here – National Health Service. What those words mean in a dictionary sense and for a lot of the public, patients and staff, is something more than just a system of payment. I appreciate you have a different view and you are open about it, but I would suggest that is quite a recent re-interpretation of the idea of a National Service.

    For a few people it absolutely is about centralised planning. But as you imply, it’s very rarely been like that in practice, and as you would bear witness many “save the NHS” advocates vehemently opposed command and control as well!

    I would be interested in further reflections here – avoiding straw men – on the meanings of “NHS” other than national insurance pot and Stalinist organisational model.


  5. Does “National Health Service” actually mean anything? The UK has never had a truly national NHS – Scotland always had (with Wales following later) a seperate NHS structure.

    If it is acceptable for Scotland to follow a different model to England because of differing needs, then shouldn’t Cumbria have the same freedom to structure their health services differently from London?

    It is amusing to see some of the “save the organisation” supporters claiming the inheritance of Beverdige. In reality the central system that Bevan implemented was radically different from the local system that Beveridge had proposed.


  6. […] Yesterday’s post made the point that some of the fiercest arguments about ‘Saving the NHS’ have been about the way in which the state has organised the NHS rather than about the basic principle of equal access for all – free at the point of need. […]


  7. […] Tuesday I tried to make the argument that one of the main aspects of the NHS that some people were […]

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