So the perpetual crisis of the NHS rolls into another of its acute phases. Having had much more contact with the health service than I would have liked in the last two months, I can confirm that parts of it are chaotic and overstretched. To submit to its cold embrace is a similar feeling to entering an airport - once on the wrong side of reception you become kine. You leave your humanity at the gate. My wife said to me, "Your trouble is that when you actually get to see a doctor you try not to seem ill". This is true. It stems from my desire to fight against the dehumanising aspect of UK healthcare.
Anyway, what to do about Britain's best-loved institution?
The NHS's problems stem from the fact that we are not giving it enough money to fund adequately the demands we as a population make on it (I'll qualify this proposition in a moment).
This is happening for a number of reasons. Inflation in the NHS runs at about 7%, about three times greater than current domestic inflation. Moreover the range and complexity of available treatments is very much greater, more complex and more expensive than in the late 1940s. At its inception the average working man died before he was 50. Now he lives until beyond 80.
It's very expensive to maintain an old person. Our population is getting top heavy with the elderly, which means the proportion of people paying taxes to fund the NHS is tending to shrink. The population is also getting bigger quite quickly, to a considerable extent because of migration (one of the great pities of this debate is that almost no-one can bring themselves to say this in public, something which also cripples the national conversation on housing, inequality and the environment).
Many elderly people remain in hospital because there is nowhere they can adequately be looked after. Often their relatives don't want to take the responsibility themselves, or no local authority places are available.
A lot of people lead very unhealthy lifestyles. A quite frightening proportion of Britons is obese.
Demand and cost are increasing at a rate which is outstripping our inclination or ability to pay for the health service.
We could fund the NHS more lavishly by paying more tax. History tends to show however that there is a maximum that governments have been able to screw out of an electorate. From memory it's about 36%. We are there or thereabouts at the moment. The likelihood is that HMG would fail to bring about significant increases in funding without cutting spending elsewhere. Those arguing for NHS spending increases - the Labour party for example - need to explain what other services they would cut instead.
Of course, this being the Labour Party, the likelihood is that they would plug the gaps with borrowing. To recap, HMG is already borrowing more than £1 billion every week just to stay afloat. With Philip Hammond's recent abandonment of plans to balance Britain's budget by the end of this parliament, the Government's finances are already teetering close to the point of no return, calculated by some economists as the point at which debt equals about 100% of GDP*. In any event, the increase would essentially involve financing current spending (as opposed to infrastructure) by borrowing, which is morally indefensible, involving as it does using future income streams (ie the income of the yet-unborn) to fund the lifestyle and services we want to have today.
If the NHS's problems can't be fixed by increasing taxes or borrowing, what can be done? Here's a range of piecemeal solutions -
Clamp down on health tourism. One trust which has carried out a pilot scheme reckons to have saved hundreds of thousands of pounds. Roll it out nationwide.
Monitor trust spending more closely. An NHS trust in Manchester recently advertised for an Assistant Diversity Co-ordinator at a salary of £70,000. One imagines that together with her boss this will be costing the trust the best part of £200,000 per year. A Doctor friend tells me that the Chief Exec of this Trust is a raging Trotskyist, so no surprise there.
Train more British doctors and nurses. Locum staff are costing the NHS hundreds of millions.
Penalise those who don't take their health seriously. Impose a sugar tax and a minimum price for alcohol.
Campaign to consolidate centres of excellence. It's much better to have one urology unit with four consultants rather than two fifty miles apart with two consultants (yes, I know people don't like it).
Outsource routine operations like hip operations to the private sector, which can specialise and institute economies of scale.
Make GPs provide better services for the same money. As the Junior Doctors strike showed, the medical profession has been treated with kid gloves for far too long. The public starts off with great sympathy for doctors, until it discovers the realities of their pay and pension arrangements. Doctors work hard, at least at the beginning of their careers, and are suckling at a very generous teat.
Make people pay to see a GP. I pay £8 for a prescription and about £20 to see a dentist. There's no reason why a similar arrangement couldn't work in the NHS. By all means make the treatment free for someone who could prove they were on benefits. A service which is free at the point of use invites unrestricted demand. There is simply no disincentive for the daft or hypochondriac not to visit the Doctor. As with the judicial system, there has to be a financial cost of accessing the service or it will be overwhelmed.
Incidentally, the cost of seeing a GP in Ireland is about £50. The cost of going to Casualty without seeing a GP first is about £100.
This brings me back to my third paragraph. It implies that somewhere out there a nameable sum exists which could adequately fund the NHS's demands. There is not. The more money you give the NHS the more people ask of it.
Will Theresa May's government grasp the nettle? Of course not. No government will, as long as the pain of inaction is perceived to be less than the pain of doing something.
The Labour Party will never introduce NHS charging, notwithstanding the comparable situation with prescriptions and dentistry, because, no matter how unfit it might be for the 21st century, the NHS is its founding achievement.
Elements of the Tory party might be aware of how to begin fixing it, but they know it would mean electoral suicide.
I can see only one scenario in which the requisite steps might take place. That would be after a long period of Labour government with attendant financial incontinence and NHS disaster. Then, and only then, might the Tories pluck up the courage. But at this stage it is impossible to see that scenario lurching into being.
The NHS crisis - not going anywhere soon.
*By happy coincidence, the same day I wrote this piece the Office for Budget Responsibility issued a report saying that the public finances were on an "unsustainable path" and that at the present rate of deterioration public sector debt could increase to 234% of GDP in 50 years time. It blamed increased spending on the NHS and state pensions in particular. If the OBR is right our economy will of course be toast long before 2066. Something will have to be done. What? When? And by whom?
