What part of “No” do you not understand?

My son taught me this response and very useful it has been in defusing my internal tensions.  However they are building up again as I read that the acute sector of the NHS is to undergo a “reset”.  A reset would be fine if it delivered.  It won’t.

The acute sector is in crisis. Two-thirds of acute Trusts are in serious deficit.  A “reset” would work if (1) it wrote all the deficits off and (2) it ensured that they would not come back.  This requires a lot of money which isn’t there.

Large numbers of Trusts (all of them in my part of England, without exception) are in “special measures”.  This means they are not performing to the required standard, whether in financial or clinical terms.  If it’s the financial state that is the problem, see the above paragraph.  If it’s a clinical problem it is almost certainly due to a lack of staff.  Fixing this requires a lot of money which isn’t there, not least if a Trust needs to cover gaps with agency locums, which cost even more lots of money.

Bust Trusts are often burdened with serious debt from Private Finance Initiative (PFI) funding, as many projects are based on long repayment terms at crippling rate of interest, which sucks a lot of money out of real healthcare.

Many Accident and Emergency departments are working at full capacity despite being short of staff, burdened further by bed shortages (or blocking because patients well enough to leave hospital but with no system to get them out).  To fix this problem requires lots of money – either to increase acute beds, or to upgrade social services support, or both – which isn’t there.

Many Commissioning Groups, or CCGs, which buy acute services, are facing severe financial difficulties and are trying to reduce costs, in one instance by the quite extraordinary suggestions that GPs stop referring any non-urgent patients to hospital.

So (I put that in because it now appears essential to preface a response from anyone in research) acute services, which are commissioned by CCGs, are bust and/or judged to be failing clinically.  To be less bust they need to cut staff, and to stop failing clinically they need to employ more staff.  This is an oxymoron. Of course, failing units could shut.  After all that’s what failed businesses do.  However that then reduces the already perilously low bed numbers and shifts the problem elsewhere – and given that every hospital is in the same boat will cause chaos.  Of course, the hospitals that remain open, requiring vastly more beds to cope with the displaced patients, could always expand, but would have to do so by adding to their PFI burden with a rebuild.

Meanwhile the government is merrily and on the basis of misinterpretation of data pushing on the concept of a seven-day service, which requires even more lots of money to cover rotas, overtime etc. It also appears to be indifferent to the scandal of generic drugs manufacturers escalating their prices without any apparent justification.  And the public still expects, in this Kafka-esque situation, everything to be completely free.  This is not a case of trying to fit a quart into a pint pot, but trying to fit Kielder Water reservoir into a test tube.  The purchasers cannot purchase, the providers cannot provide and yet everyone sits round thinking up yet another reorganisation or “reset” to add to the list of failed solutions since the 1950s.

These have never worked.  Some were devised by highly sensible and intelligent people. If they haven’t fixed it after all this time, what makes anyone think that it can actually be fixed at all?  I feel a sense of deja vu creeping up.  I have said all this before, and while it gets steadily worse, and deficits pile up in yet more places, “Nero” Hunt fiddles as Rome burns.  And, of course, makes things even worse by slagging off the doctors.

All right, you say, you have identified problems, and irreconcilable ones at that, but what are your solutions?  I suggest some or all of the following.

  1. Abandon PFI or refinance very PFI project to reduce historic and ridiculous interest rates to today’s levels
  2. Sort out the scandal of drug overcharging
  3. Stop some free prescriptions.  If someone needs thyroid replacement let it be free, but not the multitude of other drugs that are also prescribed but have nothing to do with replacement.
  4. Stop doing some expensive and marginal things. For example, is there any reasonable point in administering anti-cancer drugs at £30,000 a pop to gain six weeks of life?  And likewise is there any justification for resuscitating, or indeed treating, elderly mentally frail people in intensive care units when the quality of life when they leave the unit is awful?  This is of course contentious, but we must face the reality that the NHS as currently working is unaffordable.
  5. Stop statins (bee in bonnet here, but the costs are astronomical).
  6. Abandon any idea of seven day working until finances are demonstrably stable.  Which may be forever.
  7. Run the NHS either as a fully subsidised state monopoly enterprise, or as a business, but don’t pretend that it’s possible for it to be both.  And if it’s a business, then close bits when they go bust.  A true market will soon work out what works and what cannot.  That will focus the mind wonderfully!