Monday, 30 June 2014

The NHS: fit for 1948 but for 2014?

This past weekend I decided to spend more time reading the newspapers and leaving the do-it-yourself projects for another day. Consequently I got stuck into an article in The Observer about the NHS' funding crisis, what might happen and what the King's Fund thought should happen.

All interesting stuff, but I felt that while many of their suggestions made some sense they were missing the point about what is really going on in healthcare in the United Kingdom. Maybe they need to reflect a little using Geoffery Vickers' idea of appreciative systems.

Vickers suggested that we observe the flux of time passing as manifested by ideas and events, compare them with our internalised standards and then decide how to respond. The NHS as it currently operates is based on society's needs in 1948: a war-wracked society where infectious diseases and poor living conditions were major problems. Illnesses could be treated and the people would return home to live out the rest of their harder but shorter lives.

But the flux of time moves on and by the time we react the situation has changed: our responses are therefore always that bit too late. So it is with healthcare: we now have a relatively affluent society characterised by good general levels of health leading to an ageing population where chronic diseases of old age are much more prevalent, and one where lifestyle illnesses such as obesity and lack of general fitness are placing increasing demands on the NHS. But the standards used in the monitoring process seem to be unchanged. Organisations like the King's Fund still look for ways to make the NHS work better within the 1948 paradigm.

The rich picture below tries to capture some of the issues that are affecting health today.

The food and drinks industry encourages people to drink sugar and alcohol and eat fat, all of which when consumed to excess cause health problems. The running down of public leisure facilities through austerity programmes, selling school playing fields and minimising the importance of competitive games in schools (as just a few policies) mean that people take less exercise and keep less healthily fit. Big Pharma relies on medicalising life so that it can sell drugs and treatments to the healthcare industry, so has little interest in a healthy population.

Seen in this light, current government policies to encourage more private enterprise to run parts of the health service seem like plans to let lunatics run the asylum - it's a great business plan if one part of the corporate empire makes people sick while another makes them better so they can keep consuming. Other plans to review targets and enforce more inspections and regulation will just drive problems to another part of the system. Scandals like that in the Mid Staffordshire NHS Trust will continue to reappear in different guises.

The problem is therefore one of system boundaries. While the NHS is seen to be there to treat illness rather than to promote health neither it nor associated politicians will look to take on the real causes of poor health, the systemic ones of poor public health policies, corporate interests in promoting illness and an increasingly sedentary population. Powerful systemic factors mean that it is likely to stay as it is.

The NHS is a fantastic service we in the UK should be proud of. But perhaps its past successes are stopping us from looking at what health systems should be about in 2014?

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