The Challenges Facing the NHS

November’s Care Conversation heard from Dr Clare Gerada, Chair of Council at the Royal College of General Practitioners (RCGP), on the challenges facing the NHS

‘Let me state categorically that the RCGP is not against putting GPs at the heart of commissioning services for their patients,’ Dr Clare Gerada told Care Conversation delegates. ‘It makes absolute sense.’

What the college had ongoing concerns about was the government’s Health and Social Care Bill, not GP commissioning itself, she stressed. ‘Firstly, it’s so large and complicated that, as NHS Chief Executive David Nicholson says, you can see it from space. And it is the end product of 20 years of increasing marketisation of the NHS.’

She had visited America to learn what happened to patients in a health market, she told the seminar, and had been ‘shocked and saddened’ by what she had seen. ‘Politicians, policy makers and managers all come back from the US rhapsodising about the system, but they never talk about what happens when the market fails.’

US healthcare provision cost twice as much as any comparable system and yet had some of the worst outcomes in the world, she said. ‘Sixty per cent of funding comes from the state. Their spend on Medicare and Medicaid is the same as on welfare, roads and prisons put together.’

The system served to simultaneously increase costs and limit choice, she pointed out, with around 80bn Americans either uninsured or under-insured. ‘Most Americans worry about healthcare costs more than anything else. People – apart from the most wealthy – can be just one serious or chronic condition away from enormous bills, or even bankruptcy.’ Seventy per cent of personal bankruptcies were the result of healthcare costs, she said, the vast majority among people who actually had health insurance.

There was a preventable death in the US system every 12 minutes, along with the highest child mortality rate of any Western country. ‘I’m not scare-mongering, but these are very scary stories,’ she told delegates. ‘And they’re scary because they’re true. In the UK we are the only country in the industrialised world where those earning less than the national average don’t have to worry about access to healthcare.’

It was not just the American situation that provided a cautionary tale, she said, pointing to the impact of Dutch health reforms designed to introduce a competitive market via insurance companies. But, while UK reforms were moving the system further towards marketisation, she was nevertheless optimistic about the future. ‘I think we have a health service that needs to change, needs to improve and needs to decide what it should and shouldn’t be providing.’

What needed to change were systems, however, rather than structure, she argued. “People now go to Scotland to see how they’re managing to improve their outcomes so impressively and so rapidly. There hasn’t been a structural reorganisation there in 20 years, and we’ve had several in 30 years – you can’t run anything properly on that basis.

‘When you want to get a new sofa into your front room, you don’t demolish the house to do it. There are enough intelligent people in the health service to make it work well, but it needs to stand still long enough to allow them to do that.’

There was undoubtedly a place for the private sector, she asserted, as well as for competition, but that competition needed to be managed to avoid what had been seen in the social care sector, with its 30,000 providers and ineffective regulation.

‘People have been saying that it’s the end of the NHS every year since it started. But, as Bevan said, the NHS will survive as long as there’s one person left to fight for it. And I’m determined to fight for it.’