NHS funding: Let's stop pretending we can see the emperor's new clothes

To pretend that extra resources are not urgently needed in the NHS is to be as foolish as the courtiers in Hans Christian Andersen's fairy tale.

Shortly before the end of the financial year one of the occasional meetings took place in this hospital where consultant staff meet senior management.  We had come to the end of Any Other Business. The new Finance Director for the Trust piped up. His voice was querulous. He had waited until the very end of the meeting to say his piece. He explained that the Trust was going to end the year with a tiny surplus but the coming year would be one of great uncertainty. Not only were there cost pressures of inflation including the lifting of a pay freeze, but the Treasury’s requirement for continuing cost improvement would apply and the tariff, the price paid by the commissioners for each episode of activity in the hospital was being reduced. He was very worried.

This air of financial uncertainty is passed off as normal throughout the Health Service. The Royal Colleges, the NHS Confederation and even the King’s Fund take it as read that there will be less money around in the future.  Nobody considers it to be their responsibility to draw attention to the immense harm this is doing to health care in the United Kingdom.  

This is not new. The conduct of political control of the NHS purse strings is rarely questioned. Just occasionally someone makes the comment that everyone is thinking but no-one dares utter, like the child in Hans Christian Andersen’s story who was the only one who dared mention the king’s nakedness. A few years ago it was Lord Winston who in a New Statesman interview commented both on resources for specialist care and on the shabbiness of the under funded hospital in which his mother was a patient; this comment proved catalyst for Tony Blair’s of decade of increasing funding for the National Health Service. The Treasury exacted its price for enacting this; the NHS was required to meet targets to show the money was being well spent. Clearly the officials of the day did not understand Goodhart’s Law which tells us that when the measure becomes a target ceases to become a good measure so the meeting of targets is no way to assess what the NHS is achieving.  

Indeed it causes distortions and the conflicts. Gary Walker was Chief Executive of the United Lincoln Hospitals NHS Trust when, as he informed us in February, Dame Barbara Hakin told him that his Trust was required both to care for acute emergencies and meet the waiting list targets for planned surgery without extra funding for the extra operations. This shows us how with its inadequate funding, the NHS becomes a competition between patients for resources.

It is expected that the Health Service will meet this future with much less work done in hospitals and much more “in the community.”  This is why hospitals’ funding from “Payment by Results” tariffs has been reduced by £2.4bn both in 2011-12 and 2012-13 to free up resources for to develop of community services. The problem is that those services are currently in no way able to take as much load off the hospitals as this policy requires; community services will have to achieve more before the resources they need to do so are released. Components of community services are actually being reduced including out of hospital residential care such as that provided by councils which are facing their own austerity. People whose care at home is unsustainable because of the combination of health issues and the inability of their family and social support network to cope and end up in the acute general hospital as the provider or last resort. To run down its resources without reducing demands on it creates the circumstance in which the hospital fails to meet the humanitarian standards.  It is all too easy to see how the dehumanisation of patients in Mid Staffordshire so clearly described in the stories quoted in the Frances Report occurred. We now have an academic study describing the relationship between understaffing and care left undone. The behaviour of Staffordshire nurses in neglecting simple aspects of patient care in favour of meeting administrative demands is fundamentally no different from that of Barbara Hakin in dealing with the Lincolnshire issue or of Sir David Nicholson in issuing his challenge to the Health Service as a whole to do more with inadequate resources. Perhaps everyone in the service is showing the same attitude by the failure to challenge the funding issue. The chairman of NHS England, Professor Malcolm Grant agrees that “…although the NHS is one of the cheapest health services in the developed world, money is desperately tight” without connecting this increasing parsimony in an already undersized service to the way problems that are being faced or the way in which they are addressed1.

There is also a lack of perception that the poorest parts of society lose out here. It is recognised that there are health inequalities in the United Kingdom and that it ought to be possible to improve the health of poorer people with education in preventative measures such dietary changes, exercise and above all reduction in smoking, not to mention raising the general educational aspirations but there are also major issues about access to health care. It is poorer people that make use of the emergency departments rather than primary health care because that is the environment where they compete most effectively against their articulate and affluent compatriots, although that having been said, the journalist Matthew Parris who is undoubtedly articulate has argued that the emergency department of his local hospital is his preferred route into health care2. For poorer people an emergency admission is a much more likely route to a diagnosis of cancer than it is for wealthier people, but health policy is based on the assumption that everyone will come through the General Practitioner. Indeed there are huge discrepancies in the timeliness of diagnosis of cancer between rich and poor and it is timeliness of diagnosis that is the principal factor in the United Kingdom’s poor performance in the International league tables of cancer survival. Britons may not have to pay a bill when they visit the doctor but that should not be taken to mean that access to health care is easy and equitable.  

The National Health Service has a lot of catching up to do. To make the care of people with illnesses like cancer equitable is going to require much more resources for diagnosis, doing tests on more people who turn out not have cancer to identify sooner those who do. Timely diagnosis is only of use if the patient goes onto have appropriate treatment and resources are required for that to bring the United Kingdom up to speed with the rest of Europe. The demographic issue looms large here. Important illnesses tend to occur later in life and the ageing baby boom generation is now passing through that phase of life where health care needs are increasing and they are young enough to benefit from treatment.  It will not be possible to do this without more personnel and without more contemporary technology.  This will have to be paid for.

Allied to the theme of more health care being provided in the community is the proposal that specialised services should be located in a smaller number of centres. This is another policy which has not been thought through.  There is a growing body of evidence that large hospitals, mainly the central Teaching Hospitals, function inefficiently but meeting the costs of that inefficiency would be justified if the increment in quality was great enough. Against this must beset the issue of access which is again linked to the issue of socio-economic deprivation.  In the reconfiguration of the NHS which took place in the 1960s, three specialties were designated for centralisation: neurosurgery (which has never anything other than a centralised service), thoracic surgery and radiotherapy.  50 years on there is clear evidence that people, especially poorer people, who live some distance from the specialist centres are less likely to have treatment. 

Perhaps understanding this will help the powers that be in the NHS to see why feelings are running high in Leeds where there is plan to close children’s heart surgery services. Parents are not impressed by the theoretical increment in quality from fewer, larger specialist centres, but they are profoundly concerned by the reduction in access from their area of residence to the remote location of the specialist facilities.  Some services can only be provided in specialist units but the case for developing services in local general hospitals which are more efficiently sized is strong.  Those hospitals are better placed to work with General Practitioners and community services to promote efficient and effective balance between community and institutional care and this must be fostered in the future.

It is currently fashionable to quote stroke services in London as the epitome of modern centralisation; it is in fact a very bad prototype for a wholesale process.  It is the hyper acute service that has been successfully centralised which depends on the fact that diagnosis by recognising very clear cut symptoms (do make sure you know the FAST acronym). It does not work well when diagnosis is difficult; this is the pervasive weakness of strategies that depend on a specialised service with limited capacity as history shows.  The London stroke project also relies on enhancement of services in other hospitals and in the community, the centralised hyperacute service does not replace these and Jackie Ashley’s experiences in caring for her husband, Andrew Marr, suggests that the next area of growth should be in the community but not at the expense of inpatient rehabilitation3.

The perception that the Treasury has been generous to the NHS in the first decade of this century has perhaps led to the imposition of an increasing burden upon it.  One way in which the Government could ease pressure would be for the Treasury to take on the costs of its experiment with the private finance initiative so that companies who take on the construction and operation of hospitals with guarantees of decades of high levels of income do not compete with poorer patients for NHS resources.  One thing is very clear. We fund the NHS from a pre-defined budget which is to treat health care in the same way that a council treats its parks department; the latter is a worthy endeavour but its finances must inevitably be restricted and no-one is killed or maimed if the mowing and weeding are not bang up to date. The truth of the matter is that this approach puts the British patient at a disadvantage compared with others in the developed world where the funding authority is charged for the work that healthcare facilities perform.  

NHS England director for patients and information, Tim Kelsey, has announced his report “The NHS Belongs to Us All” with the revelation that by 2020 there will be a £30bn funding gap in the healthcare system. This cannot be addressed by organisational tweaks intended to save vast sums because on past performance this will further degrade patient care, although that is not to deny that the service has to develop and improve. To pretend that extra resources are not urgently needed now is to be as foolish as Andersen’s vain monarch.  

Dr S Michael Crawford is a consultant physician in an acute general hospital

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1The Times, 1 April 2013
2The Times, 16 June 2012
3Guardian, 1 August 2013

 

The conduct of political control of the NHS purse strings is rarely questioned. Photo: Getty
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Why gender became the ultimate forum for self-expression

Gender identity is now embedded in many people’s self-perception, as well as in day-to-day bureaucracy.

In November, the British high-street bank Metro announced that it was expanding its gender and title options. Customers could now register as “non-binary” rather than male or female, and as “Mx” rather than Miss, Ms, Mrs or Mr. In some ways, this development parallels the rise of Ms in the 1970s, which was popularised by feminists who wanted a title that didn’t identify women by their marital status. In practice, Ms marks women by their political affiliation instead (if you’re talking to a Ms, you’re probably talking to a feminist) but, even so, its first intention was to conceal rather than reveal information.

Mx does something different. To declare yourself a Mx is to disclose something about yourself: that your identity is outside what has become known as “the gender binary”, and you are neither man nor woman but something either in between or entirely other. This is a statement about who you are, and it comes with an implicit understanding that not being able to make that statement – or not having it recognised – is damaging. As the father of one gender-non-binary teenager told BuzzFeed UK: “When . . . you don’t identify as male or female and you only see those two boxes, then you don’t see yourself there . . . You are absent. That must hurt, and that’s what makes me angry.”

While users of Ms hoped that their title would supersede the ranking of spinsters and matrons, Mx relies for its meaning on the persistence of alternatives. You can only be non-binary if there’s a binary against which to define yourself. It is now recommended practice at some US universities for students to declare their preferred pronouns, and mandatory that these should be observed by others. Failure to do so is considered more than a breach of etiquette: “misgendering” is looked on as an act of bigotry, even a kind of verbal violence. This use of gender as self-assertion has an obvious appeal to teenagers and young adults as a parent-baffling subculture, but it starts much younger, too, with a small but growing number of primary-age children announcing that they are trans.

On one of its covers in 2014, Time magazine famously described transgender activism as “America’s next civil rights frontier”, but the proliferation of gender identity is at least as much a consumer choice issue. This was also the year that Facebook introduced its “custom” gender options, though it would perhaps be more accurate to describe them as “expansive presets”. Users can choose anything from “agender” to “two-spirit” via “bigender”, “gender questioning” and “transmasculine”, but what they can’t do is subvert the system by selecting an unapproved option. A feminist wishing to register her objections to the class structure of gender by typing in the word “oppressive”, for example, would be stymied here. However diversified gender identity becomes, it is a precept that everyone has one (if your identity and your body “agree”, you are said to be cisgender).

For some, asserting their identity is enough. For others, aligning their presentation with their sense of self will involve altering their appearance. At the least invasive level, that might demand cross-dressing. A natal female might choose to “bind” her breasts, flattening them to achieve a more masculine silhouette. Many seek prescriptions for opposite-sex hormones. At the most extreme, a trans individual will opt for surgical removal of their secondary sexual characteristics and gonads (more rarely, for surgical construction of opposite-sex genitalia), coupled with a lifetime of hormone replacement therapy.

Hormonal and surgical treatments have been possible only since the mid-to-late 20th century, and for many who choose them, these alterations prove life-changing in a positive way. But beyond the confines of the National Health Service, a consumerist edge to treatment becomes more obvious. There are doctors specialising in private transition medicine whose websites include statements such as “the only person that can actually diagnose [gender dysphoria] is the person living with the feelings”. In other words, the prescription is based not on a doctor’s medical judgement of the patient’s needs but on what the patient asks for (and is willing to pay for).

Plastic surgeons promise to transform transgender patients from “caterpillars” into “beautiful butterflies”, holding out the prospect of becoming one’s “true self”, in the same way they have long sold boob jobs and liposuction to women.

Not everyone accepts this brave new world. For conservatives in the United States, trans issues have become the next battle in the culture wars, and Republican politicians have introduced “bathroom laws” that would legally compel trans men and women to use toilets or changing rooms in line with their birth sex. Gender identity was an issue in last year’s US presidential election; a Tea Party-supporting talk-radio host tweeted: “If you want a country with 63 different genders, vote Hillary. If you want a country where men are men and women are women, vote Trump.” This vehement rejection of gender self-identification creates its own kind of identity politics.

That Donald Trump said that Caitlyn Jenner (the former Olympic decathlete whose transition became public in 2015) would be free to use “any bathroom she wanted” at Trump Towers did little to stop the perception that a vote for Trump was a vote against gender nonconformity. And, in some ways, Trump’s acceptance of Jenner’s right to use the ladies’ lavatories is not wholly at odds with the idea of a world where “men are men and women are women”: it’s just that some of the feminine people were born male and some of the masculine ones were born female. It is unclear what Trump’s presidency will mean for trans rights, but whatever happens in America will influence gender ideology worldwide.

Threats to legal abortion and equal marriage could strain some of the alliances within the trans, LGBT and feminist movements. A trans woman who has undergone surgery is in a very different situation from a male who identifies as a woman but does not want any treatment. A gay, lesbian or bisexual person who is discriminated against for their sexuality does not experience the same oppressions as a trans person (it is an article of faith that gender identity and sexuality are separate things, although in practice the division is not that neat). The political priorities of women who are victimised because they are female will not overlap perfectly with the priorities of transgender women – some of whom complained that the “pussy hats” and signs referring to female genitalia on the anti-Trump women’s marches in January were “exclusionary”.

Gender identity is now embedded in many people’s self-perception, as well as in day-to-day bureaucracy. But the messy relationship between sex and self is not going to be settled imminently.

Sarah Ditum is a frequent contributor to the New Statesman

Sarah Ditum is a journalist who writes regularly for the Guardian, New Statesman and others. Her website is here.

This article first appeared in the 16 February 2017 issue of the New Statesman, The New Times