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31 January 2000

Let’s turn the NHS upside down

We will not get better health services until we relax central control, argues Julia Neuberger

By Julia Neuberger

It’s been a bad fortnight for the NHS. The flu epidemic had us questioning, as we do each winter, the ability of the 52-year-old service to cope with the seasonal increase in demand. Its leading lights were calling for a large injection of taxpayers’ money or a revision of the way it is financed. The media were swarming around it like vultures over a carcass, looking out for mistakes and problems. Even the once-sacred founding values of the NHS – fairness and universality – have been attacked from all sides as outdated and dispensable.

Where to now for this service under fire?

The way forward is to turn the system on its head. At present, local health services are forced to meet central targets on the minutiae of life, such as waiting-lists, but are left to take the more difficult decisions about resource allocation alone. Instead, we need to build a system that sets out a national framework for the values and purpose of the NHS, within which local services make their own decisions about specific service provision, and can meet local needs more flexibly. There may be national standards for the treatment of cancer and heart disease; but it is better to leave the planning of local services to health authorities and primary-care trusts. This balance will take time to achieve, but it is vital if the NHS is to provide care that treats people equally across the country while responding to the unique needs of every community. Far from being an institution operating in a vacuum, run by a central authority, we should recognise that the NHS depends to a large extent on co-operation with social services, voluntary organisations, community groups and housing providers. Genuine partnerships both locally and nationally are vital to its success.

What do we want of the NHS? A national debate has been sparked by the “crisis” of recent weeks: now the public should be engaged not only in thinking about what the NHS is for, but about how much they are prepared to pay in taxes to support the service they require; and what they will, and will not, pay for. Only then can we begin to think about ways of covering those services that cannot be included.

We also need a clear statement of values for the NHS, underpinned by a new patients’ charter that sets out the rights and responsibilities of both workers and users. If we are prepared to pay for them, we can develop more responsive health services, such as NHS Direct and walk-in centres. Although they require initial investment, these new services may help to manage demand on the more expensive parts of the health service, such as hospital casualty wards.

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We also need to think again about how we value the people who work in the health service. We have to ask why there are shortages of doctors and nurses in the NHS, what it is that stops young people taking up those professions, and what makes established staff leave. Much can be done to tackle low morale: for example, a more positive approach to equal oppor-tunities; a reduction in central control; flexible working hours for people with family responsibilities; and an end to unnecessary demarcations between different groups of workers. NHS staff at all levels, regardless of their professional qualifications, should be involved in making decisions that affect the service. Whether people are carrying out advanced medical techniques, providing personal care to a patient, managing a hospital or cleaning a ward, their contribution to the health service should be viewed as an equally valuable part of a team effort.

Some commentators view the NHS as a drain on national resources. This assumption came to light in the recent debate about what proportion of gross domestic product we spend on the health service. Yet its critics ignore the contribution that the NHS makes to our GDP. Services to treat depression, diabetes, heart disease and back pain make a huge contribution to the health of our workforce and stimulate a whole range of modern industries such as pharmaceuticals and electronics. With adequate funding, they may actually increase GDP – not only use some of it.

The current government has promised to invest in the NHS. Like all governments since 1948, it will continue to increase NHS funding and produce a succession of policy initiatives. But we need something more. We need to invest in an NHS that really fits the founding values of equity and universality. The NHS will never be able to do everything for everyone, but we can ensure that its most important functions are carried out to an equal standard throughout the country and that people with the greatest needs are given priority wherever they happen to live.

These are not unachievable ideals. They are a set of aspirations that can be reached within a national health service funded through taxation – provided that the political will is there to engage in the processes that will turn them into reality.

Despite all the rhetoric of crisis that has surrounded the NHS this month, the service continues to function up and down the country, providing the majority of people with high-quality healthcare when and where they need it. The system may have faults, but they can be corrected with some timely surgery. The NHS is not dying, it is merely suffering a bout of flu.

Rabbi Neuberger is director of the King’s Fund