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The political debate about the extreme pressure the NHS is currently under is barely serious. In reality, there is little real difference between the parties on NHS funding and some marginal differences on structure and regulation. Don’t get me wrong, the Conservatives have made mistakes not least in an ill-advised top-down reorganisation through legislation – one which they had counselled themselves against. But rather than seeking an honest debate about a service under extreme pressure, Labour chooses to play politics in the main. This election has already assumed a depressing pattern.

Something more fundamental is at the root of the current situation. We are witnessing a systemic failure to cope with rising demand. This means there are two parts to the equation – the system and demand. Spraying more cash at the problem, in the face of extreme capacity constraints, will do little at this stage. There is very little spare capacity- i.e. people and facilities – in reality. Instead, there is simply a system with so many perversities, skewed incentives, inefficiencies that it may seem difficult to know where to begin.

Wherever one would start, it would not be with a politicised debate. There is broad consensus about NHS funding between all the parties but some marginal differences in analysis of reform. This would appear to be an issue where there is scope for broad cross-party consensus on finding solutions to long-term problems. Don’t hold your breath.

If you want to see under the bonnet view of the NHS, I can recommend that you read a superb eye-witness analysis by Robert Colvile of the Telegraph. The basic message that comes through his piece, based on some time spent in the Queen Elizabeth Hospital in Birmingham, is that there is heroic efficiency in some parts of the system but the system as whole is perverse. The target culture, tariff methodology, the divisions between different parts of the system in control, finance and governance, new regulatory requirements, bureaucratic complexity, and reaction to previous care crises such as Mid Staffs have meant a series of blockages in the system.

It’s easy to point the finger at politicians and administrators. But they work in the context we establish for them. They get the message that we don’t want to pay any more taxes but we want superb public services- which isn’t possible so they duck and dive. We use the services as if they were free to provide rather than simply free at the point of use. Colvile sees cases in A&E such as “palpitations”, “painful shoulder”, “headache”, retention (of urine)”, “deliberate self harm”, “cellulitis, toe, left” and “generally unwell”. Some of these cases may well require A&E, many don’t. On the Today programme yesterday, one patient complained that a child had vomited was not being seen. It may be unpleasant watching a child vomit but is that necessarily the priority? We put our own judgement ahead of professionals.

If we are going to resolve this fundamental stress then a fundamentally different approach is needed. More cash may be part of this but it is just one element. The chief executive of the NHS, Simon Stevens, has shown every sign of knowing what needs to be done as evidenced by the (reassuringly short) Forward View that was published last year. Last year, we published an essay by Alex Fox of Sharing Lives, People-powered NHS, which identified how to ensure that patients’ needs are met both by giving them greater control over how the healthcare resources they require are spent and ensuring that the system becomes more responsive to their needs.

So the strategic change and coordination that Simons seeks is a critical component of change. However, more transparency and responsibility for patients is necessary too. The NHS, social care, and emergency services have to work as a system. That means that resource and capacity has to appear in the right places, in the right way, at the right time. Equally, patients, through the vehicle of personal budgets so common in social care, need to understand the choices that are made are their behalf and the consequences of those choices. The days of NHS as if it were free to provide have to end. No politician is saying that today.

None of this will happen in the short-term. Instead we will get a largely simulated national debate about the future of the NHS. The parties will probably get into a bidding war on financing the NHS: who will be first out of the blocks? I might run a book. The NHS will somehow struggle through the next few weeks as it always does at enormous cost to the well-being of its staff. And we will defer an honest national discussion about the future of the NHS we need to have.

Its basic institutional ethos as a service funded out of general taxation, free at the point of use, responding to needs is not going to change and nor should it. That gives us a chance to innovate but instead we use it as an opportunity for bureaucratic overload and a non-transparent market. In the words of Dame Julie Moore, chief executive of QEH, “We’ve neither got a market, nor a managed system – it’s neither fish nor fowl. We say patients can choose, but the money doesn’t follow the patient.” I would add that the patient has no idea how their treatment is resourced and the consequences of their choices as well as the choices made on their behalf and this is very damaging.

Instead, we should be debating how to change the system so it operates as a proper system and how we can radically change the relationship between the patient and the NHS. Later this year, Adam Lent and I will be publishing a Power to Create paper on how to change the relationship between the citizen and the state. It will advocate greater transparency with more control over resources for public service users mixed with real system change aimed at securing a greater range of services, more innovation, and a greater focus on outcomes.

This will all require imaginative leadership. It is clear that there are imaginative leaders throughout the system: in hospitals (even the dreaded hospital managers that are constantly attacked), staff and professionals throughout the service, in professional bodies, and in the strategic roles in the NHS. What is lacking is real political leadership which honestly seeks to put the NHS on a sustainable footing. Unfortunately, that is needed if we are to see real change. But we as citizens have to accept our own responsibility too. Our demands and behaviours drive much of this. We need to be honest with ourselves too.

Anthony Painter is the RSA’s Director of Institutional Reform. You can follow him on twitter@AnthonyPainter


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