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(You can access the full piece, originally published by The Conversation on 30th March, 2015, here: https://theconversation.com/state-of-the-nation-ten-things-weve-learned-about-the-nhs-under-the-coalition-39334)
Unlike in 2010, healthcare was a key electoral battleground this May. In thinking through how we got from the 2010 inheritance to now, here are ten things we didn’t know then but certainly know now.
1. Promises can be reneged on
What is said in opposition before the election and what happens in practice afterwards is often different: in the run up to 2010, the Conservatives promised there would be no top-down reorganisation of the NHS, before subsequently introducing the biggest top-down reorganisation in the history of the health service – one that NHS England’s former chief executive said was “so big you can see it from space”. (A similar story could be told about New Labour’s 1997 claim to end the internal market).
2. Big structural change seldom delivers
Sometimes there are aspects that need to evolve or see radical change but (repeated) whole-scale reorganisation doesn’t work: structural “solutions” are often tempting as they look big and bold, and as if genuine transformation is happening. In practice, they reduce morale and productivity, distract attention away from improving patient care and seldom deliver stated intentions. It’s hard to exaggerate just how damaging such reorganisations can be – and the NHS Confederation has helpfully drawn attention to the constant “triumph of hope over experience” as we reorganise yet again.
3. Standing still isn’t enough
Ringfencing the NHS budget is still a cut in real terms if costs and demand are going up. Despite protecting the NHS from the cuts faced elsewhere, the health service still faces massive financial pressures (which in many ways spilled over during the A&E crisis.
4. Listening to advice isn’t a bad thing
Sometimes people who point out potential pitfalls might actually be trying to help. From the very start, the Conservatives seem to have felt that the previous New Labour government lost vital time early on by being too timid in its first term – and therefore were desperate to be quick out of the blocks in a number of key policy areas. In response, they tended to assume that any advice around potential pitfalls was an attempt to derail reform – rather than an attempt to help – and arguably did not listen till too late.
5. NHS ‘end is nigh’ is overstating it
No matter what pressures it faces, claims that this is “the end of the NHS as we know it” have so far proved wide of the mark. The NHS is so politically important that any debate about reform can quickly become polarised into a discussion about whether the changes amount to widespread “privatisation” (and about whether this undermines the founding principles of the health service). However, such terms are usually used in a very imprecise manner, with little clarity as to what “privatisation” actually means.
6. Local government has it worse
However tough things are in the NHS, it’s worse in local government which is facing what one leader described as “the end of local government as we know it”.
7. Actions speak louder than words
Care scandals can happen at any time – but talking tough doesn’t help. Events at Mid-Staffordshire, Winterbourne View and Morecombe Bay are truly shocking – and rightly led to much public soul-searching about how such terrible things could happen in a caring service. However, public inquiries with hundreds of individual recommendations, beefing up inspection regimes and ending careers only makes people more defensive and less likely to admit and learn from their mistakes.
8. An answer with no question
Integration might be the answer – but we don’t know what the question is. Following the 2011 “pause” in Lansley’s health reforms, the work of the NHS Future Forum placed significant emphasis on the need for “integrated care” – joining up health and care services for older people and those with complex needs. However, there was little clarity what this actually means, or what it is meant to achieve – and many services feel less integrated now than ten years ago.
9. History shouldn’t define the future
The only thing we learn from history is that no one learns from history. Debates about integrated care are a good example of the loss of organisational memory which has been increasing with the churn of managers, new regulatory regimes and performance measures.
10. Still delivering despite the struggle
Luckily for all of us the NHS still manages to deliver (almost irrespective of national policy). In spite of all the pressures, turmoil and upheaval, care quality is high, access is (mainly) good and the NHS still has significant public support. Even during the recent pressures on A&E, most people continued to be seen in a timely manner – and it is testimony to the hard work and determination of staff that they kept the show on the road in very difficult circumstances.