Grown-up thinking is required when it comes to the NHS, but don't hold your breath

We really need to have a difficult conversation about the NHS. No, not you and I, dear reader, but as a society. The NHS is rightly praised because it achieves well when it comes to the most difficult balancing act in healthcare: combining quality and access in the right combination.
True, American healthcare is of slightly better quality, but what good is that if many people can’t access it? Similarly, you don’t want easy access to rubbish healthcare. But whilst the NHS delivers high-quality services with excellent levels of access, it is becoming increasingly difficult to escape the conclusion that it is simply growing out of control, consuming vaster and vaster amounts of money, and increasingly escaping serious scrutiny because, ultimately, it has such a treasured space in the national consciousness that no-one who doesn’t want to be lampooned as an evil capitalist or who doesn’t want to commit political suicide will dare question whether there is a better way to do things, or at least a need for insurance or some kind of personal accounts to supplement basic care provided by a much-reduced NHS.

Today’s revelation that personal health budgets are being used for such things as riding and music lessons, Sky+ boxes and summerhouses should fill anyone with horror, but I’m not remotely surprised. This appalling abuse of NHS resources stems from the hopelessly inadequate way in which the NHS has, over the years, responded to its fundamental flaw – one which, I believe, will ultimately prove a fatal flaw. The founding idea behind the NHS was that better healthcare would lead to reduced demand. In fact, it has allowed people to live for longer, even with more chronic diseases, pushing up demand for treatments which, with the growth of health technology, have got more and more expensive. The NHS strategy has been to try and switch from a ‘sickness service’ to a ‘wellness service,’ in which prevention, and the encouragement of healthy living is encouraged. The logic is reasonable: help people, for instance, to stay slim, and it’ll be cheaper than treating the heart attacks, the avoidable cancer cases and the explosion in diabetes rates from uncontrolled obesity. The NHS has long argued that, when it comes to long-term conditions, the case is clear for emphasising prevention. I have been at the sharp end of such efforts as an NHS employee and yes, I can’t argue that preventative interventions have been shown to be cost-effective because they prove cheaper than treating the consequences at a later stage. So, on the face of it, the argument for these personal budgets and a broader strategy targeted at developing a ‘wellness service’ is pretty textbook. Except, of course, that it is not. Why? Because it moulds the service around a concept – the concept of wellness – that is infinitely flexible and could be stretched to justify just about any kind of expenditure, particularly when combined with a desire to build a care package around the wishes of the patient. Why would it be limited simply to technology explicitly built to aid with such things as self-management? If the patient feels that a summer house will give them personal space, if massages or music or riding lessons promote relaxation and stimulation, or if a Sky+ box allows a dementia patient to skip the television adverts that cause anxiety, all those items suddenly don’t seem so outrageous and the clinicians who backed the plan don’t seem so crazy.
It isn’t the argument for such items that is contentious, but it’s the idea that the NHS is paying for it, when it is forced to ration cancer drugs, can’t pay for the latest and greatest prosthetic technology and actually can’t even afford to do prevention properly. When the victorious Conservative party agreed to meet the £8bn investment recommended by NHS England, I found myself wondering how long it would be before some-one piped up that it wasn’t enough, or found something else we could spend even more money on. Answer: not 5 minutes. When the 2015 Cancer task force report was released, experts were popping up on my television and radio all day, welcoming the £8bn spending pledge, but stating clearly that this wouldn’t be able to meet the enormous financial challenge that this report presents. If, indeed, 30,000 cancer deaths could be prevented annually, surely this report should have been widely acknowledged as a national scandal? In fact, it was received with barely a whimper. Why? Because we are so used to incredible claims about what the NHS could be achieving. We are so used to being told that this or that will bankrupt the NHS. We are so used to demand after demand being placed on the NHS, and we are so used to the monumental failure in strategic and political leadership, that leads to the persistent culture of denial. No-one wants to say it, but our NHS cannot sustainably go on funding every last demand made of it. We can’t afford to prescribe E-cigarettes, however good they are at helping smokers to quit. We can’t keep funding an ever-growing array of options to ensure and maintain wellbeing, especially when it includes holidays and Sky TV subscriptions. In fact, difficult decisions to provide or refuse treatment are made every day by hospitals and commissioners, but without politicians of different parties and top NHS managers and clinicians explicitly offering ideas for the public to decide what the limits of NHS service provision will be, this necessary ruthless prioritisation will remain the cloaked preserve of boards and committees, and we will continue to live with an NHS that rations cancer drugs and apparently fails to save 30,000 lives a year just when it comes to cancer, but that can still find the cash for patients to have music lessons and summer houses on the taxpayer. Yes, I realise that these things might help with maintaining wellness, and it’s all very nice to do that for some-one suffering a long-term illness or disability, but even with protection of the NHS from public service cuts, we face a financial crisis. We’re not, and have never been, existing in the era of plenty. If people want these luxuries, they need to pay for them. What’s needed is a grown-up debate about the NHS, but what we get is endless denial, cracks papered over with promises of yet more money, and the vilification of anyone who dares to point out the blooming obvious, as being anti-NHS. Our almost child-like attachment to the NHS is so pervasive that I can only say this to you: don’t hold your breath, unless your NHS-funded yoga instructor tells you to, of course.