Health & Social Care – Analysis

Wellness in Wessex – a scan

Health tourism, at spas and seaside resorts, has been a feature of the Wessex economy for centuries.  The Romans were hardly the first to exploit the waters at Bath.  The Bristol Royal Infirmary (1735), the Royal Hampshire County Hospital (1736) and the Royal Devon & Exeter Hospital (1743) were among the earliest modern hospitals in England outside London.  Vaccination is credited to both Benjamin Jesty in Dorset and Edward Jenner in Gloucestershire: either way a win for Wessex that went worldwide.  Aneurin Bevan, architect of the NHS, drew on the experience of community organisations in the Welsh mining valleys but also acknowledged those that had arisen in our region, stating of the GWR Medical Fund Hospital at Swindon that: “There it was, a complete health service.  All we had to do was expand it to embrace the whole country!”  Today, Oxford University is one of the world’s leading centres for medical research, and Wessex is home to some significant specialist facilities of national importance, including Broadmoor Hospital in Berkshire and Porton Down in Wiltshire.

Wessex does not have a large legacy of heavy industry, which in other regions has left many former workers in poor health.  We do though have a large retired population, whose care is a significant element in local authority budgets. 

Population growth places sustained pressure on health facilities: GP appointments, hospital beds, and ambulance response times.  The London parties support growth but will not commit to providing the associated infrastructure.  Health facilities are not included in the developer contributions made to local authorities; spending on them is dependent on Whitehall.  Any provision therefore is reactive, so we run to stand still.  Only WR opposes population growth; this policy would enable us to catch up and eventually enable services to improve.

Health care in rural areas is a particular concern for WR.  We do not necessarily oppose centralisation, especially where the benefit for patients is clear.  As Bevan put it, “There is a tendency in some quarters to defend the very small hospital on the ground of its localism and intimacy, and for other rather imponderable reasons of that sort, but everybody knows today that if a hospital is to be efficient it must provide a number of specialised services.  Although I am not myself a devotee of bigness for bigness sake, I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.” There has been a trend towards larger GP practices, also described as polyclinics, able to provide a wider range of services, up to and including day surgery.  We see this as a better outcome than either unnecessary centralisation at district general hospitals or the continuation of small village surgeries where that represents a poor use of professional staff time.  Research suggests though that there is no one-size-fits-all approach and polyclinics may operate better in some areas as a hub-and-spoke model.  We support options such as online consultations and postal delivery of prescriptions that help to mitigate the remoteness of life in some parts of Wessex.

Refreshing the vision

The NHS was planned to be comprehensive, but today’s service falls short.  Dentists, opticians, and pharmacists are examples of health-related professions that operate largely outside it.  In England, prescriptions are no longer automatically free, though they are in Scotland, Wales and Northern Ireland.  We envisage a Health & Social Care Service that restores the ‘cradle to grave’ principle.  There is no reason why a rich country cannot afford it.  No additional cost to society is incurred, for example, by making prescriptions free: the cost moves from the patient to the taxpayer and a lot of paperwork is saved.  Exemptions already mean that, in 2016, 89% of prescriptions in England were dispensed free of charge.

We see no public benefit in private sector involvement in NHS management.  Private hospitals outside the public sector duplicate public provision, or enable it to be run down to unsafe levels, and should not be supported.

Health and social care in Wessex would be fully devolved, as they are in Scotland, Wales and Northern Ireland.  In Northern Ireland, the two aspects have been managed since 1948 as a unified service, sometimes referred to as the ‘NHS’, though the official name is Health & Social Care (HSC).  In 2014, Scotland began to introduce a formal integrated system that makes health boards and local councils jointly accountable for delivering the nationally agreed outcomes in their areas.  We envisage a Wessex service working closely with its neighbours on cross-boundary issues, with ambulances for example being directed to the nearest available hospital and any financial consequences tallied later.  A Wessex health administration would work with all UK administrations on issues of common interest, such as biosecurity, bulk purchasing, and data management.  Infection knows no borders and frequent co-operation at European and global levels would also be required.

The NHS has operated through a series of regional organisations from its inception.  These have included the Wessex Regional Hospital Board (1959-1974) and the Wessex Regional Health Authority (1974-1994), though neither served the whole of Wessex.  Their experience indicates the specialisms that have tended to be managed at regional level, including blood donation, capital expenditure planning, staffing matters, and latterly the ambulance service.  In 1945, Bevan anticipated that health regions could be subsumed into elected regional governments at some future date.  Whereas the Wales health region has indeed become part of a devolved structure, the NHS in the English regions has become both fragmented in some respects and over-centralised in others.

Hospital catchments do not match well with local government boundaries and so it is likely that hospitals or groups of hospitals will need to continue as independent organisations.  These should be accountable to the community served; they should not be run as businesses, aloof from users.  They should be structured so that the community, not central or regional government ministers, is responsible for the appointment and dismissal of management.  Parking charges have been largely abolished at hospitals in Scotland and Wales and we would expect the same for Wessex. 

Because bed-blocking is the key issue requiring better co-ordination, we see hospital management as including responsibility for ‘downstream’ care, such as convalescent units, and liaison with those managing long-term care for the elderly and disabled.  The ‘Integrated Care System’ partnerships that have been introduced in England are a step in this direction but continue to blur accountability.  More ambitious change is needed.  Northern Ireland’s experience of a unified structure is that significant institutional barriers remain, with too much focus still on hospital-based care.  Continuous criticism is therefore needed to ensure best practice.  In Northern Ireland, while health services are free, social care is means-tested.  Any kind of means-testing is socially inefficient, requiring paperwork, money-chasing and awkward cases at the margins.  Where independent living is demonstrably no longer an option, people should be admissible to long-term social care, free of charge, just as they would be admissible to hospital in a crisis.  That is the implication of a fully integrated system.  However, this principle needs to be paid for and funding assigned to regions fairly.  If someone has lived in London or Birmingham, for example, throughout their working life, then a suitable amount of public money should be transferred to Wessex government funds if they retire here.

Primary care provision is likely to be a better fit for local government.  In pursuit of our aim of community-building, we would wish to see GP surgeries or health centres serving the same areas as secondary schools, libraries and other local services.  Although the public investment in local health facilities is often considerable, the 1940s model of GPs as independent contractors remains essentially the same.  That model is less attractive than it was, leaving general practice open to corporate takeover.  To provide a better alternative, GPs should be salaried employees, like all other public sector professionals.  The contractor model also makes the development of polyclinics less effective.  Pharmacies should be fully integrated into local health facilities, so that prescriptions issued electronically from the doctor’s desk can be ready for collection on leaving the building.

Every little helps

The ‘social determinants of health’ include income, education, employment and travel conditions, housing, residential environment, crime, traffic, and early years.  Health Impact Assessment is a useful tool that should be applied to all new policies to ensure that health outcomes are improved as a result, or at least are not worsened.  For example, mental health issues with no organic cause may be better treated by reducing the demand for services than by increasing the supply: less precarity, not more psychiatry.  Our goal is to see NHS spending decline, every year, but for the best reason.  Not because society is too mean to fund what is needed but because the need itself is in decline.  However, health care will still need to exist; alternative approaches must show that they deliver real improvements and are not simply a distraction or a drive for false economies.