How responsive to patient’s needs and expectations does the NHS need to be?
This may seem an odd question because surely the answer must be very, very responsive, but as we shall see a part of the policy and politics of the NHS for the last 60 years has shown that the answer to that question has not been that simple.
The policy story so far.
The Government is trying to bifurcate the debate into saying that you are either in favour of their reforms or you must be in favour of the status quo. Those are obviously not the only choices, but if you believe in different reforms it is obviously important to develop a different way forward for them, and to work them out in some detail.
Over the next 6 months I want to start this process by asking a series of questions (around 10?) that all NHS reform programmes need to answer. I am starting with the questions because, as someone deeply involved in the policy and practice of NHS reform for the last 10 years, I of course have some opinions about the answers. But because my answers have been worked out in the first decade of the century they may not be the right ones for 2020.
So what I am trying to do, by June, is to try and get some agreement on what questions NHS reform should be answering by 2020.
The governing framework for this is that the questions and the answers must be within the parameters of NHS values.
In 2020 I want a health care system that works for that decade and is within the funding and access principles of the NHS as it is constituted at the moment. Paid for out of national taxation with equal access for all, free at the point of need. At the last election the future of the NHS was secured because the biggest proportion of the population ever agreed with those principles. This strong majority agreement makes the NHS politically untouchable and that was one of New Labour’s main achievements.
But who can say where the public will be in 9 years time? In the election after next some parts of the population may be detached from those values. I would argue for a reform policy that would further secure most of the population’s approval. To do that the NHS is going to have to demonstrate that it can not only meet the needs of those that believe in equality but can also meet the needs that patients and medical staff have of other aspects of a modern health system.
My first post in this series concerned the question of how any system ensures that health services keep up with the intense innovation that is likely to happen over the next decade. It’s no good innovation happening in one part of the system and not pervading the entire NHS. So we need a reformed NHS that pulls medical innovation into every part of the system.
This post asks a different question and concerns the importance of meeting the public expectations of how a health system should treat them, the patients and the public.
All of these questions will need answers which demonstrate that a system funded through general taxation can at least equal if not surpass other systems in how it treats patients.
Other health systems may work well with patients because patients can buy better customer care with extra cash. In a whole range of aspects of life we are used to judging between different providers of goods and service depending on how they treat us. How does a system based on NHS values provide the same relationship with patients?
Even quite progressive people question whether this is something that the NHS should aim for. Throughout the first decade of this century when New Labour argued that the NHS should be able to meet rising public expectations of how they should be treated there were those who felt that this was the wrong question.
One of the reasons that public expectations of public services have risen is because of a range of new private sector experiences of consumption. And, the argument goes, since those experiences of being treated better as an individual had been led by the middle class then some would argue that the NHS seeking parity with middle class experience of private sector services is the wrong thing to aim for.
Indeed I remember in 2002/3, when waiting times were falling, a number of people were saying that it was just not possible to meet rising expectations in a public service. The public had to get used to the idea that they could not have the same expectations for public as well as private services.
For those of us who want to maintain the basic principles of the NHS this is dangerous stuff. Because if we ever simply believe that public service cannot ever compete with the way in which private service offers responsiveness then sooner rather than later the public will move decidedly away from the public service to the private one. What used to be thought of as “middle class flight” would involve all classes that could afford an alternative.
For a few on the far left, the argument went beyond this. The very idea of treating people as individual customers was wrong. If we treated people as individuals it would automatically favour the middle class who were in some way “better” at being individuals than the working class.
Many people who live in the real world find this sort of argument just plain barmy as it so demeans working people. But there are important ideological points within the political argument so let’s examine them.
There are those on the left who feel that individual experiences are in some way less valid than collective ones. (Although I must say snidely that most of the people who think this have good jobs, second degrees and own their own houses). But for me one of the main aims of progressive politics has been to ensure that working people can live better lives for themselves and their families.
Some of this progress has come from collective work. People band together in political parties, trades unions and community groups and change the political environment around them. But most of the progress that people make for themselves and their families comes from individuals and their families working harder to earn more and to improve themselves. Workers went to what used to be called “night classes” and are now usually OU courses and worked hard to get on after they finished their day job.
Of course if you have a bit more money and a bit more education it is easier to get on, but progress for working people has only happened because people have bent their intellectual back and got on.
It is true that a lot of the experience of being treated well as a consumer has come from the private sector. (Although of course this is not universal. Many people did buy services from bad private sector organisations and found they were not well treated). It is also the case that middle class people had those experiences first of all.
But one of the successes of progress is that more and more people who do not have as much money now expect to be treated well as consumers. People who buy holidays from cheap travel agents feel that the travel agents can’t treat them in a certain way or they will move to a different travel agent. That still works whether you have a lot of money or a little.
Rising real wage rates has changed the way in which large sections of the population now experience being treated by organisations that sell products. And they use that experience to judge both private and public sectors.
In the last year a variety of patients have said exactly the same thing to me “If my hairdresser can text me to remind me of an appointment, why can’t my doctor?”.
Two provisos here. The first (and thank goodness) is that some parts of the NHS do text you to remind you of your appointment. But not many. Second, why does this matter? The hairdresser is reminding you because they value your custom, and people feel, if only a little bit, valued. It matters because people feel that this is a normal part of what they expect as service. They feel that this is treating them with respect and allowing them to run their lives in an easier way.
The NHS as a whole system, needs to learn that all communication systems, phones, texting, emails and web sites are not one-way methods of communication but two-way.
This may seem a little thing. But actually it is a necessary prerequisite for the revolutionary change that health systems must make if they are to survive. Unless by 2020 the NHS recognises that patients have the potential to add most of the value to their health care that at the moment is the monopoly of medical staff, their kit and drugs, then the NHS will go bust. If we want to unlock the potential of patients adding value to their health care then the health system has to fully involve them in all aspects of that service.
The economics of health care in 2020 demands that patients are fully involved in choosing it. This calls for extensive two-way conversations and involvement. It calls not just for meeting rising public expectations, but for them to be exceeded and led forward.