Sacred Cows

As a recent returnee to the UK after several decades of self-imposed exile, it’s impossible to avoid the daily media coverage of the state of the NHS, especially in an election year. Having worked in healthcare systems internationally, and while acknowledging that all healthcare systems are convoluted, the structure of the UK system has always appeared inordinately complex given that it is overwhelmingly single payor (more than 80% of the £280 billion spent on healthcare in 2023 was by government). The ‘simplified’ image above from 2017 gives some flavour to this intricacy (now, of course, hopelessly out of date) and begs the question as to how such unnecessary complexity was created and why it persists. There remains, nonetheless, a reluctance to publicly advocate for radical reform, in part due to the lingering, though rapidly dissipating, fondness for the NHS, and also, in part, by an unwillingness by some to jeopardise their annuity income stream from advising or supplying the NHS.  Instead, the narrative, often for political expediency, is centred around underfunding as the root of the problem. However, this is a lazy and self-serving refrain and is not borne out by the numbers. UK healthcare spend represents an ever-increasing proportion of total government expenditure (source IFG):

Moreover, real government health expenditure per capita, even on an age adjusted basis, is also on a long-term upwards trajectory (source IFG):

The key issue is that the system structure, funding, and regulation is, to use a technical term, a dog’s breakfast (I considered other adjectives, but these would have been caught by the sensor). I doubt that any lay member of the public could explain the role of any of the following in healthcare (note this is only England): NHS England, NHS Digital, NHS Regional Teams, Transformation Directorate, Academic Health Science Network, Integrated Care Partnerships, Integrated Care Boards, NHS Trusts and Foundations, Primary Care Networks, Local Authorities and, no doubt, a myriad of others missing from this list. The public interact with the health system at the coalface and have little insight behind the curtain.

What the public does see, however, is a system that is in hyper rationing mode, which translates to 1) long waiting times for many types of care and even denial of care in some instances; and 2) progressive diminution of the qualifications of staff providing care. The former consequence has had much public airing, the latter less so. For example, access to GPs is, in too many cases, woefully inadequate and leads to increased hospitalisation, yet large numbers of GP practices have closed, and newly qualified and locum GPs cannot find work as their roles are progressively usurped by lower cost, non-medically qualified staff. In the realm of physical health, the public are now experiencing what those with complex neurological illness (i.e. psychiatric illness) have been on the receiving end of for a long time – cookie cutter, superficial symptom management by non-medically qualified staff, often online.  Rest assured, however, I’m sure that there’s still a doctor or facility somewhere with a deep pocketed professional indemnity insurer that can be sued when the proverbial hits the fan.

No amount of inquiries, commissions, and reform aimed at optimising the existing system will resolve the fundamental reality. Even advocates for enhanced primary prevention have missed the mark. History has shown us globally over many decades that the public generally aren’t that interested in their health data (especially those at greatest risk) and without a highly predictive and proactive model of primary prevention, leveraging sophisticated data and marketing techniques, any initiative is doomed to fail.

The downward trajectory of the NHS, both in terms of access and quality, is, I fear, locked-in for the long-term. The likely change of government in July won’t impact the dynamic unless they throw large amounts of new money at the system. I suspect, however, that their appetite to incur significant additional debt and deficit to fund healthcare will run up against the realities of financial markets and their capacity to cannibalise other parts of the budget is equally constrained. Those believing that envy taxes on the affluent will fund the problem are as deluded as those who believed that Brexit would return rivers of gold to the NHS.  The top 10% highest earners already contribute over 60% of income tax receipts in the UK, and, ironically, a significant proportion of the affluent already pay twice for healthcare – they fund the NHS through their taxes but largely forego utilisation in favour of the private system which they fund via additional PMI premiums or self-pay.   

Social determinants of health offer no encouragement. A few random grim statistics: 1 in 5 children regularly miss school; 2.7 million adults don’t work due to long terms sickness and 9.2 million adults in total (over 1 in 5) are not looking for work; 64% of the adult population are overweight or obese. Declining educational standards, driven by long-term relegation of the importance of education, likely plays an outsized role – out of 24 nations, young adults in England (aged 16-24) rank 22nd for literacy and 21st for numeracy. England is behind Estonia, Poland, and Slovakia in both areas.

If the healthcare system is to pull itself from the progressive descent into the mire, then radical surgery to the system structure, funding, and regulation is likely the only viable escape route. In this spirit of slaughtering sacred cows, here’s a few suggestions:

1.      Data, Insights, and Action

a.      Mandate digitisation and enforce coding and interoperability standards for all healthcare IT systems such that a holistic, consistent real-time dataset is available to healthcare providers, consumers, and researcher and development.

b.      Use the data predictively and proactively at a population and individual health level. For example:

i.      Proactively identify people with gaps in care (there are thousands of gaps) and recall them proactively to close the gaps.

ii.      Predict morbidity and hospitalisation (it’s not that hard with a full data set) and address these risks via sophisticated community programmes.

iii.      Proactively identify those with chronic and complex illness and enrol them in sophisticated programmes to reduce avoidable hospitalisation.

c.      Use the data to identify and promulgate provider best practice. For example:

i.      Enable providers (individual clinicians, departments, hospitals etc.) to see their performance metrics against comparable peer groups.

ii.      Identify best practice, understand methodologies for delivering this, and incentivise best-practice providers to evangelise their methods to peer groups.

d.      Use the data to inform and develop new funding and care models and plan for service needs.

e.      Use the data to drive large scale uplift in medical and life sciences research and development for the benefit of population and economic health.

2.      Infrastructure and People

a.      Rapidly increase the number, scope, and sophistication of general practices with a doctor-led, multidisciplinary team (nursing, allied, social workers, care coordinators, case managers etc.) to focus on management of chronic illness in the community (including remote monitoring etc.). Develop specialisation (people, programmes, and systems) in the large-scale management of multimorbid illness in the community given that these patients are major consumers of healthcare.

b.      Cease building large acute general hospitals and focus instead on modality specific ambulatory surgical centres where the majority of routine elective surgery can take place on an outpatient basis (same day or short stay) with much greater efficiency and efficacy.

c.      Substantially uplift the scale and sophistication of clinical homecare services so that the vast majority of medical patients, including palliative patients, are treated at home and surgical patients can be discharged home quickly. A dedicated clinical homecare stream for psychiatric illness, integrated with outpatient and inpatient care should be constituted.

d.      Increase the acuity of existing large acute hospitals to manage the complex patients that truly need to be in such facilities.

e.      Substantially Increase clinical provision in care homes to minimise avoidable hospital transfers.

3.      System Structure, Service Delivery and Funding (this may get marginally more controversial)

a.      Privatise all healthcare delivery concurrent to implementing a well-resourced commissioning and regulatory regime. Services would be delivered by both for-profit and no-for-profit enterprise. There is no rationale for government to deliver services and incur the infrastructure costs as long as commissioning of services and enforcement of compliance is sufficiently sophisticated.

b.      Transition to value-based models of purchasing services where providers are incentivised for population outcomes, experience, and efficiency rather than block funding or activity volume funding. Concurrently, link total healthcare funding to economic prosperity (e.g. via a dedicated payroll tax) such that the system and its participants have to adjust to the total funding pool available.

c.      Heavily incentivise the uptake of PMI by employers and consumers and transition the PMI system from risk rated to community rated, eliminating pre-authorisation and blanket exclusions for pre-existing conditions. This should remediate the deficit in PMI penetration in the UK and take pressure off of the NHS. Concurrently mandate minimum loss ratios (e.g. 80%) to ensure greater PMI product value.

Alternatively, we could just continue with the current model which appears to consist of perpetual reviews and commissions led by esteemed industry veterans, white papers, strategic plans, major transformation initiatives, and persistent decline.