The Manifesto Project: Fixing the British health system

Between an excursion to London for a New Culture Forum meeting, and chronic summer insomnia, I’ve not had much writing time this week. I’ve spent it looking into health related matters. This isn’t really my field so I’m fumbling in the dark, but that’s why I’m publishing extracts. I’ve had some enormously helpful feedback on other issues. The manifesto is shaping up nicely now. I’m up to eighty pages and thirty thousand words.

Health and its related subject areas could probably do with a manifesto of its own, preferably written by more knowledgeable people than me, but one of the themes of this manifesto, where others fear to tread, is that Britain must face up to some hard choices - one of which is that Britain cannot sustain a fully comprehensive free health service which is open to all comers. Something has to give.

As yet, I haven’t nailed down a structure for this section, and it’s difficult since there are so many interrelated issues, spanning multiple concerns. I’m probably not over the target yet but here goes…

Health

For political purposes, virtually all parties will declare that the NHS is fundamentally broken. But this is wholly self-serving. The NHS is a huge organisation. Much of it works after a fashion, and some of it works very well indeed. What is needed is a mechanism for improving the worst bits, to bring them up to the standard of the best. The very last thing the NHS needs is another disruptive restructure. Persistent political meddling is part of the problem.

What we need to do is break out from the "reform - failure - reform" doom loop, and put effective system monitoring in place, on the ground, so that weaknesses can be picked up early, and tweaks devised, without burdening the system with a progression of disruptive reforms. The key policy element, therefore, is to devise a monitoring and self-correction mechanism which allows for a regime of continuous improvement, without the disruption of the doom cycle.

The popular narrative has it that the NHS has too many managers and administrators. But without effective management and administration the entire system would rapidly collapse, and doctors would spend even more time on administration. We would agree that too much back office time is devoted to political agendas such as DEI and climate, while lapses in front line administration can be fatal.

The reason is as much to do with the fact that Whitehall has too much of a role in determining how hospitals should be managed, demanding ever more elaborate and costly reporting, often on  issues unrelated to health. While data gathering and public health surveillance is important to improving health outcomes, much of it is intrusive and pointless. We will order a comprehensive review.  

In terms of care delivery, we note that care is often treated separately to treatment, when in fact, they are one and the same. What’s needed is a long term plan which recognises that large, centralised hospitals are bad for patient recovery, and are difficult and expensive to maintain and clean. They are as likely to cause illnesses as cure them.

Usually, the best recovery space is in the home. Our policy will be to restore healthcare to the district level. Many regions are served by one or two large hospitals, often far away from where people live. A journey across a UK city can take at least an hour by car, incurring parking costs, and longer by public transport. We must return to the model of district hospitals and specialist clinics, geared for care in the home, with improved interoperability between organisations.

There has been a consistent tendency in UK policy to create new joint committees and governance arrangements across health and social care in hopes that more collaborative service delivery would naturally follow. They have been insufficient to address the culture, norms, systems and processes needed to support integrated ways of working and fundamentally change the way services operate. We favour a Royal Commission to investigate what was actually happening on the ground, and where the system continues to fail, then reporting back with recommendations for improvement.

We note that discharging people from hospital is one area where a disparity in funds between hospitals and other services can cause major problems. Across the UK, discharging people in a timely manner and to the right place continues to be a major problem, and depends on the smooth running of community hospitals, care homes, and domiciliary care.

Pressure on services outside hospitals is harder to measure but also substantial. Large numbers of patients experiencing delayed discharges from hospital is a sign of limited capacity in social care and other community-based services to support people when they leave hospital.

On an average day in July 2023, nearly 12,000 acute hospital beds – out of a total bed stock of around 100,000 in England – were occupied by patients who no longer had a medical need to be in acute care but could not be discharged home or elsewhere (though the majority of delays are likely to be attributable to the NHS, for instance due to difficulties arranging NHS rehabilitation support, rather than social care services). 52 In June 2023, an estimated 992,189 people – children and adults – were waiting for community health services in England, such as community nursing and intermediate care.

Meanwhile, the care home sector is a mess. It is contingent on cutting every corner, exploiting low wage foreign labour, and the sector has become a backdoor for immigrants and their dependents. The Party will close this visa scheme and end the reliance on foreign labour. This has come about because we ceased to recognise care work as skilled work. We must restore care work as a valid career path with structured career progression.

To that end, we propose a system of tied district housing for care nurses to live in the locality, with a view to improving retention and promoting long service. Service amounting to ten years will be rewarded with a discounted right to buy. The intention here is that care patients know their carers by name, and over the long term. They will be part of the community.

This will be contingent on a basic paramedic qualification, and for this we expect maximum out of hours flexibility so they may be a named first responder for patients in their care, dispatched at the same time as an ambulance, so as to guarantee emergency assistance within a reasonable timeframe. The aim of this policy is to make care an attractive proposition with genuine career avenues and scope for personal development. We will make some skills transferrable so that care professionals can move easily into professional nursing. 

Though coming nowhere close to dealing with the problems, we commend the SDP’s suggestion of a public volunteer service for old age care. Those over 65 who volunteer for front line roles in the public aged care sector will receive credits toward the costs of their own aged care, at the rate of £10,000 for each year of full-time service. In effect, this will reduce the upper limit on costs a person can be asked to pay toward his or her social care under the October 2023 cap. Families who accommodate a parent over 80 years old in the same dwelling will be entitled to deduct 100% of the cost of state-funded aged care services from taxation.

General Practice

Overcrowding in casualty departments has long been a symptom of the dysfunctionality in local general practice medicine. There is no good reason why GP practices should not be available at most times in the day, and would improve health provision for busy full time workers if they were.

The Party believes that health provision overall should be based, where possible, in the community, and that long treks across town to large central hospitals are a failure of public policy. We favour district hospitals, but also multifunctional general practice clinics which are equipped to take low urgency cases out of casualty departments.

If a modern GP practices can operate 8am-5pm, then they can operate 7am until 11pm. It's just a matter of resourcing, which can be arranged if non critical workload is taken out of A&E. We need this because there are many good reasons why some people aren't able to go see a GP in work hours, and leave treatable conditions until they are acute, and must go to A&E.

The model we propose is something halfway between a walk-in clinic and minor injuries unit attached to a GP practice, with the emphasis on keeping most non-critical medicine at the district level with integrated care.

With more strict A&E admissions criteria, we can take the workload away from large hospitals, which aren't the best environment for recovery anyway. Policy in the last three decades has focussed on building large, centralised regional hospitals, a long way from where people actually live, and with no health provision in the community at times when they're likely to get sick, they have no choice but to use A&E, often for non-critical ailments.

As we outline elsewhere in this document, the Party is concerned by the service’s reliance on foreign doctors, many of whom lack the cultural empathy and language skills to build effective relationships with patients. We will work to curtail the use of foreign doctors and use mystery shopper inspection techniques to detect bad practices.   

The service also suffers from ever-increasing demand from foreign nationals. The NHS is a national health service not an international health service. It is open to widespread abuse by non-UK citizens. Our message is simple. Foreigners will be charged for using the NHS. Non-payment results in removal.

Health Recruitment and Retention

The “Conservative” government removed the Resident Labour Market Test (RLMT) for doctors in 2019, leading to an explosion in the number of foreign doctors joining the NHS, and an exponential rise in competition ratios for speciality training.

Britain is now a complete outlier in terms of not giving priority to its own graduates for training posts. Australia, Canada, New Zealand etc. all prioritise their own doctors for training, and foreign doctors have to do a certain about of service before being eligible to apply.

Britain trains only half the number of doctors that it needs, meaning that the country relies on attracting doctors trained abroad, largely from Africa and South Asia. It should be noted that foreign-trained doctors are more than twice as likely to be referred to the GMC as unfit to practice – often for sexual misconduct.

It has suited the British medical profession to keep in place a system that maintains a hierarchy between native and overseas-trained doctors. We are turning away too many well-qualified 18-year-olds from medical school for every one we take. Medical schools need more places available so that they can accept and train more students on foundation programmes and specialty training places.

Nurse recruitment

Before university-based nursing degrees in 1986 students did not pay student fees.  The health service paid student nurses a minimum salary and accommodation was available at a reasonable cost. Tuition was provided by specialist nurses on site and students had practical placements for 3 months  in various settings providing them with the opportunity to implement training, clinical skills and care for patients, residents and individuals needing their care skills. Resulting in a qualification as a State Registered Nurse or a State Enrolled Nurse.  Students had to pass end of year exams, hospital final, and a final exam.

To qualify as a State Registered Nurse, students completed a 3-year course.  The entry criteria being ‘O’ levels and an interview in the 1980’s. The qualification included management. Qualified State Registered Nurses had to prove competence and pay to retain registration.

To qualify as State Enrolled Nurses, students completed a 2-year course.  The entry criteria being ‘O’ levels and an interview in the 1980’s. This training fitted easily into most lifestyles and family commitments.

Today good vocational nursing staff reach a point in their careers where to progress they must join the administration. In light of that, we will review pay and career trajectories to ensure nursing experience and expertise stays on the wards.

We will re-introduce past training methods for nursing staff. 

• The Party will remove the current requirement for a nursing degree although this would remain an option.

• The Party will re-introduce State Registered Nurses (SRNs), their training will be tailored to individual career goals.

• The Party will re-introduce State Enrolled Nurses (SENs) and create a 1-year foundation care course which could be a basic qualification for care.

• The Party will ensure that student nurses become part of the workforce in hospitals and other care settings.

• The Party will create a nurse apprenticeship scheme

Covid aftermath

Public opinion is sharply divided on Covid lockdowns. There are many nuanced positions. We are not persuaded by the case for lengthy and expensive public enquiries, which in any case will be disputed and disregarded by those who don’t like the findings. We do, however, see the utility in a national readiness programme, establishing a commission to author a new comprehensive pandemic response plan for novel viruses, with an emphasis on avoiding lockdowns.   

Health, Care & Welfare funding reform

Just about every area of government necessary for a functioning society is basically under-resourced and stretched beyond its ability to cope. The stark truth that few want to face up to is that Britain simply cannot sustain a comprehensive welfare state, especially when we're importing the world's sub-literate peasantry. Even with mass deportations, the choice is a welfare state or a functioning state. You simply cannot have both. Politicians end up diverting money to whoever squeals the loudest even if that means letting criminals out early and leaving the roads to crumble.

As such, something has to give. Some aspects of the welfare state will have to revert to being a basic means-tested safety net. Health is one area where demands on the system are unrealistic for universal provision. There is an ever widening spectrum of ailments and conditions, not all of which can be addressed by the NHS.

As such, the scope of the NHS will have to be narrowed to general practice medicine and complex treatments. Routine treatments such as hip replacements and heart operations can and should be outsourced to private clinics, with care configured for home recovery.

In terms of funding, we need to restore National Insurance as genuine insurance system, administered separately from other treasury concerns. We would then look to phase it out over the long term.

It is our intention to encourage the trend of patients seeking their own healthcare avenues. To that end, policy will promote the growth of friendly societies. Friendly Societies were voluntary co-operatives, usually based locally, which at one point covered about half of the country—but they were growing swiftly. Their potential was, alas, killed by the National Insurance Act of 1911 and the onset of state welfare provision.

Most societies allowed their members to choose their level of pay-in; how much was paid out was determined by numerous factors, but criteria usually included how much you had paid in, how long you had been a member and your actual need.

Friendly Societies would, of course, also provide competition for the big insurance companies, thus helping to guard against a leap from state dependence to corporatism. Or, of course, Friendly Societies might choose to re-insure their deposits with the said companies. As such, Friendly Societies would provide an assurance-insurance framework that the vast majority of people could access; where they did not currently exist, commercial insurance companies would fill in the gaps.

We would than look at means-tested match funding by the state for individuals on lower incomes or with more complex health needs. Obviously, Friendly Societies would not pay out to those who have not paid in. As such, private charity would be the welfare option solely for those who have no other option at all. This is a welfare scope that private charities (state assisted if needs be) could easily deal with.

Dentists

The overstretch we see in NHS dentistry is a result of too many people wanting something of value for free.  It doesn’t work and it never will when there is no constraint on demand. Much of the burden is remedied by removing any entitlement from immigrants. But why stop there?

Basic private dental care is now highly affordable for most working families. The delays and difficulties obtaining appointments are barely an issue for private patients. Dentistry is one of the slam-dunk cases for free markets and customer choice. There is no good reason why the dentistry sector should not be fully private.

We do, however, appreciate the need for support for low income families and pensioners. The Party will establish a means-tested e-voucher system redeemable at any private practice. The model works for basic optometry and there’s no reason why it should not apply to dentistry. Teaching hospitals in major cities will maintain free walk-in dental clinics for emergency treatments on a first come, first serve basis.

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This is not by any means exhaustive, but I’m hoping it’s enough to start a wider debate. If I’m completely wide of the mark, please chime in.

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