One thought on “Healthcare in the United Kingdom

  1. So much good sense from so many respondents. The ojcibteve is widely shared of a good hospital, reasonably close, in a national service sharing best practice’. Even to think of the service we all wish’ is to think of democratic expression. We may thank the Coalition proposal for raising the fundamental choice to be made between democracy and variants of human husbandry’. As a retired doctor, also a patient and a relative, I welcomed the promise of the Health and Social Care Bill 2011, at first sight the liberation’ of all to ensure equity’ and excellence’, within a reformed system of Health and Social Care, preserving the 1948 NHS principle of treatment free at the point of need’.Unfortunately, definition was lacking as to the meaning of principal terms:1. The liberation’ intended is for competition, in pursuit of profit, leaving quality to be defended by regulation’ rather than advanced by secure conscience and free communication.2. The promised equity’ in care will continue to be as far as might be deserved’, inequality of access left to be dictated by inequality of political power or insurance cover, poverty left as deserved and to be only palliated by state or private charity.3. The hoped-for excellence’, serving the top end of a market with unequal access, might easily be both exclusive and precarious in its isolation, and its impact on national statistics might be overwhelmed by a long tail of poorer performance, emulating the United States in value-for-money failure.Many have drawn attention to the downstream semantic deficiencies of the Bill and of the Listening exercise. We are invited to comment on four groups of questions, in areas sensibly to be addressed only alongside each other:1. With respect to the leading question, how can we best ensure that competition and patient choice drives NHS improvement’, we should rather be asking what steps must be taken to liberate inventiveness and care and funding as appropriate to democratic ambition?’ At present we can only guess at the dimensions of patient choice’ that in a democratic society might be thought worth the bureaucracy’: given equality in the market’ we might wish to choose our surgeon, priority in non-urgent procedures, the latest of room facilities, etc. In a democracy the essentials of health care would not be delivered in a levelled playing field’ for the material elevation of doctors or managers or share-holders. Even if, in a democratic society, global and sectional healthcare budgets were adequate, competition would play a part in the allocation of funds for individual training, for particular research projects, for service developments, for new sites, etc. Healthy competition would be on merit, for society, not tainted by fear or greed possessing concerned individuals. We do not have to choose between systems half-understood in America or Europe, or in recent party propositions: we can choose democratic liberation.2. With respect to the vital question how can we make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making’, we might trust to luck (!), to political salesmanship (and luck!), to simple humanity (our care for the unfortunate, and luck!), to humanity expressed through inherited belief systems (injunctions to care, and luck!), or to the social contract offered by democracy. A democratic society might make mistakes, but it will tend to make its own luck’, to afford what is wanted and what is deserved, by the agreement and contribution of all. If we give up income inequality (to give and not to count the cost), and set a savings maximum at a reasonable level (my cup runneth over), we will free ourselves from fear and greed, enabling trust and liberating conscience. We need openness rather than transparency’ (having to watch out and seeing through’ each other’s dastardly schemes), and rational trust rather than accountability’ (having to defend or hide the hardly defensible). GP-led Commissioning, set-up out-with democracy, cannot emulate democracy: no mote than could PCTs working to equality agendas’ in recent years. Including the voices of other health professionals, patient representatives and politicians, and replicating much of past structural complexity, will quid soon be found essential in preserving or in re-creating the creaky NHS of today. The current proposal appears set up to allow a shake-down to a system of local private NHS-franchise-holders, sized for viability (comparable to PCTs), and like PCTs offering competition or co-operation according to population geography. Adopted as proposed, much bathwater and a few babies will no doubt be thrown out, much more of financial bureaucracy will no doubt be added, and the transition costs (financial and human) might alongside other looming problems within months or a very few years precipitate final demand for democracy.3. With respect to the linked questions, how can we ensure that advice and leadership from NHS staff themselves on improving services and tackling patient needs are at the heart of the health service’, and what more could we do to ensure that commissioners collaborate to fit around the lives of patients and carers, and the particular circumstances of certain conditions’, let there be freedom of movement of people towards worthwhile work, and freedom of voice to attract funding towards worthwhile work, no personal financial advantages and fears to corrupt, just the joy of the worthwhile and the ever better. In all of the scandals that over decades have continued to emerge, in our NHS’ as elsewhere, someone knew’ or had concerns. Our great need is for the liberation of all, making all representative of all. Only income equality can deliver the security required for universal freedom of conscience. The logic has to be faced every labourer treated as worthy of hire if we are to enjoy the fruits of democracy, an end to the rush to use up the Earth, a future of not hundreds but millions or billions of years.4. With respect to the question how can we make sure that NHS staff in the future have the right skills to meet changing patient needs’, the need is to respond to demand, and if possible anticipate both increase and decrease in demand, erring on the side of over-provision, trusting in the good sense of trainers and trainees, all aiming for careers of service’ rather than careers of shelter or financial advantage’. There is scope for far more cross-fertilisation of ideas and practices, with earlier recognition of need to adapt, or focus more narrowly, or move on, unimpeded by personal and family financial considerations. Strategic planning will always be difficult, more so with commercial secrecy. Past arrangements were poor, the current I am not involved with, the proposed will have to be proved in a context of chaos, I would guess leading to greater variation in quality, increased emigration, and even greater reliance on imported labour with attendant difficulties of integration here and of loss from countries of origin. Until we have genuine democratic government all free to represent all we can only guess what systems of care and investment a democratic society would choose. Until we have such a democratic context, it must be the responsibility of pro-democratic governments both to lead towards democracy and to frame legislation as far as possible as if for a democratic society.We live in a society that has worked and fought for democracy. If a democratic future is wished, then each generation must educate the next to that end. In the spirit of Benjamin Disraeli, truly to educate our masters’ we must show willingness to educate ourselves. As a start we need to have a shared language, recognising ambiguities and clarifying central intents in the use of words, aiming for sharable understanding based on a logical sequence of value choices. I would commend the prime choices of faith in the worth of caring, and trust in the wisdom of genuine democracy, not to officiously strive’ but to give care to others’ as we would wish for ourselves.The Coalition has to deal with the world of today, but we all today could affirm our choice for a democratic future, taking account of life’s trials and seeking to reform the NHS as if for all, for patients and relatives and staff and society as a whole.

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