NHS birthday badgeOn 5th July 1948 the NHS was born. That means in a couple of months this grand old lady will be 70 years old. At an age when most people would be retired and enjoying life at a relaxed pace she is having to work harder and harder than ever before.  More and more is expected from more and more people with restricted resources. She is definitely experiencing some health problems of her very own. It all makes you wonder:

What is the life expectancy of an NHS?

Although no-one knows the answer to this question, many commentators openly speculate. But no-one has ever had a patient like this and certainly not one with these symptoms – or have they?

Let’s go back to the start.  The NHS had a very difficult birth. Though it may be surprising to hear, not every doctor was on her side and would have preferred to ‘let nature take its course’. Dr Alfred Cox, a former Medical Secretary of the BMA, has gained a degree of historical notoriety from his assertion in 1946 that the plan to develop the NHS was “like the first step, and a big one, towards National Socialism as practiced in Germany.” He went on to liken Nye Bevan, who was championing the cause, to a “medical fuhrer” who would “strike down doctors’ cherished professional independence.” If the NHS is often treated like a political football in the present day then it is apparent that this is not a new phenomena.

Much of the current woes arise from the challenges in financing the service. Again this is nothing new. As far back as 1951, with the NHS struggling past its infancy, Prime Minister Clement Atlee proposed the introduction of prescription charges to address the monetary problems. Although this led directly to the collapse of his Government, these charges came into effect the following year. So, as well as being a political football, the NHS has been in financial troubles throughout her entire life.

What’s the simple answer?

If only there was one.  Publicly funded healthcare is incredibly complex. There are multiple challenges. Unfortunately, when faced with such complexity any small action can appear futile or simplistic and we become hopeless. It’s easy to get trapped in an increasingly negative downward spiral.

Much of the time, the debate around finding a solution is focused on financing.  We all want the best care we can receive but how much are we as a society and individuals prepared to give up to fund the NHS? That can lead to a 2-dimensional debate. It helps to balance this with a third dimension – controlling costs. Discussions on controlling costs can easily be lost in accusations of simplistic cost-cutting, being unrealistic or unfair. Yet we are regularly confronted with tangible examples.

Marginal gains

The most recent edition of the BMJ (361:127-168 No 8151) leads with the cover headline, “Emollients for childhood eczema: money down the drain?” which questions the benefits of emollient bath additives. Relevance of continued provision of this treatment is now being hotly debated – expect a strong counter argument by the pharmaceutical suppliers.  But even if a proportion of the £23.1 million being spent on its supply can be saved without any impact then this would appear to be a small step in the right direction.  The idea that “there is no such thing as an insignificant improvement” leads to the concept of the aggregation of marginal gains.

There are others. Lord Carter’s 2016 review into ‘unwarranted variations’ made the bold claim that £5bn could be saved in England alone by addressing long standing poor practice in relation to running costs, absence, infection rates and supplier costs. Little surprise then than current focus within the NHS includes staff well-being and sepsis. Further savings may be possible by really looking into the subject of defensive practice with the related unnecessary investigations and appointments.

Not that any of this is easy. For example, a common point of discussion during our Advanced Patient Communication Skills Course is how to deal with the demanding patient.  You will be familiar with constant pressures for procedures, anti-depressants, antibiotics or an equivalent from your personal discipline. GPs and dermatologists are likely to face similar pressures from parents who fear what reaction will occur from ceasing emollient bath additives.  They may well perceive it as a cut in the level of care they are receiving. Education is an essential part of any change.

The problem with the marginal gains idea

Every little instance of waste being halted contributes to the aggregation of marginal gains. Will it be enough to save the NHS? Probably not. It’s easy to imagine the NHS always existed. Yet she’s only 70 years old. And just like any old lady that we love, it’s hard to imagine here no longer being with us. But its possible this that could turn out to be another example of the circle of life?

The ultimate end point for the accumulation of marginal gains is easier to predict.  You eventually reach the peak of the mountain with nowhere to go. So it can only ever be a part of the answer. Will we ever be able to make the transformational leap to a different mountain and a new system? Possibly. But until we know what that mountain looks like, there are many marginal gains for us to be getting on with.

Stephen McGuire – Head of Development