We are coming up for elections in the UK and the National Health Service (NHS) is always on the political agenda. However, nobody has the real discussion. They get bogged down in waiting lists and costs and rationing. But none of us has really decided what the NHS is and what we want. We confuse medicine and health and we put them into a strange administrative stricture called ‘business’.
We have taken on a ‘business model’ for health and health provision. (We have taken on a business model for everything it seems and money is the root of all decisions rather than what it is that we want; our values and aspirations). This business model has probably come from the USA where health is a very big, private business with large vested interests that want to keep it that way.
In a naïve, at best, and daft, at worst, way we have fallen for this model while having an NHS which was set up with a completely different, and in many peoples’ mind better, aspirations. We are in danger of losing the NHS. I have nothing against business. I have a lot against turning everything into currency. You know the definition of a cynic: ‘a person that knows the cost of everything and the value of nothing’. I do not want health to become a mere cost, rather than a true value.
Let me explain what I think business is for those who spend years and lots of money doing business degrees and ending up as Business Administrators- which is not the same as being a business man or woman.
Business has one model really:
In other words, business is about making a profit. It of course looks at getting customers in to spend their money and be loyal to your brand, but the real ethos is, buy cheap, sell dear.
Point number 1: For the NHS to take on this model is deeply and profoundly stupid. The NHS is not set up to make a profit. It is about curing people of an illness (the medical model). That is what it was set up to do: treat people.
The NHS is not free. All the people that work in it are paid. It is given money by the tax-payer to do that. It is a good use of taxes. Those people that are paid to work in the NHS then in turn pay their taxes.
There is a problem in that the NHS is generally used by people who do not pay taxes: children and older people, but the families of the children and the older people themselves have paid taxes into the system. In fact, there is a separate tax for Health and Welfare called National Insurance. The major problem with all British Governments is that they do not ring-fence that money and use it for the purpose it was set up for. It has become just another form of tax, when in fact it is meant to be a public insurance for health care.
Point number 2: The whole point of hospitals and doctors is to repair you and hope you don’t come back. The one thing the NHS doesn’t want is customers. It does not offer a loyalty card for frequent users! It should not offer a card for those that don’t use it to get some sort of discount. It is there for when we need it. If we were all healthy we would not be using the NHS and that is really the goal. So the NHS is only there for when we are not healthy and is not touting for business.
Businesses need people to buy their products so that they can make a profit. They spend money advertising their goods to attract people to buy their brand and then hope they like it so much they will come back and buy more of it, that they will feel it value for money, while the business also makes a profit. That is not the medical model.
Of course that is the medical model for which the NHS was set up. The health model needs each individual to take responsibility for their health. The NHS is a safety net for when things go wrong, rather than promoting its services, touting for clients.
Some businesses think they must diversify. This is usually a big mistake. Because you had a good idea and made it work does not mean you are the source of all knowledge and ideas. If your idea was a food product, it does not mean that you should go into fashion or home furniture. This is the big mistake of many an entrepreneur. We see it on programmes such as Dragon’s Den where successful entrepreneurs forget themselves. They had one good idea and maybe some luck. This does not make them the world’s expert on other ideas (or politics, education or health).
Point number 3: We need to decide what Health is and what Medicine is and what Social Care is and what Care is and then act on our findings and aspirations.
Our NHS is really for healing those who have become ill. It is good at acute care. It patches you up and then you are meant to be able to take care of yourself as a grown up individual. You are meant to be able to maintain your own health, that is called homeostasis and is the root of all our health, our ability to carry out our lives, our Activities of Daily Living (ADL) such as breathing, walking, feeding, excreting, communicating.
Some of us cannot do all these things and need constant help. That is care.
Some of us lead unhealthy lives and put ourselves at risk. We are repeat offenders/customers in the NHS. But that is our choice and entitlement.
We need to decide about the NHS at a fundamental level as we have some great things about it and some very poor things about it.
We keep blaming it for the poor health of the nation, but firstly, it was set up for acute care and secondly, the British are just culturally not very good at health. We are very good at medicine and clinical care. We do have public health and health promotion, but it is very badly done. We are good at epidemiology, the causes of a disease upon a people, a population. But we are not good at being healthy. We do try to promote health, but we tend to do it in patronising and infantilising ways, merely irritating those we are aiming our good intentions at. It is often carried out by people who do not really understand what they are saying, grasping at the latest poor research findings of a rather weak correlation, such as more people in the summer drown than in the winter and then ending up with some profoundly stupid proposal (should we ban summer or swimming?).
We train our doctors and increasingly our nurses in what is called the Medical Model. It is very successful at diagnosis, finding out what is wrong with somebody by inventing tests and investigations to see which part of us is not performing well, say our haemoglobin or our pulmonary circulation. By investigation we diagnose and then we treat, medically, with pharmacological drugs or by surgery. That’s it. It does not cure your life. It fixes the part that is wrong. The NHS was set up to do that. It should not be accused of being bad at other models as that was not its point.
In the UK we have not decided what health is and who should care about it and who should care about us so we do not know what it is and what we want and what we are willing to do as a nation.
In France they have. So perhaps we can look across the channel to them. The difference between France and Britain, according to the presenter Melvin Bragg is that ‘France is cultured and Britain is civilised’. I think he has made an important point there.
The French have a philosophy of health and of hospitals. They build them differently. They look at health differently. They have a different education to us. All school children study philosophy. They are not embarrassed about having discussions about meaning and context. We are.
The population of France cares about its food. We don’t. We will eat any old crap so long as it is cheap. They care about many of the basic things that we don’t care about. They have a culture of beauty. To have a care service run by people who don’t care about how things are is never going to work.
So while patching people up is done very well by the NHS, caring isn’t. We are civilised people in the UK, so we care about people, but we are not cultured so we are a bit careless about how we care, what care we offer. We don’t have a great culture of care. How can you be taught to care by someone that doesn’t care for themselves or others?
When I was young I had school cookery lessons by a woman who taught us to cook food that was really nutritionally poor and had no flavour to it. I got the impression she had never eaten sumptuous food or been exposed to a variety of cookery books and had her imagination stimulated. How could she teach us to eat well if she had not experienced what that was? She lacked food culture.
We need to learn how to improve the health of the nation. That is a philosophical debate about personhood, independence, community, tax, care, identity, homeostasis, ADLs, ethics and values. It includes funding. It does not include business. Health should not be a business. It should be an ethic. How we care about ourselves and each other. What we want and how to achieve those aspirations and values.
We were told, when we privatised everything, that we would have better services. All we have seen is larger profits for share-holders. A country that does not own its own infrastructure is not really a country. Why would you fight to defend Thames Water, Eon, Glaxo’s, Pfizer’s or Virgin Trains?
We were told that efficiency is the model for business (profit is, actually). Efficiency is a method of getting maximum profit. Speed to get to the end is the goal of many businesses. There is a cookery programme on TV where chefs compete to see who can make the fastest omelette. Really? Why would you want to eat the fastest omelette rather than the best? We have made many valuable commodities into puerile entertainment to generate money. But we must put our values and aspirations back on the agenda.
Point number 4: We must stop the internal market in the NHS competing for money on false objectives. How fast you can do something is not the root of medical practice or care. Time and motion studies should not be the ethos of the NHS. Competition among health care providers has not been shown to provide better care.
The NHS is fabulous at treating illness. It is not fabulous at caring. It is very poor at holistic care. It has the right ethos, but needs better training for caring. We do not have a culture of health and that is what we need in our population and in our NHS. But we must not throw out the NHS because it does not do what it was not set up to do. It was set up to cure. It does that very well. We may want to extend it to care and health, but we need a debate about who should be doing that and what it is we want. It may need a separate structure for health care or it may need a cultural shift, an educational change. We need to keep business out. Health should not be conflated with business, nor should the NHS.