Graham Leicester: The NHS needs to care, not just cure

THE coalition Government's claim to have "saved the NHS" from the carnage of the Comprehensive Spending Review has unravelled with surprising speed. All parties assured us during the General Election campaign that the NHS would be "safe in their hands". But there was still some doubt whether that pledge could, or indeed should, be delivered with so many other vital services under threat.

True to its word, the government has guaranteed marginal year on year budget increases amounting to 0.4 per cent in the next four years. But the hollowness of that settlement has quickly become apparent.

In the real world inflation in the NHS has been running at close to six per cent to keep pace with rising costs and the increasing demands of an ageing population. In the sixty plus years of its existence spending has grown in real terms by an average of four per cent a year - even whilst we have been trying to contain it.

So it does not take a brain surgeon to work out that there is trouble ahead. Harrowing stories, patients on trollies, hospital closures, drastic rationing. As Polly Toynbee put it recently: "Here is a volcano waiting to erupt".

In some senses the dawning realisation of the coming crisis is a promising sign. IFF published a report earlier this year, Costing an Arm and a Leg, that rang the warning bell: "A plea for radical thinking to halt the slow decline and inevitable collapse of the NHS".

But - as might be argued across the piece - the government has only got half the message.

NHS spending is on an unsustainable upward path. But simply cutting off supply is not likely to save the patient. Especially when it is accompanied by a radical reorganisation which bodies ranging from the NHS Confederation to the British Medical Association itself have denounced as half-baked at best. We need something more intelligent than this.

Which leaves many looking to Scotland to come up with a better way, a Plan B, a last chance to save the NHS. Will we rise to the challenge?

The early signs are not promising. Spending on health in Scotland has doubled in ten years to 10 billion. It now accounts for ten per cent of GDP. Yet Health Secretary Nicola Sturgeon tells us just "passing on the proceeds of the rise in NHS spending south of the border" plus an additional 100m in efficiency savings will "protect the quality of patient care".The parallel commitment to end prescription charges suggests she is deep in denial.

Nothing we have heard from Labour leader Iain Gray suggests he lives any closer to the real world. He makes exactly the same tired pitch about cutting management costs to protect the frontline. None of this rings true - least of all to those actually working on the frontline.

They know better than anyone that for decades the full gamut of measures - efficiency drives, "lean" process redesign, reorganisation, innovation, technology, emphasis on prevention, competition, health promotion, you name it - has failed to make any significant dent in the budget. And that is true not only in Scotland but across the developed world.

This is because none of these measures touches on the underlying drivers of health inflation: an ageing population, changing disease profiles, more chronic conditions and unforeseen consequences of medical treatments themselves such as rising bacterial resistance to common antibiotics.

Fortunately there is a growing number of people within NHS Scotland itself now ready to engage with these challenges at a deeper level. And that willingness is attracting attention from south of the border.

So it was that earlier this month a group of clinicians - many now in senior management positions - and other interested parties came together for a day's workshop to start developing a more hopeful approach.

The task? To design "an NHS that will provide universal healthcare according to need, free at the point of delivery, meeting contemporary patterns of illness and other public expectation, as part of an integrated approach that sustains healthy, fulfilled lives at a fraction of the present cost." That design brief found an echo in the arresting simplicity of a leaflet sent to every household in Scotland at the birth of the NHS in 1948: "The National Health Service will provide medical, dental and nursing care and there will be no charge. Every man, woman and child can have the benefit of this Service. It is there for us all, rich and poor alike. We are paying for it out of taxes, rates and insurance contributions."

It became clear over the course of our discussions that a large, unspoken part of the public desire to "save the NHS" - almost at any cost - is the sense that it is a "state of exception" in the midst of the otherwise global triumph of the market.

There is a moral universe encapsulated in those few sentences, a declaration of how, after the ravages of war and depression, we intended to relate to and care for each other.

And that, it transpires, is the hidden resource on which we can fashion Plan B. Too many people in the room - senior clinicians remember - had stories of a system driven by the needs of an increasingly specialised and technical profession rather than the needs of the patient.

That, ultimately, is the insidious driver of health inflation.Friends and family forced to accept treatments they do not want, elderly relatives hospitalised against their wishes, technicians treating that part of the problem that fits their expertise and happily ignoring the rest.

Like one poor soul callously discharged with the words "we don't have any prescription for a crap life".

At the heart of the new NHS will be the restoration of care - the disinterested, compassionate, professional relationship that characterised the NHS's founding ethos but which has been buried under scores of specialisms from the professional bodies, reinforced by shallow government targets that pander to the false simplicities of the medical model.

The generation of clinicians and managers now on the frontline, those to whom it has fallen to steer the NHS through these turbulent times, yearn for this restored freedom.

The freedom to care for their patients, to respond to their needs and their wishes, to support their capacity to heal themselves. And some of those in the room have been further inspired by the visit to Scotland earlier this year of leaders from the Alaskan health service.

Fifteen years ago these people wrested control of their budget from the Federal Government and radically redesigned their healthcare model not around diseases and targets but around people.

New recruits to the service undergo a three-day training programme on how to offer their undoubted technical mastery in the context of a supportive therapeutic relationship. It is led not by some outsourced training supplier but by the CEO herself.

Could it happen here? Look around and you'll find it already is. Frustrated clinicians voting with their feet, moving out of their professional silos and into the community. Developing Plan B will take some time. But we confidently predict that it will not be long before at least one health board area in Scotland is ready to step up to the plate as the Alaskans have done. That is our intention.

In the meantime the recipe for failure is clear: measure the success of reform in terms of money rather than quality of care, and crush the spirit of your professional staff rather than engage and inspire their deeper vocation. The current remedy is doomed on both counts.

• Graham Leicester is Director of International Futures Forum www.internationalfuturesforum.com