NHS crisis, what NHS crisis? Take your pick. Accident and emergency, under-staffing, or any other local or national health crisis you can think of.
In the next five years we can expect to lurch from one crisis to another. It is vital we understand their underlying causes because otherwise we will find it very difficult to create durable and credible solutions. We need to focus on two areas – health inequalities and accountability.
The deep-rooted causes of ill health that trigger a great proportion of crises are inextricably linked with economic inequalities. Unless we acknowledge head on the correlation between social class, income and health we are missing the root causes of what we need to address.
In the late 1970s the Labour government commissioned Black Report found that the introduction of the NHS and welfare state had improved health across the country, but too many health inequalities still existed. Today, 35 years on from its publication, the problems persist, as we were reminded in 2010 with the Marmot Review report, Fair Society, Healthy Lives.
Significant numbers of people who attend primary care and accident and emergency units often do so because of conditions that would have benefited from public health programmes, whose value I have seen first-hand working in the NHS in Bristol.
Many of the improvements were founded on Labour’s implementation of policies from 1997 to 2010 that built on some of the Black Report’s recommendations.
To help give children a better start in life, for example, the Labour government launched Sure Start providing parental support and early years education, often in the poorest areas.
To encourage good health by preventive and educational action, Labour invested in public health in our communities, banned smoking in public places, and put healthy eating on the curriculum. It resulted in tangible improvements in public health in communities across Bristol.
When public health was transferred to local authority control, under the coalition government, it suffered due to local government cuts. Now there are further cuts to come. People need support to improve their own and their families’ health, and the focus on public health in the five-year forward view is to be welcomed. But local authorities will need support to make it happen.
Then there is the problem of accountability. Look at any local or NHS ‘crisis’ and ask, ‘who is accountable’ and ‘who can sort it out’? Things get complicated.
Following the re-organisation of the NHS, the lines of accountability in our health service are muddled by an over complex matrix of organisations who all play a part in commissioning, delivery and monitoring of health care.
Take a few examples from Bristol. The two accident and emergency departments in our Acute Trusts are mainly commissioned by Bristol Clinical Commissioning Group, North Somerset CCG and South Gloucestershire CCG. These are supported in their commissioning function by the Commissioning Support Unit, an organisation now covering the South of England’s population of 10 million people. The CSU has all the finance, information, quality and performance functions but my constituents in Bristol South constitute 78,000 people – less than one per cent of this huge, now remote organisation. To this add in three different local authorities and community trusts, Monitor, the Trust Development Authority and NHS England as both commissioner and the body which ‘determines day to day running’ of the NHS.
Now breathe out. It is a matrix that leaves those leading and working within the organisations facing too many ways – and it baffles the public. It is hard enough for patients to understand the system, let alone influence it.
So in trying to address this or that health ‘crisis’ we are stymied on two fronts. There is no strategic or funded approach to public health to help prevent the crises we currently see. Second, we have no ability to react to the crises when they happen because the levers no longer exist nationally or locally, and the lines of accountability are so unclear. That is why the government recently had to intervene and announce ‘success regimes’.
My constituents love the NHS and willingly pay for it from their taxation. It is time they were treated as equal to the professionals who have run it, and given some power over how it is run. The solutions to these crises are being held back by remote and undemocratic decision making and the influence of vested interests.
If we are to transform the health system to reduce pressure, support people to look after their own health and offer highly responsive, effective and personalised services out of hospital then we have to start treating the public and patients as partners, not nuisances.
Karin Smyth MP is member of parliament for Bristol South
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