I like to think I am a jovial dinner party guest. However, there is one thing guaranteed to turn me frosty: tell me you have paid your taxes and are therefore immediately entitled to NHS care with few corresponding responsibilities. Expect me to politely, but firmly, disabuse you of that notion.
When the Welfare State was established, it was based on the premise we instantly provided universal coverage for the population. If you were retired, you immediately received free healthcare from the NHS though you had never “paid in” to the system. The basic idea has always been that those of working age pay for the care of those who are beyond it. So you are not paying in for your care: you are paying for the care of your parents and grandparents.
This model worked well in the 1940s, when the welfare state was founded and when our population was a pyramid shape – far more young people than old. Now, it’s more like a rectangle: a rapidly ageing demographic and an unbalanced birth and death rate. In this situation, the premise on which our care system was founded becomes irretrievably broken. We are left with an NHS in which trusts are struggling with unprecedented deficits, while older people are trapped in hospital beds for want of more appropriate support elsewhere.
We are not the only country grappling with these demographic changes. But I believe we aren’t addressing the situation as well as other countries. In my judgment, if you live in the UK and have a health problem, you are more likely to end up in a hospital than you are in other developed systems.
That is not a criticism of the institutions providing our healthcare. The NHS and its employees have served us brilliantly for 70 years. But our system has not delivered alternatives to traditional models. The focus remains hospital-centric even though most ill health is now chronic rather than acute. Technology has not been adopted at speed. And the workforce has become dominated by specialists when we need generalists who can care for older people with multiple conditions.
None of this is news to people working in the public sector. In NHS England’s Five Year Forward View, these themes are writ large. Healthcare is institutionally and organisationally conservative, and always has been.
This is not a conservatism shared by consumers. For instance, most prefer the ease of internet banking to a busy branch at lunchtimes, while the bank can alter the makeup of its workforce in branches. The interests of bank and consumer are aligned.
We need to replicate this in healthcare. Consumers have a strong track-record of forcing rapid change. They just need to be able to use their power.
In healthcare, that means giving patients accurate and easy to-understand information about the performance of various care providers – and letting the poor organisations fail. It means explaining what is and isn’t possible given their diagnosis, noting the increasing prevalence of chronic conditions. It means changing our habit of infantilising patients and giving them responsibility for their own health instead. And it means helping them understand the constraints in which we operate.
I believe the vast majority of the population is capable of taking on such a role. But politicians, with their mind on re-election, will never want to explain to constituents that it may be better to shut the local A&E department because it cannot deliver good care. I cannot hold them at fault for wanting to avoid difficult conversations about our Welfare State. Where they are responsible is in not creating an environment in which such a conversation can flourish.
A Royal Commission to explore how we can maintain our Welfare State and meet the needs of our population is long overdue. I can’t say what the outcome would be. But I am certain we cannot continue the way we are. I have news for any dinner party companion of mine – your parents paid for their parents’ care, you’re paying for your parents’, and there aren’t enough young people to pay for yours.
If our national dialogue around that, and all the other complexities we now face, is not sufficiently sophisticated and honest, we may as well start mourning the Welfare State right now.