Last Thursday the think tank Res Publica launched a report into the state of the National Health Service, and proposed that a greater role for mutual societies might be key in building a sustainable health service for the future.
We are all familiar with the diagnosis – we have a growing elderly population, a dwindling younger, tax paying population, greater needs for long term medical care for chronic health conditions than ever before, more expensive medicines and procedures, et cetera, et cetera.
Government spending on health, as a proportion of GDP, has risen from 3.9% in 1960 to 7.5% today, and it continues to rise. 25% of the population account for 70% of this expenditure – mostly on long-term illnesses. Within the next decade, the report concludes, the NHS could go bankrupt trying to meet this mounting level of need without a massive and continual increase in its funding.
At the same time, the NHS was set up to care for those with acute illnesses and injuries. Complex, long term care and treatment needs are a struggle for a system designed to focus on one problem at a time. If a person needs several types of medical assistance at once (eg cardio vascular, orthopaedics and endocrinology), needs social care, transport assistance and re-housing, it can be a bit of a muddle getting all the services working together. Health and social services authority boundaries are not always coterminous, there will be grey areas in care that different bodies claim is not their responsibility (and so end up as no one’s responsibility!), and it is possible for a person to be admitted for a non-acute issue and none of the other providers to be aware. Good coordination between services is not impossible (I know, I have seen it happen), but it is difficult (again, I speak from personal and professional experience!). And underlying all this is the question of who pays for what.
Res Publica suggests that mutual societies should be more central in funding, providing and coordinating healthcare, Mutual and Friendly Societies are set up for the benefit of members, not shareholders, and have been working well in social and medical care and insurance for centuries. The think tank also suggests that the whole system of health service regulation needs to be streamlined and should focus not on throughputs but on patient outcomes – in particular on how well services work together to provide integrated care.
It is a good principle. One of the fundamental criticisms of the failed Mid-Staffordshire NHS Trust (and the other NHS institutions that failed to recognise and act on that failure) in the Francis Report was that they lost focus on the integrated care of the patient and focussed more on achieving throughputs targets. So, for example focussing on getting more people using the same hospital bed in the same time period may miss the point that it is the same patient coming back each time because they were discharged too early or with inadequate assessment and support. Measuring throughput does not give you any idea of what was the outcome for the patient in the long term.
And mutuals, like credit unions and food banks, have a long history in Britain of addressing social needs. Many hospitals and much health insurance prior to the start of the NHS came through mutual societies. And the report estimates that achieving better integration by working with such bodies can save billions off the NHS budget by avoiding unnecessary admissions, avoiding duplication of services, and so forth.
This is all well and good, but the long term issues won’t be addressed just by making care more effective and efficient. We can build better and better hospitals at the bottom of the cliff, but we could save a lot of grief by building more railings at the top. Most long term illnesses are lifestyle influenced – cancer, diabetes, heart disease, lung disease, all are affected by diet, exercise, smoking, alcohol consumption, etc. Most of the major health gains in the nineteenth and early twentieth century came not from advances in medical science, but in better housing, good sewerage disposal and clean water supply, rising income levels and more access to cheaper, good quality food. Address the causes of ill health, and you save the need for a health service.
In the nineteenth century Britain the major public health threats were from infectious diseases, especially waterborne infections. In the twenty-first century, the major challenges are non-communicable diseases. The need now is not for changes to physical infrastructure, but to lifestyle and social attitudes.
The salvation of the NHS is not going to come from one quarter. I will once again make my plea that the church has role here – whether in health education (eg though Parish Nursing programmes), debt counselling, credit unions, or even taking on the running of local health services (as it did prior to the NHS).
Maybe we need to look at setting up new healthcare mutual/friendly societies to provide more integrated care and support in the community, tackle social isolation through local community meeting places. We have a national and global track record in this, and we are already picking up the pieces as people fall through the welfare net. Soon, we will be doing the same with health needs, whether we plan to or not. Why not start now to plan how we can work with health and social services to be part of a sustainable health and social care network in our nation. It’s not a new idea for the church in the UK, but it is one we need to rediscover.