Years of successive governments taking opposite approaches to modernising the NHS has prioritised political expedience over of patient experience. Britain’s health service proved woefully unprepared to deal with the Covid pandemic during which clinicians were left unprotected and thousands of care home residents died. Even without the coronavirus outbreak it is likely we would have seen hospital maternity departments and mental health units perform little better than they did before the NHS existed.
The industrial revolution saw a migration from the countryside to the city as people sought employment in mills and factories. Poor diet, cramped housing and unsanitary living conditions caused illness and disease. Industrialists found sick workers were less productive than healthy ones and all the money spent on training was wasted when skilled employees died prematurely. Companies such as Krupp and Siemens in Germany and Lever Brothers and Rowntree in Britain began spending money on employee welfare and recruited doctors and nurses to work in company health centres. Otto Bismark, chancellor of Germany realised healthy citizens made healthy soldiers and built a state welfare system built on the model employed by companies. The second world war provided a wakeup call for Britain which now, like the rest of Europe, regarded healthy citizens as a strategic resource and in 1948 created its own national health service.
Healthcare is funded by way of insurance purchased by the patient. Sometimes these insurance schemes, typically those provided by employers, are described as ‘non-contributory.’ However, as these schemes are funded from company profits (or unpaid labour) the employee a payor rather than the payee. It is now rare for a company to have an inhouse hospital and instead treatment, should it be required, is provided by third party medical facility. Britain’s National Health Service NHS) is funded by way of a National Insurance Scheme, which also funds a state pension, with contributions from both companies and their employees.
While a person may decide not to join a company’s private health scheme, especially if they are fit and healthy with no family history of serious illness they cannot opt out of Britain’s national insurance. Even so, as we shall see later, attitudes to health at different stages in a person’s life has had a marked impact on the NHS.
NHS hospitals are owned and run by the state and the intention was, when the NHS was founded that as far as the patient was concerned treatment would be free at the point of care.
A basic grasp of demographics is helpful when determining why the NHS periodically comes under pressure. After the first world war and the influenza which followed there was sharp rise in the number of people born in the UK and there was a similar increase in births following the second world war. The first population boom was amplified by refugees who arrived in UK during the 1940s (exiled east Europeans along with German and Italian prisoners of war)
The first generation of boomer experienced their first age related medical conditions during the late 1980s and early 1990s and by the late 1990s the NHS was struggling to deal with the number of additional patients needing long term treatment. Up until this point the NHS had been able to keep pace with the constantly changing healthcare needs of Britain’s population through over provisioning. How it coped on this occasion was explained in Wireless Healthcare’s report on caring for the ageing – discussed later.
While the uptick in births in the late 1940s was smaller than the one in the 1920s, thanks in a large part to the NHS, the number of children surviving into adulthood was proportionally greater. The second boomer cohort has been supplemented with young workers from Britain’s former colonies. There were approximately 300,000 additional births in 1947 and, statistically, we can expect these people, along with the 700,000 others born in that year will die in 2030 (1947 plus the UK average life expectancy of 83 years). This is equivalent to the additional deaths caused by Covid compressed into 12 months. The number of additional deaths in 2031 will also be close to 300,000. Covid, whose victims were principally drawn from the long tail of the first boomer generation and members of the second with underlying health conditions, will be looked on in eight years’ time as a mere ripple preceding a tsunami. However, for the NHS, as we saw in the late 1990s, deaths are not the problem, the real challenge is treating all those people now afflicted with their first age related condition. As many of these late middle-aged boomer’s health went declined just prior to the pandemic the NHS has been caught on the back foot and faces an acute, decade long, capacity crisis.
Politics and Reform (follow the money)
The NHS is one of Britain’s last surviving, state-run organisations employ 1.4 billion people and has an annual budget of £136 billion: no surprise this massive organisation has become a political battleground. The Conservatives believe privatising NHS would rid Britain of the last remnants of the socialism and without the NHS the Labour Party would be a much-diminished force in British politics. Socialists, on the other hand, battle to maintain state ownership of the NHS with a near religious fervour. Politicians within the two main political parties however are more concerned about party funding going forward than history and ideology.
Many of those 1.4 million NHS employees are paying members of trade unions such as UNISON or UNITE both of which support and help fund the Labour Party. Socialists, quite rightly in many cases, believe Conservative governments use healthcare reform as cover for chipping away parts of the NHS and handing it to non-unionised private companies. This both reduces the amount of state funding finding its way into the Labour Party’s bank account via trade unions and at the same time increases the amount of donations the Conservative Party. Labour would obviously prefer reforms that increased the number of employees.
Wireless Healthcare Reports
In the wake of the Dot Com healthcare was one of few growing markets for Internet technology. Beginning in 2002, Steinkrug Publications produced a series of reports outlining the opportunities open to IT vendors within what would prove a rewarding, but at the same time, challenging sector. The political and economic constrains were those described above. This is a retrospective looking at what succeeded, what worked, what failed, and work still left to do.
Caring for the Elderly
“Let’s think outside the box – before we end up in one.” Someone said in 2002 at a conference on caring for an ageing population. Amusing when you are only fifty years old, not quite so funny twenty years later. We had just published our first Wireless Healthcare report which identified opportunities for IT companies in growing market for medical devices and services to support elderly patients. By this time the NHS had almost got to grips with the capacity crisis caused the 1920s baby boom cohort reaching the end of their lives. The problem was solved by a combination of initiatives including:-
Local authorities, responsible for providing social care, working more closely with the NHS.
An increase in spending on healthcare by the Blair/Brown Labour government enabling the NHS to both recruit more nurses and community health workers and increase the number of hospital beds.
Investment in healthcare IT marginally improving workflow within the NHS.
An increased focus within the NHS on caring for the elderly.
Speaking to clinicians and hospital managers during the early 2000s the impression was very much ‘problem solved.’ Few mentioned the reason the provision of care was now keeping pace with demand was due to most of the elderly ‘customers’ responsibly for the capacity crunch (commonly referred to as ‘Bed Blocking’) having died. Britain was experiencing a hiatus in the growing demand for care thanks to the relatively low birth-rate during the late 1930s and early 1940s. The second cohort of elderly patients, far bigger than the first, were not due to arrive in A&E until the end of the next decade. Problems that go away on their own have a habit of coming back on their own.