Why are those in charge of the NHS blinded by delusional optimism?

A year ago I predicted that the deficits, shortfalls, waits and safety concerns that were growing fast at the time would keep growing, putting the NHS under insurmountable strain.

Broadcasters and thinktanks were unwilling to make similar forecasts, despite the evidence, because they either believed the government’s reassurances or were afraid to be seen as negative speculators.

Yet my predictions proved optimistic. The NHS today has bigger deficits, increased staff shortages, waiting times not seen for more than a decade, and an utterly demoralised workforce, exemplified by the junior doctor dispute.

The hyper-careful General Medical Council recently highlighted how serious the situation has become with its unprecedented declaration of “a state of unease in the medical profession”.

Three examples demonstrate the steep gradient of decline:

• In two years, the key performance marker, A&E waits, has worsened from more than 95% of patients waiting four hours or less to under 90%. The number of patients waiting over four hours has doubled – two million in the past year, with nearly a quarter of a million in February alone, a 400% increase on the February figure five years ago. Figures published this month show the numerb of patients waiting in ambulances outside A&E for more than an hour, unable to be taken into the hospital, has doubled in a year.


• In 2013-14, the NHS deficit was £114m. In 2015-16, the deficit of a single trust, Barts Health, was £134m and the NHS deficit was £2.45bn – a 20-fold increase in two years. Nearly all trusts finished 2015-16 in a deficit and have remained there.
  


• The number of delayed discharges from hospital, which have been a big problem for years, are also increasing at an alarming rate. The delays are not only unpleasant, they waste a lot of money and lead to worse care. This month, the Care Quality Commission suggested this problem is reaching a tipping point [pdf].
  

Despite this, news of the NHS meltdown has been buried. It was displaced from headlines by the EU referendum, and last winter’s deterioration was concealed due to the fact that the NHS broke tradition by not publishing national weekly performance information for that period.

The shortfall in money and staff needed to meet demand and the parallel shortfall in social care still exist. If nothing is done to arrest this, the decline will accelerate. Waits will get longer and some patients will die before being treated, while others will become permanently disabled and lose their livelihoods. Yet those responsible for the NHS still refuse to act, blinded by their own delusional optimism, or perhaps wilful deception.

From its inception, the NHS worked on a fixed-cash limit, which placed limitations on what was provided. Something fundamental changed with the Blair/Brown resource injection into the NHS in the early 2000s. The increases were undoubtedly generous but accompanied by a foolhardy view that because of that practically anything was possible. As John Reid, former secretary of state put it: “We’ve given you the money. Now do the job.” He might also have added a helpful reminder to use the money wisely.

By 2006, the NHS was in financial meltdown: resources had increased but demand had soared. Things were belatedly put back on an even keel by optimising deployment of the resource injections. But by the time of the coalition government in 2010, it had become impossible to do this. Resources were constrained and prices reduced to below cost, but still demand grew.

The final nail in the coffin was the creation of NHS England in 2014, which had no responsibility for providers or their viability and sustainability, but which had power to buy services at prices that didn’t meet costs at volumes that exceeded trusts’ capacity to deliver services punctually and safely.

In 2014, NHS England’s Five-Year Forward View claimed that with an investment of £8bn, the NHS would be able to make up the rest of the £30bn deficit in efficiencies – this despite the fact that those who had to find the savings had not been consulted. Repeatedly since then, there have been government claims (eerily reminiscent of Reid’s) that the NHS has been given what it asked for and that should be enough. Not so.

Within a month of the Forward View being published, the NHS entered its worst winter crisis in a decade, unforeseen in the document and only eclipsed by the next: that of last winter. Two years on, the sunny uplands predicted in the Forward View are nowhere to be seen.

Is there a way out? Possibly. To maintain services and meet increased service demand, prices must be based on real costs, not buyers’ wishes. If they were, capable providers would survive and thrive. Incapable ones could be replaced, creating reasonable competition and reducing costs to the minimum safe level. If buyers wanted more from their investment they would have to pay more – as we do in other aspects of our lives. This would create a self-regulating, efficient system. So why don’t we just do it?

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Why are those in charge of the NHS blinded by delusional optimism?