Richard Smith: A critique of Cyril Chantler’s plan for saving the NHS

richard_smith_2014Cyril Chantler—paediatric nephrologist, medical school dean, NHS manager, former chair of Great Ormond Street, and much else—is quite possibly the wisest man in the NHS. So we should play close attention to his plan—set out in one and a half pages—for saving the NHS. (Chantler submitted a longer version to the House of Lords report on sustainability of the NHS, and it’s online. His evidence begins on page 289.)

The core problem of the NHS, and other health systems in developed countries, is that it hasn’t kept up with the epidemiology or the needs of the population. Set up to treat and cure episodic diseases like infections it finds itself overwhelmed by people with multiple, incurable, long term conditions. The main needs of the population are not for mostly end stage hospital treatment but for services in the community, including primary healthcare and social care.

More of the same cannot be the answer. Even if more money could be found to prop up the current system it will not provide a long term answer.

Chantler describes the main problems in the NHS as an overemphasis on hospitals and underinvestment in community services, with the inevitable consequence that there are people in hospital who do not need to be there, overcentralisation of the NHS, and lack of democratic and local accountability.

His answer is to build up community services away from central control but with both local and national accountability. Recognising the need to avoid new legislation with all the political interference that means, he proposes that health and wellbeing boards, which already exist, become responsible for managing both patients with long term conditions and social services. The boards would commission general practice and nursing, pharmacy, and other services in the community. There would need to be “considerable improvement in the quantity and quality of community services and the support of specialists to these services.”

At the moment health and wellbeing boards are responsible for populations ranging from 1.1 million (Birmingham) to 34 000 (Somerset). Chantler proposes that local authorities with populations greater than 100 000 divide into community health and wellbeing boards with populations varying from 100 000 to 50 000. Funding, which comes from both the NHS and local authorities, would be delegated to them with accountability to both local authorities and the NHS.

The community health and wellbeing boards should also act as community hubs with a range of services, including urgent care centres, specialist medical consultations, community nursing, diagnostics, maternity and mental health services, community pharmacy, children’s centres, therapy services, and other community services.

In other words, the centre of gravity of the NHS would shift from hospitals to the community.

Chantler observes that three other major problems with the NHS are perverse financial incentives, over-regulation, and deficiencies in the postgraduate training of doctors.

Although the NHS is regularly immersed in controversy, there is general agreement among those most familiar with the NHS on the direction of travel—away from hospitals and towards community services. The problem is how to get it done, how to get there from here.

Critics will, I think, see two major problems with Chantler’s proposals.

Firstly, there is no confidence at the centre with the capability of local authorities to run health services—or anything. The tragedy at Grenfell Tower showed up the failings of the local authority, which doesn’t even have the excuse of penury that applies in most local authorities. Who wants to be a local councillor starved of resources, handed almost insoluble problems, and then castigated for not solving them? There are, as we all know, highly capable people in all communities, but how to get them involved? The answer could be, as Chantler suggests, to give them real power and real resources.

Resources are the second problem. Chantler’s plan would mean a major shift of resources from hospitals to communities, from healthcare to social care. Unfortunately, resources are constantly sucked in the opposite direction. Clever specialists think up ever more elaborate interventions and grow bolder in what they attempt to keep people alive; some patients seize any opportunity no matter how small to fend off death; pharmaceutical companies develop new drugs, all of them expensive but few of them offering much value; device manufacturers build new imaging machines and ever better artificial hips and the like; and medical researchers provide a flow of new possibilities—for example, in genetics. Few of these innovations reduce costs.

Chantler, like other policy makers, argues that spending will have to increase to pay for transformation, but it’s hard to see substantial new sums in the near future, and even were the money to be forthcoming most of it would, I predict, be sucked into hospitals.

The brutal, unpalatable, and politically impossible truth is that to achieve better services in the community we need fewer hospitals, fewer specialists, and tight restraints on any innovation that increases cost.

And I see two more, deeper problems: Chantler’s plan seems to continue the old model of “healthcare being done to people” rather than a model of “people being responsible for the health of themselves, their families, and their community with the help of health workers.” After decades of people going to doctors to have their health problems “solved,” shifting the responsibility will be a major cultural change.

Then Chantler is perhaps adopting too narrow a view of “health.” No matter how hard we try, people like Chantler and me, who went to medical school half a century ago, continue to think of health as “the absence of disease.” We talk of prevention, but even then we are adhering to the model—because we are preventing disease. Health is about much more than the absence of disease, and more important to most people than avoiding diabetes or obesity is having an agreeable place to live, security, a job with meaning, strong relationships, and the chance to play. Resources need to be shifted not just from hospitals, but from “healthcare built around the disease model” to the broader ingredients of health.

But Chantler’s model—with community health and wellbeing boards as opposed to hospitals being the main building blocks of the NHS—does allow the possibility that the boards could promote people rather than professionals taking charge. They might also adopt much broader views of health—even to the extent of “health” being perceived more as a function of communities rather than of individuals.

A response from Cyril Chantler:

The evidence for my proposition is in the references in the House of Lords submission. We spend 9.8% of GDP on healthcare against an OECD average of 9%. Some countries spend more but they tend to have social insurance systems, which have higher administrative costs, though less political interference and are therefore more accessible—at least according to the editor of the European Health Consumer Index report. The reference I gave in the submission (7) is for the 2015 report, but the 2016 report is now online. Again Holland is top and we are 15th.

Local authorities overall are not rubbish and they manage social care by a mixture of commissioning, direct provision, and involving the voluntary sector. Roy Griffiths’s second report convinced Mrs Thatcher against her instincts to support them continuing to do so (Griffiths R. 1988, Community care: agenda for action. London: HMSO.)

In any case, I propose joint commissioning boards between NHS clinical commissioning groups and local authorities through the health and wellbeing boards; this is beginning to happen in some localities. In Scandinavia the local councils are heavily involved in commissioning health services, so why don’t we just try it as well? Holland has set up a system that works, so why can’t we learn from them? In both countries the health service seems better in terms of outcomes and availability.

The answer isn’t and can’t be lots more money, and what we are doing now does not work so what next? A public healthcare system available to all is available in many countries and we do not need to give up on our NHS. As you say, it needs to address much more successfully issues of improving health and reducing health inequalities. This needs local knowledge and local action.

Finally, most large organisations needing a major change in strategy recognise the need to “front load” such change. I would borrow from the Treasury the sums to invest in primary and social care in the expectation that the money would be found at the end of a three to five year transformation period by the slowdown in the growth of hospital expenditure that would result.

Again, what is the alternative?

Richard Smith was the editor of The BMJ until 2004.

Competing interest: None declared.