Richard Taunt | “The NHS will Die”

Richard Taunt: I think there are still parts of the NHS which absolutely should be held up as the model. But, bits are creaking and in need of a good look at, and probably a good overhaul.

DMacA: You wrote that ‘the NHS will die’. Tell me how you see the life cycle of the NHS.

RT: Unless we can have a very different sort of conversation about those factors, those fears, that we have for the NHS, which are often felt but not said, I think there is pretty grave danger.

DMacA: In terms of this lifetime in the NHS, and we all have to change in our lifetime, what would you change, what are the changes that need to happen?

RT: The first of these factors, the first reason why the NHS may pass away is simply ‘Youth’. We talk a lot about the impact of an aging population on health systems around the world. The bigger factor than older people needing care for the NHS will be that young people simply don’t want to work for it any longer. We’re already seeing a generational shift in how people think about work with more people being interested in the well-being offered by their employer, the ethics of their leaders, than other factors. Currently it’s not looking too good for the NHS and the organizations which make up our health system. The fact that 30% of NHS staff often think about leaving, the fact that one in seven UK training doctors now practice overseas with working environment being top of their list of reasons for looking elsewhere, causes us to think about if we have prioritized sufficiently creating the environments in which staff want to work. And, when we have what is arguably one of the most centralized health systems in the developed world, how can we create workplaces where people are empowered and able to tap into their intrinsic motivation for wanting to work in health in the first place, rather than, where we often end up, which is in a system which can feel incredibly pressurised, incredibly micromanaged by various levels of hierarchy and take people away from the reasons why people choose to go into healthcare in the first place.

DMacA: One of the factors you mentioned that’s changing is the aging population. I’m a lot older than you so who’s going to look after me?

RT: There will always be a greater demand for healthcare workers so I think, globally, there needs to be a pretty big recruitment drive. I think we talk about 19 million jobs in health needed by 2030. How healthcare is an attractive profession for people who are currently working in healthcare, and thinking about whether to stay or not, or looking to join, has to be, in my opinion, at the top of every health system’s to-do list. If people think that actually, no, I’m not going to do this, the work environment is not one which gives me personal joy, I’m going to look outside healthcare, health gets into a real problem. Because we want to have more health, we are going to need more health because of demographic factors but, crucially, we want to be cared for in new and absolutely right ways. But, this carries with it the need for a lot of people who are willing to do jobs, which in a lot of areas, including the NHS, look increasingly unattractive.

DMacA: Recruiting people is difficult, the other thing is paying people. So, can we really afford the health care that we would like?

RT: Once again, every system will be pushing against a barrier of how much can we spend, what do we want to spend our money on. I think, for me, the important point to remember is that the health care we receive today in any country is innumerably better than 20 years ago. It’s incredibly better than 40 or 50 years ago. But it will still be judged to be inadequate in 50 years time. Every age is looking at their healthcare system saying- we’ve got an issue with the budget we have, how much can we possibly do. Within the NHS- the role of politicians is so central. They’re in a position where they can make or break change and, currently we are in a position where I think there could be a bit more honesty, realism, as to what a health service can and can’t provide. We are probably eighteen months away from an election- where there will be an opportunity to see different visions put forward by politicians. We are already starting to see some debate about what is necessary for the NHS to flourish, both in terms of resources but also in terms of change. I think politicians do play a particular role within the NHS but I think, where we get stuck is, that we normally conflate political leadership with politicians having all the answers. So, I think part of this honesty has to be politicians who say change is required but we do not have all of the answers ourselves and we need to work with the population. We need to use new methods. We’re particular fans, here at Kaleidoscope, of methods from deliberative democracy, citizens juries for example. We need to work with our population in new and creative ways to deal with some of these tensions and trade-offs where there is no easy answer. It’s not that we just need to scour the numerous healthcare journals to find the perfect health system. There are real trade-offs here which require a level of understanding and sensitivity, but also diversity of opinion so, how we best work with diverse groups and diverse perspectives to get to a place which is not going to be perfect. I think we should be honest about that but its a darn sight better than where we could otherwise be.

DMacA: You mentioned something that caught my imagination and that’s consulting with the people on the ground in a kind of a people’s parliament, a discussion group. Is this people deciding the priorities for health? Is that an opportunity?

RT: The really exciting development, I think in public engagement and public consultation, is to go well beyond consultation and think about how you can equip people, representative groups of people, to lead debate rather than just respond to it. So, the use of citizens juries increasingly around the world, in areas such as climate change, in terms of abortion law in Ireland, offers real hope in terms of how you can actually have people supplied with all of their right evidence, supplied with information, supplied with a difference of view, and being able to say, given all of this as a representative group of the population, this is our set of recommendations. That’s a very different model to the government writing down some clever thoughts in a PDF and sending it to people and saying, respond by next Thursday please. It is a different type of conversation which I think is at the heart of how we move to a different settlement, a different sort of health service.

DMacA: One of the issues that people are concerned about, and they’re certainly very vocal, is primary care services. It looks like it’s going to be impossible to meet the needs or the wants of the population.

RT: I think in primary care, we’re so often stuck in a bit of a black hole. You don’t have to have been around in health for very long to see the same arguments come round, and the same promises come round, and the same realization that the promises haven’t been met, come around. And we all go around again and again and again. One of my wonderful colleagues here at Kaleidoscope, David Haslam, was reflecting just this week on a piece which he wrote 20 years ago about the crisis in general practice, which you can just cut and paste and put straight back out today and just increase the volume of certain sentiments. So, there is a need for a level of reflection as to how we are still in the same place, what’s actually going on under the surface that we’re not dealing with. For me, part of that would be to say that we have been talking for decades if not longer, about how we need to rebalance our health service in favour of primary care, how we need to rebalance our medic numbers in favour of general practice. But, it’s not gone there. What are some of the deep underlying factors which are causing behavior to continue in the same way, despite us saying – No we don’t want this, we want to do something different- but then it doesn’t happen. I think a moment of pause to consider why, when we’ve been in this place before, why change has not happened and, are we focusing on the right issues, rather than jumping to easy sound bites and what looks like the real concern actually may not be.

DMacA: David Haslam was at one time chair of NICE (National Institute of Clinical Excellence) and NICE was brought in to create a buffer between healthcare and industry. That buffer seems to be being eroded. Where do you see the future of the relationship between healthcare and industry, particularly the pharma industry.

RT: NICE has been phenomenally successful. You can see that in a number of different ways in terms of how it’s transformed certain dynamics within the English health service, in terms of how it’s a model that has been used and copied in numerous health systems around the globe. This does go back to the fact that the potential for healthcare will always be greater than the ability to pay for it in the UK, but also in any health service. That is a dynamic that we’re always going to live with. We are always going to have organizations which come up with new ways to extend life, and the quality of life, which of course they’re able to do. That is very different to having a publicly funded health service focusing on the right publicly funded services and treatments. So it was essential to create NICE 25 years ago, and it’s even more essential now, to be able to make the sorts of decisions which are utterly necessary but increasingly sensitive.

DMacA: The other area that people talk about as potential answers to some of the problems in healthcare, is the use of technology. Do you see technology offering many answers?

RT: Technology will continue to offer huge potential in which care can be improved. The issue is that we then say- great, we’ll have some more of that please. I think there is this risk that we view healthcare as something which can be fulfilled, a computer game which can be completed and so, if we can just get a bit of technology here, a bit of technology there, it will take us to that zenith and we’ll go- great, we’ve completed our health system now and we can we can go and spend money on something else. Everything we know about health is- that’s not how it happens at all. We will use technology and it will do things which are wonderful, and we’ll say great and what’s next. Absolutely, we should be thinking about all of the different ways which technology can be used but let’s not fool ourselves that once we’ve used this level of technology, that we won’t want to use the next frontier after.

DMacA: We’ve spoken about all the challenges and problems and limitations of health care. It would be really nice to finish on an optimistic note. Have you any optimistic thoughts for those of us who are trying to grapple with the problems of healthcare in the future?

RT: I am incredibly optimistic, despite writing a piece which starts ‘The NHS will die’ because healthcare is still, in my opinion, the most wonderful industry anyone could want to be part of. The joy and privilege of being in an industry whose very purpose is to offer care and compassion and support to those who are vulnerable and in need. It takes some beating. So, the real advantage health has, in terms of confronting the challenges, is that this is something which people are intuitively intrinsically drawn to. It’s how we work with that intrinsic motivation, it’s how we support people who see their individual purpose aligning with a collective purpose, which will have to be at the heart of how health in the UK, and far beyond, develops over the coming years, decades, centuries. This is a long game.

DMacA: I love that thought of how we can align the individual motivation with the collective purpose. Rich, it’s been fun talking to you. Thank you very much indeed, and thank you for your insights into healthcare policy and the future. Thank you.