{"product_id":"coming-ready-or-not-the-realities-the-politics-and-the-future-of-the-nhs-reflections-on-the-potential-of-consumer-power-to-renovate-health-care-public-policy","title":"Coming Ready or Not! - The Realities, The Politics and the Future of the NHS: Reflections on the Potential of Consumer Power to Renovate Health Care (Public Policy)","description":"\u003cp\u003e\u003cstrong\u003eBook info:\u003c\/strong\u003e Coming Ready or Not! - The Realities, The Politics and the Future of the NHS: Reflections on the Potential of Consumer Power to Renovate Health Care (Public Policy) (Hardcover, 336 pages) – Edward Everett Root Publishers, 2017. Language: English.\u003c\/p\u003e\n The critical challenges to the British NHS are the consequences of us all living longer, having to manage chronic conditions over time, expecting and demanding more, and being denied many innovative new drugs (notably, for cancer) which cannot be afforded at present by the too narrowly funded NHS. This needs to be changed, in line with more successful funding systems in Europe, Australia, and the Far East, where outcomes are much better than in the UK. This radical new book offers economic solutions based on direct financial incentives to the individual to care for themselves better, to save and invest in future funding, for a much broader funding base including the greater use of insurance, and to ask government to re-appraise the system urgently. It will be controversial, and will spark lively new debate, as well as serving as a student text for courses concerned with healthcare, and clinical practise.This new book follows Professor Spiers’ several successful previously published commentaries on the NHS and public policy, including Who Decides Who Decides? Enabling choice, equity, access, improved performance and patient guaranteed care, published by Radcliffe Medical Press.  \n\n                                         Editorial Reviews                   About the Author   The author has been a Prime Ministerial Adviser and has held senior national and local appointments, including being a member of the National Care Standards Commission and Chairman of the Patients’ Association.           Excerpt. © Reprinted by permission. All rights reserved.   'Coming, Ready or Not!'The Realities, the Politics, and the Future of the NHSBy John SpiersEdward Everett Root, Publishers, Co. Ltd.Copyright © 2016 John Spiers\u003cbr\u003eAll rights reserved.\u003cbr\u003eISBN: 978-1-911204-03-9\u003cbr\u003eContentsThe author, ix, \u003cbr\u003eBy the same author, xi, \u003cbr\u003eAcknowledgements, xiii, \u003cbr\u003eForeword by Professor Philip Booth, xv, \u003cbr\u003eStop press on Cancer services, xvii, \u003cbr\u003eIntroduction, xxi, \u003cbr\u003ePART ONE:, \u003cbr\u003e1. \"Coming, ready or not!\" The realities, the politics, and the future of the NHS, 1, \u003cbr\u003e2. The Great Divide. What you believe if you are a centraliser and a statist. What you believe if you are a dynamist, 25, \u003cbr\u003e3. Beware 'Choice'!, 39, \u003cbr\u003e4. How to make the market?, 53, \u003cbr\u003e5. Practising being practical, 63, \u003cbr\u003e6. The moral approach of the radical right, 65, \u003cbr\u003e7. Incentives, and the problem of knowledge, 69, \u003cbr\u003e8. Berlin's Two Concepts of Order, 87, \u003cbr\u003e9. The radical agenda now, 89, \u003cbr\u003e10. No Master Plan, 93, \u003cbr\u003e11. What's in the way of change?, 101, \u003cbr\u003e12. Abolish the customer? Or, safe in whose hands?, 111, \u003cbr\u003e13. Tell me, doctor, what will make choice real?, 117, \u003cbr\u003ePART TWO:, \u003cbr\u003e14. 'Only half way to paradise'? Social enterprise initiatives: the opportunity, the challenge, and the deficits of individual empowerment, 135, \u003cbr\u003e15. Money is not enough. Or, why Mr. Brown's approach cannot work, 143, \u003cbr\u003e16. Inside-out. Or, the contradictions revealed by present policies, 157, \u003cbr\u003e17. History as it might have been. And Might Still Be. Labour's opportunity for Health Care Reform, 167, \u003cbr\u003e18. Illustrating Liberty. The cases of Miss B, \u0026amp; of MMR, 197, \u003cbr\u003e19. Is choice disempowering?, 207, \u003cbr\u003e20. The 'My Daughter' test. Championing the patient, 213, \u003cbr\u003e21. Uncurling the rope, 219, \u003cbr\u003e22. Right Place, Right time. The relevance of NHS estate management to advancing the reforms. Or, How many beans make five?, 227, \u003cbr\u003ePART THREE:, \u003cbr\u003e23. No More Soviet 'Akademogorok.' Or, Stop Taking the Medicine from Dr. Marx, 235, \u003cbr\u003e24. Sidney Webb, 'self-deadness', \u0026amp; the NHS, 245, \u003cbr\u003e25. Open Sesame! Derek Wanless and the official revelation of crisis in health care, 261, \u003cbr\u003e26. Working practises in the medical profession. The Health Service Journal\/Glaxo Debate, 23 May 1995, 271, \u003cbr\u003eAN ENTERTAINMENT [?]:, \u003cbr\u003e27. Whatever Can We Do With The Kids Today? The 'Heritage Hospital Experience.' A Bank Holiday treat, 277, \u003cbr\u003eTHE KEY MESSAGE:, \u003cbr\u003e28. Changing the rules, to achieve change, 287, \u003cbr\u003eIN CONCLUSION:, \u003cbr\u003e29. Conclusion, 297, \u003cbr\u003e30. Finale, 309, \u003cbr\u003e\u003cbr\u003e\u003cbr\u003eCHAPTER 1\u003cp\u003e\"Coming, ready or not!\" The realities, the politics, and the future of the NHS.\u003c\/p\u003e\u003cbr\u003e\u003cp\u003e\"Nothing lies like the truth.\" Nelson de Mille.\u003c\/p\u003e\u003cp\u003e* The issues remain unaltered, despite the lapse of time. Indeed, startling so. And so I reprint this talk, given as the Annual Lecture to The National Association of Primary Care Annual Conference at the International Conference Centre, Birmingham on 15 November 2001. There were a thousand doctors present. Over-ambitiously, I prepared much more than I could deliver in the time. I have taken this opportunity to print the text in its entirety.\u003c\/p\u003e\u003cp\u003eThe topic I have been given by the examiners asks me to address the present, future, and politics of the NHS. How to fund and guarantee the delivery of prompt access for all to appropriate quality care is clearly the question of the day. And the question is asked and influenced more by culture and politics than by any other factors.\u003c\/p\u003e\u003cp\u003eI accepted your invitation even though I do not have the detailed knowledge and experience which you have in actually delivering care, in doing it day to day. And so I hesitate, with the words of Dickens' A Christmas Carol in my mind. Where he said \"it is always the person not in the predicament who knows what ought to have been done in it, and would unquestionably have done it too ...\" And when I look at the complexity of what you do I have a sense that every day the more I know, the more I know the less I really know.\u003c\/p\u003e\u003cp\u003eFor me, this lecture, however, is a return to the perennial issues that engaged me at Brighton – to try to see services from the patients' point of view. To be concerned about access, quality, funding, responsiveness, behaviour, culture, patient voice, and the impact of political realities. Cash, capacity, choice, competition, and compassion – if you like. As I consider these dilemmas and continuities I am reminded of what the Australian marine biologist Julian Pepperell wrote: \"May the fish that get away lure you back again.\" I have retained this commitment despite my experiences at Brighton. Indeed, this may be because, as W. S. Gilbert says in the wonderful recent film about the Savoy Operas, Topsy-Turvy, \"There is something inherently disappointing about success.\"\u003c\/p\u003e\u003cp\u003eThis lecture is necessarily a rapid and rough ride over a large and bumpy field. And too cursory a look into some rather well-swept corners. But I will try to offer a framework for considering the culture and political nature of British health care, the daily realities that culture and politics shape, and how a genuine transformation can occur. I try to figure out why things mean what they mean – if you take my meaning.\u003c\/p\u003e\u003cbr\u003e\u003cp\u003eI will address the following questions:\u003c\/p\u003e\u003cp\u003e1. Can the NHS as presently structured ever deliver the promised equity, 'fairness', reliable individual access, choice, improved performance, and patient guaranteed care??\u003c\/p\u003e\u003cp\u003e2. Must we go through the present cycle of increased investment but little cultural change to demonstrate to public and politicians that it cannot do so?\u003c\/p\u003e\u003cp\u003e3. Will the Prime Minister himself insist that the next general election is about health-care, funded, purchased, and provided on a different basis – and if so, why?\u003c\/p\u003e\u003cp\u003e4. Is higher taxation and either voluntary or compulsory health insurance inevitable and a necessary financial model, if we want to financially empower the individual so that we can actually deliver the founding ideas of the NHS?\u003c\/p\u003e\u003cp\u003e5. How can patients become more self-responsible – and, indeed, professional lives become more liveable?\u003c\/p\u003e\u003cbr\u003e\u003cp\u003eThese questions get to the ground of all the dilemmas. Most fundamentally, how to make sufficient money happen, how to enable individual choice and provider competition to happen. So as to increase choice, control costs, improve quality and productivity, change the culture, and expose poor performance to scrutiny and direct incentive for improvement. And what that means in individual lives. These are cultural and moral questions. Each helps us to ask how we can attain an equitable, accessible, reliable and affordable system of care and a different way of seeing ourselves, too. With much more cash and more capacity, with more choice and competition, with better outcomes and higher life expectancy, and with higher morale and professionally satisfying work.\u003c\/p\u003e\u003cp\u003eA system which encourages consumer choice and more accountability, both of professionals, providers and of consumers themselves. A system which requires patient self-responsibility, personal self-awareness, individual self-care and the responsibility to make cost-conscious, cost-effective - often difficult – choices. Balancing risk, with the individual making the inevitable and necessarily personal trade-offs. Learning as an adult. Being an adult.\u003c\/p\u003e\u003cp\u003eIf we want this we had better think seriously about how to structure an approach, what it is going to cost, and how it is going to be financed. Is this achievable only through higher taxation to match European levels of investment, and more direct payment through insurance or through other devices to increase private investment?\u003c\/p\u003e\u003cp\u003eThere are many different realities. Yours will depend on what you do, the pressures in your work, and how you view the world. I take it that for politicians the political realities in health care mostly concern votes, re-election, and surviving change. For them the issues are short-term. The realities for professionals are, of course, about treatments and results. But these lives too include the influence of politics on patient benefit, and professional satisfaction. The realities for the patient concern access – or its denial – diagnosis, choice, and outcome. They ought, too, to concern self-responsibility, self-care, life-style, and a proportionate view of what is possible. But there are few direct incentives encouraging and rewarding this. Too few appreciate that the best way to avoid the cure is to avoid the illness. And that the most appropriate rationing is probably to ration oneself. Without direct and personal economic incentives it is very difficult to get people to do what they envisage to be against their short-term interests.\u003c\/p\u003e\u003cp\u003eHowever, the overwhelming common reality in our present system is that politics is more important than patients, doctors, or medical practice. And it is a particular political mind-set which insists – albeit with benign intentions – that \"rational coordination\" and more planning is pre-ordained and can correct the failings of a centralised structure. It is indeed this structure and its assumptions which disempowers everyone involved, including the politicians. And because there is no free market in health care, never think there is no market. There is. There is a political market. It follows the rules of universal suffrage. Votes are bought in it. And, it seems, that every attempt to change the nature of the NHS either makes much of it worse, or merely reinforces the systemic failures.\u003c\/p\u003e\u003cp\u003eIt is in the political structure where these tensions resonate. It is here, too, that interest groups block change if they can. It is here that politics itself blocks the path to more dynamist, more innovative, more creative solutions. Politics itself has institutionalised these difficulties. But I will suggest it will be the political imperatives of an electoral system which will now impel and compel change.\u003c\/p\u003e\u003cp\u003eWhen he was Minister of Health the late J. Enoch Powell said that politicians are concerned with the general consequences of individual decisions, but doctors indeed, all those associated with primary care – are concerned with the individual relationship with the patient, and with the consequences of general decisions made by politicians. These tensions persist. Rudolf Klein called them the tensions between \"an absolutist ethic of treatment and a utilitarian approach to resource use.\"\u003c\/p\u003e\u003cbr\u003e\u003cp\u003eb. The major constraint to change is cultural, and thus political. \"The prison of awe.\"\u003c\/p\u003e\u003cp\u003eThe major constraint is cultural. This is, indeed, the crucial political reality. Max Weber said that man is an animal suspended in webs of significance he himself has spun. The iconographic status of the NHS makes prisoners of us all, ministers included. [1] For the cultural, practical, and political problems of British health care are a common inheritance. Perhaps the most important constraint on reality, present, and future is this \"prison of awe.\" This mythical mirroring of realities. This credulous willingness to believe. The NHS a symbol of sanctity in a wild world. We are all prisoners of this occult status of the NHS. Or have been, until lately. Emotion, perhaps inevitably, is at the root of much of our difficulty. It is, curiously, because of this that the NHS is both fundamentally stable and constantly volatile. An NHS constantly changed but persistently the same. The British have been married to the NHS, as Venice to the sea. But, as Professor Nick Bosanquet has said, \"the power of the ideal often swamps any objective assessment of the means.\" [2] Thus we have often confused an ideal best feasible care – with an institution.\u003c\/p\u003e\u003cp\u003eA fundamental example concerns the notion of public service. And the proper protection of \"the public domain\", in the interest of the well-being of all. Is it really true that public service can only be given by public sector organisations? And must we only choose between state monopoly and open markets? What do we mean by \"public service\"? We need to consider how private and voluntary means also regularly deliver public purposes. Public enterprise has shown it can serve the public interest. The Concordat is re-defining public service by realising that good service to the public – in harmony with 'public-service' values – is given by many organisations in the voluntary and in the independent sector. This has long been so. Long-term care. Acute care. Mental health care. The entire Hospice movement. Services delivered to high standards. We are now beginning to see more diversified provision and more from the private sector, whilst retaining the public service ethos by which the NHS has defined itself. And the clock has not struck thirteen.\u003c\/p\u003e\u003cp\u003eTo try to get the job of NHS reform and modernisation done within the old nationalised structure New Labour has very significantly increased spending. And it has shifted ground remarkably, too. The two-part Concordat, although still a very small part of all that the NHS does, is crucial psychologically and politically. [3] It is the first open-minded major bulletin of change for the strategic development of public-private relationships. The Concordat is one sign of the search to find politically negotiable bridges to a changed system. So, too, in my view, is Mr. Alan Milburn's Fabian Society lecture, his comments concerning choice of GP and hospital treatment, more provider freedoms and incentives to improve performance, stressed when he appeared before the House of Commons Health Select Committee as it reviewed Department of Health expenditure. There was a significant shift in thinking since The NHS Plan was published. But there is a good long way still to go.\u003c\/p\u003e\u003cp\u003eFast-track surgery units and specialist centres such as orthopaedics; overseas buying; the NHS renting private care from the independent sector; foreign companies setting up units here – all these increase provision and flexibility. The search for real change is on. However, the problem of how to get more sustainable revenues remains, as does how to empower the individual. And these are the unavoidable issues. The great guns, if you like. How they come about and how they change power relations – and the controls exercised by politicians – is crucial, too. For cultural change is essential. And this can only be prompted in large part by empowering service users financially, jointly and individually, in mutual-aid organisations. And empowering those who give service to do so. Indeed, it is not only insufficient to increase revenues without such a change. For the changes in quality, provision, responsibility, and funding which we seek are, I believe, otherwise unavailable unless there is significant cultural change.\u003c\/p\u003e\u003cp\u003eThe NHS is wholly politicised. But it is not this government alone which has politicised health care. Nor is it this government alone which has micro-managed the system. Nor are Tory claims that they will reverse this at all credible, at least without very significant cultural changes. For the NHS is inherently political, endemically centralising, and necessarily limiting to patient information, patient choice, and user responsibility. Its financial structure, too, necessarily limits the funds available. Of course, any health care system is political in some senses. But not all are centralised, bureaucratic, or limiting culturally in quite the way that ours is. Ours has entrenched centralisation and bureaucracy, because it was built on political assumptions which rejected dynamic user-led evolution. We live in a system where government decides what it is appropriate for the individual to spend on health care.\u003c\/p\u003e\u003cp\u003eIt is these problems which make it so difficult to make the NHS a patient-focussed service. I know that your organisation had endorsed this aim. And, of course, those such as North Bradford PCT which have achieved much through empathy and imaginative management. But they press at, and designate by implication, the limits of a system in which the less well-served patient has no choice, exit, or individual financial clout. Patient choice without individual, self-responsible financial clout will, I suggest, remain a chimera. Much mental health care, too, as the Sainsbury Centre emphasised again last month, remains persistently tied to the medical model. Users and carers remain uninvolved in care planning.\u003c\/p\u003e\u003cp\u003eBut even if they were to be more involved Trusts would remain very controlling. Many CCG's do much to try to shift this. However, stronger CCG's as purchasers are not in themselves a sufficient change. For the user has to be able to choose between purchasers. It is not sufficient nor is it appropriate to give the power to \"decision-makers\", as the Conservative health spokesman Dr. Liam Fox has urged. Two reasons why. First, doctors and professionals should be the advisers. Not the decision-makers. Second, the service user should be the decision-maker. And individual revenues should have to be sought from willing consumers. Then behaviours and attitudes would necessarily change. And, as I will suggest, revenues would increase, as would individual self-responsibility.\u003c\/p\u003e\u003cp\u003eAs he reminded me, my friend Julian Amery once told Harold Macmillan that \"Good jockeys ride difficult horses.\" The present effort at reform is revealing how difficult things actually are, and how hard it is to achieve change through politics. It is also revealing to the public and to the media that the old approach looks likely to be insufficient. For example, official figures released on 9 November showed an increase in NHS spending from £44.2 billion in 2000\/l to £48 billion this year. There was a sharp fall in waiting times, but no significant increase in the number of hospital patients treated. The impact on patient satisfaction (and on NHS productivity) is therefore probably small. However, an effort including major new investment in trying to make the present system work may be the only way for people to understand that it can never work. The only way they are going to stop believing in it.\u003c\/p\u003e\u003cp\u003ePoliticians wish to manage change, and to survive it. The evidence of little change despite much larger investment – though hurtful in the short-term in poll ratings – is, I think, a necessary prelude to a shift to a radical solution. It creates the opportunity for politicians to persuade themselves, one another, and the public at large. And to lead a different kind of debate.\u003c\/p\u003e\u003cp\u003ePoliticians, too, are prisoners of the system, and the history that systems create. They, like everyone else, need help in finding devices for effective change. Ministers set initiatives in place, willing the difference. They live in a universe where levers seem to be connected to live wires, but often aren't. Even someone like the present Secretary of State – Mr. Alan Milburn MP – who is certainly knowledgeable, committed and courageous. He has, for example, sought to tackle the hospital-driven culture and is negotiating for the performance data of individual doctors and clinical teams to be personalised. He doesn't think the problems are only about money. Indeed, he is challenging many assumptions, including his own. He has made it clear that we need a variety of ways to access quality care. And that the monolith is as problematic as the lack of money.\u003c\/p\u003e\u003cp\u003eBut the Secretary of State has, however, no alternative but to seek to micro-manage in a system without price, market, or user responsibility. Mrs. Thatcher's Secretaries of State were in the very same spot. And the so called \"internal market\" modestly offered cost-efficiencies but offered no choice or exit for unhappy patients, no individual financial control for informed patients, no dynamic entry for new providers, no sufficient demand-side shifts despite the relatively brief experiment with GP fundholding. Indeed, it gave markets a bad name without even trusting them. \u003c\/p\u003e\u003cbr\u003e(Continues...)Excerpted from 'Coming, Ready or Not!' by John Spiers. Copyright © 2016 John Spiers. Excerpted by permission of Edward Everett Root, Publishers, Co. Ltd.. \u003cbr\u003eAll rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.\u003cbr\u003eExcerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.\u003cp\u003e\u003c\/p\u003e                                           ","brand":"John Spiers","offers":[{"title":"Default Title","offer_id":46070024667370,"sku":"9781911204039","price":115.36,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0714\/5301\/6298\/files\/41fpx0Q31pL._SL1500.jpg?v=1781238314","url":"https:\/\/textbookme.store\/products\/coming-ready-or-not-the-realities-the-politics-and-the-future-of-the-nhs-reflections-on-the-potential-of-consumer-power-to-renovate-health-care-public-policy","provider":"TextbookMe","version":"1.0","type":"link"}