NHS: Too Big to Scale?
Bigger is Not Better
Unlike Germany’s competitive and nimbler healthcare system, the UK’s NHS relies on command-and-control. But the indicators reveal a NHS system gripped by short-termism with resources focused on hospital care instead of preventing expensive hospitalisation, explains Dr Tony Hockley.*
On Easter Sunday the minister announced that his plan had delivered 121,000 protective gowns for care staff within a two-day period (for 3 million health and care personnel), and that the delay in responding to queries on protective equipment has been cut to less than three days. He had already set himself the challenging target of delivering 100,000 COVID-19 tests per day by the end of April, with a total of around 300,000 diagnostic tests done by mid-April. By this time, Germany had already conducted 1.7 million tests across some 170 laboratories. Some commentators are already highlighting the devolved, federal health system as a potentially important factor in the German capability to scale up testing so rapidly.
Once this crisis is behind us there will be much considered analysis of the comparison between the capabilities of the German health system and those of the NHS. At present it is far too early to judge success or failure, but the capacity of German healthcare to deliver widespread coronavirus testing at speed and scale will be an important focus for future analysis.
In 2004 George Baum from the German Ministry of Health and Social Security, gave his observations on the country’s post-reunification health system, in a pamphlet (Systems for Success: Models for Healthcare Reform) for Politeia. Baum noted that the system is based on a philosophy that marries social solidarity with competition:
‘The German approach has always been based on a firm belief that people’s needs are better met in a system where competition exists and where private suppliers work for patients who are also their customers. Indeed competition is at the very heart of the philosophy which underpins the delivery of healthcare in Germany. Why? Because it both guarantees people’s dignity and promotes technical innovation.’
The NHS is now moving in the opposite direction, as integration displaces the remnants of the so-called “internal market” of the past 30 years. As with previous reversions to command-and-control, this seems to be driven more by an ambition for cost control than any vision for future care and systemic reform. The best indicator of a system that is gripped by short-termism is that resources remain focused on hospital care instead of preventing expensive hospitalisation. For all the fine talk and multiple reports over many years, very little has changed. The NHS remains a treatment service, not a health service. The inability to respond to the population health needs of a viral pandemic, but the extraordinary capacity to scale up hospitalisation, provides a stark reminder of this perennial problem for the NHS.
Analysis of the UK response to the COVID-19 pandemic has focused on ministerial decisions and the science behind them. As yet, no-one can forecast how this will play out for any country given the level of scientific uncertainty, so this tactical analysis is inevitably inconclusive. After the herculean efforts to tackle this coronavirus pandemic critical analysis must turn to the systemic issues that ministers have faced regardless of their tactical decisions.