The Italian philosopher, Niccolò Machiavelli once remarked that “there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to indicate a new order to things, for the reformer has enemies in all those who profit by the old order and only lukewarm defenders in all those who would gain from the new”.
Previously, I wrote in this column about the foundation hospitals experiment in Britain, and remarked that, at this stage it would be hard to say who had been the more influential: Tony Blair with his mixed economy view of public and private providers delivering choice and quality; or Gordon Brown, whose statist tendencies are closer to the core value of a national health service.
The health service think-tank, the King’s Fund, may have provided some answers to that key question with its retrospective review, published just this week, of progress since the report by former banker, Derek Wanless, urged a massive hike in spending and root-and-branch reform.
Wanless, who authored both the original review in 2002 and the progress report, looked at four key questions: if the extra resources needed had gone in; how they had been spent; if the health service was better or worse as a result; and what improvements could be made for the future.
These are the very same questions we are asking here, and I suspect people in most other countries would be asking of their health services.
In terms of economic growth and public spending, both Ireland and Britain have travelled a broadly similar road over the past decade. Both have made spectacular economic gains since 1997, and both have opted to channel much of that additional money into health services, with the result that health spending in both is now close to the EU average.
Ireland has quadrupled its health budget in the space of a decade, albeit off a much lower base. The UK has increased the amount of cash going into its health services by a massive €60 billion since 2002.
Over 40 per cent of the extra cash in the NHS went on pay and price inflation, although the benefits have yet to be “fully realised” from the agenda for change. The experience on wage costs here has been similar. We bought off the public sector unions with a billion-euro benchmarking for change process which, by any objective assessment, has delivered little of substance.
Although the increases in frontline staff numbers here have been significant, the true cost of benchmarking in terms of resources forgone for capital development and additional recruitment, may never be known.
Yet, it is clear that even more money will have to be found for all the new developments and staff, which are still required in both countries. In the UK, they are aiming to build at least 100 new hospitals, modernise over 3,000 GP premises, and recruit even more new doctors, on top of the 7,500 extra consultants and 2,000 GPs in place since 2006.
While the co-location initiative seems like an imaginative solution to the beds crisis here, we are still light years away from developing the physical infrastructure for a fully-functioning, responsive, accessible primary care service. That said, the education and training infrastructure for the doctors, nurses and allied health professionals is now largely in place.
The area where both countries know they can make real headway is through using technology to improve care and management processes. However, the experience of both has been mixed to say the least.
The PPARS fiasco has made our health services wary of using technology but it must be understood it is the widespread use of technology by the private sector which gives it a unique competitive advantage.
In Britain, the biggest peace-time project, as the NHS’ IT modernisation initiative is often described, is threatening to undermine the recent productivity gains in the NHS. A common thread between the two countries is the difficulty of persuading staff that they ought to change, when they are neither rewarded nor penalised for continuing as they are.
What becomes clear from reading the Wanless Review is that underlying population health problems – those things that are “rooted in the way of life of the people”, as Dr Brendan Hensey, a former Secretary General of our own Department of Health once put it – will have a serious, negative impact on any service that could otherwise perform well.
With the diseases of affluence now on the rise, the challenge is to find a new balance between the managerialism necessary for a sustainable health service, and the mission that underpins one capable of responding to major challenges. Perhaps Blair and Brown have both been proven right to a point. Machiavelli on the other hand had it sussed from the start!