Over the next two years, the NHS budget will top £205bn, and then the cuts will come – or will they? Andrew Lansley, the shadow health secretary, has said a Conservative government would increase spending on the health service after 2011. On the other hand, David Nicholson, the NHS chief executive, has said the service will have to make "efficiency savings" of between £15bn and £20bn from 2011 to 2014. Add to that an ageing population and a rising number of people with long-term conditions. At present, 45% of the population have one or more long-term conditions, absorbing 80% of the NHS budget. So how will the health service cope?
How can it improve quality, increase productivity and shift the organisation from a "sickness" service to a promoter of good health and wellbeing? The need to make that shift is beyond doubt. Keeping people fit and healthy and out of hospital is an imperative for both the quality of life of individuals and to deal with future financial pressures.
Two steps have to be taken to help make that shift happen. The first is that politicians have to begin to tell a different story about the health service. Instead of concentrating on hospitals, acute care and waiting times – important as they are – Labour and Conservative politicians need to highlight the hugely varied and imaginative ways in which preventative measures are beginning to make a difference to Britain's health. A difference that is especially important to communities in which deprivation and the absence of neighbourhood regeneration means that health inequalities hit hardest, so life is shorter and often more restricted and painful.
The political narrative has to start referring to measures such as health trainers recruited locally, subsidised gyms and healthy living centres that offer training, nutrition classes, parenting support, debt and benefits advice, courses and guidance on how to self-manage a long-term condition. This is health seen in its widest context.
Second, the grip of the consultants and GPs has to be loosened. The NHS has 1.2 million staff. Thousands upon thousands have good and often simple ideas about how to improve the service; help patients and cut costs – but too often those ideas go nowhere.
In the NHS, too often, there isn't the space, the time, the management structure to encourage and develop ideas that might also involve a certain amount of risk. If an idea comes up from the lower ranks, too often – in a target-driven culture – it goes straight in the waste disposal unit.
Since Lord Darzi's review, money and measures have been introduced to try to accelerate the necessary shift in attitude. A "right to request" a "spin out" has been established that recognises that all frontline staff have the option to set up a social enterprise and, if it is viable, to keep their NHS pension and receive a three-year contract from the NHS.
In addition, the Social Enterprise Innovation Fund (SEIF) has £100m to invest in innovation and the Regional Innovation fund (RIF), controlled by the strategic health authorities, has another £220m.
While a step in the right direction, SEIF and RIF money amounts to pennies in comparison with the NHS's entire budget. What also has to be avoided is a situation in which these "new" social enterprises simply replicate existing NHS services. What they have to offer instead is holistic, preventative care that puts the patient in charge and improves wellbeing and quality of life.
Bernadette Porter, for instance, is a nurse consultant who has worked with multiple sclerosis patients for more than 20 years. Her good idea was to put emailing and video conferencing in their care. It might sound obvious but it took a lot of drive to overcome the resistance of professionals.
In her scheme, GPs seeking a consultants' advice on a neurological matter can email and expect a response directly, rather than having to wait days for a reply to a letter. A patient can go locally to a video conferencing centre to have a checkup instead of travelling miles at much greater cost to the see the specialist in person. In addition, a patient handling their own care can call a nurse on a hotline for advice rather than leaving a message in the hope that at some point the call will be returned.
Over the next 12 months a pilot will test out this linked service called NeuroResponse, funded by Porter's employers, UCLH foundation trust and the Young Foundation's Health Launchpad. Feedback is already good. Once it becomes a service it will save literally thousands of pounds per patient but, more important, it gives the person much more control over their time and their medical help, and it improves the quality of their lives because it averts emergency admissions to hospital.
Fifty people a week are diagnosed with MS, many of them young; they don't want to see themselves as patients for life. Many will have years of living with the disease. Porter's good idea can help. Her social enterprise encapsulates how the NHS has to change. We can no longer afford the traditional superiority of the man or woman in the white coat and some technology-averse professionals. Consultants, for instance, like to see patients in person, even if it is to tell them there's no change. That's costly – especially to the patient's time. Incredibly, some hospitals still don't use email, so for GPs and consultants to use it to communicate is, for some, a step too far. Allowing telecare, a nurse at the end of a phone to help an MS patient, for some consultants, is an unwelcome dent to their professional pride. But it works.
The publication sent to NHS staff to inform them about their right to "spin out" and set up a social enterprise, says: "The most important reason for making a request will be to improve the service you want to deliver and to respond to an unmet need. If you think that the social enterprise model with its independence, flexibility and community involvement is the best way to achieve this change, then you should consider putting in a request."
A great deal of what's done in the health service is driven by hierarchy and tradition: that's the way it's always been. Good ideas for change can come from staff, from patients, from individuals who have never had a day's illness in their lives. All it needs is a fresh pair of eyes and a healthy disregard for custom. That's what politicians need to be talking about – how to put the health back into the NHS.
