For Twitter or Google, whose revenue potential is stratospheric, analysts have difficulty in defining how ‘sustainable‘ their business model is.
Turning the NHS into a Darwinian ‘survival of the fittest’ always implied that there were bound to be winners and losers. With recent legal decisions firmly deciding that NHS Foundation Trusts, as “enterprises”, cannot merge on purely economic competition law grounds is a profoundly significant decision, you can certainly say we are living in dangerous times.
And yet ‘sustainability’ is possibly the most misused word in English health policy. It means different things to different people. Its ambiguity means that it is highly popular, particularly for its midleading potential.
I was having dinner with a senior lawyer in Stockwell the other evening, and we both decided that, for many, the word had become synonymous with a meaning of ‘maintained’. We felt this usually led to a discussion of ‘we can’t go like this’, thus softening up the discussion to save money.
There is some method behind this madness, however. Rather than spreading money thinly around various hospitals, possibly there can be fewer hospitals with a ‘safe’ level of resources.
This argument clings onto the idea that the NHS funding is finite, and increasingly ‘unaffordable’. This of course is a perfectly rationale argument if you assume that the Government is incapable of producing economic growth. And for the last three years, the Government has taken us on a turbulent rollercoaster ride of GDP when the UK economy had been recovering in May 2010.
It is currently argued by some that the most successful healthcare organisations are those that can implement and sustain effective improvement initiatives leading to increased quality and patient experience at lower cost. Indeed, the NHS itself has produced a “Sustainability Model and Guide” to support health care leaders to do just that.
Next year, the “NHS Sustainability Day 2014” will feature tools and case studies with proven technologies, methods and projects that have yielded promising results. Technology is often cited as a potential source of the ballooning NHS budget, but the NHS simply has to learn how to order and use technology which is most appropriate for the needs of employees.
So why have the media and other professionals actually lost sight of the actual definition of ‘sustainability’? The politicians have an agenda to make the NHS more ‘affordable’, given the parties en masse wish to embrace ‘savings’ and not be THE parties of high taxation. This, however, means that politicians are being somewhat economical with the truth, and a responsible media here is critical.
Sustainability is the “capacity to endure“. In ecology the word describes how biological systems remain diverse and productive over time. Long-lived and healthy wetlands and forests are examples of sustainable biological systems. For humans, sustainability is the potential for long-term maintenance of well being, which has ecological, economic, political and cultural dimensions. It usually comes from an idea that you look after the people involved, and the environment.
Thee most widely quoted definition of sustainability, as a part of the concept sustainable development, is that of the Brundtland Commission of the United Nations. It was provided on March 20, 1987: “sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”
However the neoliberal approach taps into the oft-quoted saying, “The richer get richer; the poor get poorer.” Power always gets in the way of fairness in the game of sharing. With ‘finite resources’, unfortunately there will always be winners and losers. For parties which claim to offer ‘comprehensive, free-at-the-point-of-need’ NHS, clearly it is impossible to square this particular circle.
Irrespective of the ageing population, which is a sensitive argument as it implies that aged individuals are a ‘burden’ on the rest of society despite the value that they have generated over their lifetime, “demand” appears to be fundamentally outstripping “supply”.
According to the 2008 revision of the official United Nations population estimates and projections, the world population is projected to reach 7 billion early in 2012, up from the current 6.9 billion (May 2009), to exceed 9 billion people by 2050.
In 2009, McKinsey says the NHS can save an initial £6bn-£9.2bn a year over the next three years through “technical efficiencies”. This produces a cumulative three year saving close to the £20bn NHS chief executive David Nicholson has been talking about since his annual report in May.
But the McKinsey report went further, suggesting the NHS could save a further £10.7bn a year on top by improving quality and shifting care to the most cost effective settings. Sir David Nicholson, as in effect the NHS’ CEO, grabbed the bull by the horns. Unfortunately, some Foundation Trusts have used ‘efficiency savings’ to run skeleton staff who are always a number of patients ‘behind’ in the Medical Admissions Unit or A&E.
According to a previous report from the National Audit Office, in 2011-12 there was a large gap between the strongest and weakest NHS organisations. The difference was particularly marked in London. At the time, there were 10 NHS trusts, 21 NHS foundation trusts, and three Primary Care Trusts (PCTs) reported a combined deficit of £356 million. The NAO estimated, based on their census of PCTs, that without direct financial support, a further 15 NHS trusts and seven PCTs would have reported deficits.
Sustainability is an issue in the Lewisham case (judgment here). Judge Silber remarked that on occasions it has proven impossible to improve speedily the performance of a failing NHS organisation sufficiently to secure an adequate quality of care for its patients within sustainable resources. For that reason, an exceptional bespoke procedure was introduced to deal with situations which arise,
At paragraph 3, Silber describes it as follows:
“in the words of a senior official of the Department of Health, Dr. Shaleel Kesevan, “where very occasionally it proves impossible to improve the performance of an NHS organisation sufficiently to secure adequate quality of care within sustainable resources”. This regime is entitled the “Unsustainable Providers Regime” (“the UPR”), which as its name shows was intended to deal with failing NHS organisations.”
It is clear then that some of the basic, actual, definition of ‘sustainability’ has got lost in translation. This is unfortunate given that the primary purpose of politicians, of all shades, should not to be to mislead the general public whether intentionally or unintentionally.
Above all, the NHS should be in touch with its wider environment. This does mean that the NHS should look to the forests or trees for inspirations. It means that when 50,000 protest lawfully in Manchester, there is no news blackout and people are genuinely concerned about why people are so upset.
It means listening to local residents in Lewisham. It does not mean instinctively using hardworking taxpayers’ money to appeal against a decision from the High Court in the Court of Appeal.
It also means listening to the views of nurses when they’re in a job, and listening meaningfully to them if you need to sack them. It is not as if the NHS is actually short of work to do, which is why some find it objectionable that there are staff cuts with ever-increasing demand.
That is the true meaning of ‘sustainable’. Unfortunately, the current Government is producing amendments to the insolvency regime to make neoliberal closures easier for the State, quicker than you can say, “Earl Howe”.
The NHS might be truly ‘sustainable’ if you pay especial attention to hardworking hedgies, as per the Royal Mail privatisation. To take the neoliberalisation of the NHS to the limit, you could sell it off as an initial public offering (or flotation). But is this another difficult choice the public are being shielded from?
The word “sustainable” has been bastardised. It has been taken away from its true meaning from the macroeconomics. Such abuse of language is symptomatic of an abuse of political power.
Many posts like this have originally appeared on the blog of the ‘Socialist Health Association’. For a biography of the author (Shibley), please go here.
Shibley’s CV is here.
