Reflections on the NHS... and why we might be our own worst enemies

Yesterday, I blogged about my recent minor surgical procedure, noting how well everything went, how kind and caring the nurses were, how efficient the surgeon was. And it got me to thinking about the NHS, not something that I've had much cause to do in the past. You see, as a very infrequent user of the healthcare system - I've been pretty fortunate to remain in good health - it is the sort of thing you take for granted. It will always be there, it will be free (well, freeish), and it will cure you if you're ill, and save you when you get broken.

Its status as a national institution is such that it was showcased in the opening ceremony of the London Olympics, and was protected from cuts by the incoming government - David Cameron promised that, you will recall.

SInce then, the NHS has come under pressure. Yes, the budget has been ring-fenced, and has kept pace with inflation. However, funding a national hearth care system is more complex than simply ensuring that it has the same amount of money in real terms. Inflation in the healthcare sector is traditionally higher that it is generally, and you can't manage demand in the same way that you might otherwise. And, as we find new and exciting ways of prolonging life, whilst more and more of us adopt lifestyles that make us more vulnerable to illness, injury and disease, the demands upon the system change.

You can deal with that in a number of ways, I guess. You can simply increase the funding available, you can charge for some services, you can seek organisational savings or you can just axe some services altogether. You might attempt a combination of some or all of these. But, the problem is that if you raise taxes, the opposition attack you. If you charge for services, or reorganise, or axe services, likewise. And, if you're a politician, you might conclude that it's all too difficult and give up.

Unfortunately, like any successful organisation, the NHS has to change to face the changing circumstances as they emerge. How many expensive pieces of kit can you have, and where do you put them, how do you incentivise your staff to be more efficient whilst maintaining service coverage, how do you address the demands of local residents, who have differing priorities in different parts of the country? All of these things require thought and the ability to adapt, and yet we protest about change, condemning it as meaning the end of the NHS as we know it when we know that, after every supposedly radical (and widely opposed) change in the past, it has still been there, still dispensing healthcare to all at a cost far lower to the public purse than it does in places like the United States.

But, if we continue to have opposition parties blindly oppose change whilst not engaging with the creation of a vision for the future of such a critical public service, we risk preventing changes that could save the NHS for decades to come. Instead, we need political parties and campaign groups to come together to create a shared view of what we need as a country, rather than treating the whole thing as a football to be kicked from one end to the other whilst the rest of us look on.

We will probably need to be pretty creative about the future shape of the NHS, we may even have to make some compromises in order to secure the broad principle of free at the point of access healthcare, but with an aging, increasingly unfit population, we're going to have to do something...

Reorganisation and angst in a corridor of uncertainty

I work for HM Revenue and Customs, as some of my gentle readers will be aware, an organisation which has had a few mishaps in recent years. Given that we raised approximately £380 billion for the Exchequer last year, you would think it self-evident that getting the structure right would probably be a good idea.

For many years, I toiled away, safe in the knowledge that I knew my management chain, could identify it most of the way up to the Board of Inland Revenue, and could be fairly certain that everyone in that chain had a vague idea as to what I did and where it fitted in.

Sadly, as the Department moves towards increasingly specialised roles, and away from the old concept of generalisation, I'm beginning to experience some existential doubts. I understand, and accept, that technology allows us to operate in ways unimaginable when I started but the old skills, whereby experienced officers could spot discrepancies, errors and evasions simply by reviewing a tax return have been replaced by risk analysis done by computer. The human touch seems to be being lost, at a time when the public are becoming increasingly keen on quality customer service.

We've also imported 'management skills' from the private sector, a concept which claims that a manager can manage any type of work as the skills required to do so are the same the world over. If only life were that simple... In a basic clerical situation, it may well be effective, but I work in an environment bound by tax law, and if you've ever seen a library of tax legislation, you'll understand how complex that is.

My current boss has had the dubious pleasure of managing me for more than a year now. He doesn't really understand what I do so ends up asking me for a report whenever an issue relevant to the group comes up for discussion. However, I'm not in those meetings so, if a counter-argument is put, he isn't equipped to fight our corner, a key role for a manager, I might suggest.

Since merging with our friends in Customs and Excise (they can kick down your door at four in the morning and requisition helicopters... am I jealous, you bet I am!), life has been one of permanent revolution, with new structures, new management jargon and the reconstruction of all that was recognisable as a chain of command. The latest rumour is that my team will be managed remotely by an Senior Officer (SEO, in old money) somewhere in London and Anglia Region. I look forward to discussing my promotion potential with someone seventy miles away who meets me once a month, if I'm actually at my desk.

I'm still loyal to, and care deeply about, the concept of HM Revenue and Customs as a core public service, after all, that's the very reason I joined the Department in 1986. However, it would be nice to be reminded in the midst of a maelstrom of reorganisation that someone out there cared about me...