This Week's Big Questions: Is the current reform of the NHS desirable or workable? Is Ian Brady mentally ill or evil?

Answered this week by novelist and cultural critic Raymond Tallis
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Are the Coalition’s current plans for the NHS desirable and workable?

The Coalition’s Health and Social Care Act 2012 is a Semtex suppository inserted into the rear end of the NHS. As a result, it is now struggling to cope with the most catastrophic and expensive redisorganisation in its history.

Resources are going to become scarcer as government plans for wasteful privatisation unfold. With eye-wateringly expensive tendering processes overseen by lawyers, taxes being diverted into profits for multinational healthcare entrepreneurs and integrated services torn into fragments, we shall get less for more.

The good news is that the most toxic parts of the Act can be repealed without further reorganisation. Labour has promised to do this. We need to hold them to this promise.

What, if anything, needs to be changed at the NHS to make it more efficient in health outcomes and economically sustainable?

International comparisons show that the NHS was until recently highly efficient. An independent Commonwealth Fund report in 2010 on healthcare in seven industrialised countries placed the NHS high on quality, efficacy and access to care and at the top (above Netherlands and Australia) on efficiency.

If further privatisation is stopped, we shall return to this high level of efficiency. If not, we shall move towards the abysmal situation in the US where, according to a report published earlier this year, 18 per cent of GDP (nearly twice that of UK) delivers health outcomes that are at or near the bottom of 16 industrialised countries.

Even if co-operation replaces competition, there will still be challenges. Professionals should be free to introduce novel, properly evaluated ways of managing chronic illness, to suggest rational concentration of specialist services in (fewer) centres of excellence, and propose new ways of working to integrate health services and health and social care, so that people get the help they need rather than help dictated by the services that have been historically available. A culture of candour and kindness needs to be fostered to address failures in care in some areas.

Like it or not, we will have to have a grown-up, honest conversation about what services should be regarded as priorities, and how much people are willing to pay, through taxes, for care that should, of course, remain free at the point of need.

Is health tourism a serious drain on the NHS’s resources?

According to official figures, health tourism costs the NHS about £12m a year or 0.012 per cent of the budget. The mean-spirited commitment to a “clampdown” is driven by a government wanting to out-Ukip Ukip. Most doctors are disgusted and will resist the invitation to set aside the ethos of their profession, and indeed their common humanity, in order to act as outposts of the defunct Border Agency, hounding ill people who come to them for help.

What lessons can be learnt from the scandal at the Care Quality Commission?

The CQC is the latest of a series of government agencies that have been created to fill the vacuum left when Labour abolished inspections by professional bodies, such as the medical royal colleges, that were too keen to tell inconvenient truths about deficiencies in patient care. The CQC is an arm of government and staffed by individuals who may be discouraged from upsetting their paymasters. They need to be replaced by visitors drawn from professional bodies with appropriate expertise whose first loyalty is not to the government of the day but to professional standards and the quality of care.

Should presumed consent for organ transplant be extended to all of the UK?

Organ transplantation is life saving but many people die awaiting a suitable donor. This is unacceptable, particularly as the vast majority of people would be happy to donate organs, but may fail to get round to registering or their organs are lost for logistical reasons. Presumed consent is the only way to ensure offered organs are collected. Though I like to think of my body as a smorgasbord of benefactions after I die, others alas may object to saving the life of a fellow citizen at no personal cost. So there should be the possibility of opting out of presumed consent.

Is Ian Brady mentally ill or evil, or both?

There is no easy answer. Brady is a psychopath, but such personality disorders are not clearly psychiatric illnesses comparable to, say, paranoid schizophrenia or hypomania.

However, the rejection of his bid to be moved from Ashworth High Security Unit to a jail where he would prefer to be, as he would find the company more congenial, seems right. Importantly, it has received the support of the families of the murdered children who have suffered over many years, not the least because Brady has compounded his cruelty by refusing to tell them where his victims are buried.

Raymond Tallis is the co-editor with Jacky Davis of ‘NHS SOS: How the NHS Was Betrayed – and How We Can Save It’, £8.99