Explaining the NHS reforms using only the 1,000 most commonly used words in the English language

The new NHS structure

Have you ever heard of Up-Goer Five? It’s a game where people try to explain a hard idea using only the ten hundred most used words. It’s not easy. It makes you think really hard about what you mean.

Huw Jordan said I should use Up-Goer Five to explain what I think of the big changes that happened not long ago to all the hospitals and doctors and stuff. Here we go.

There are four parts. Part one is about how things worked a long time ago. Part two is about what changed since then. Part three is about the stuff the people who are now in power just did. Go straight to part three if you just want to know about that. Part four is about what all this stuff means.

Stuff that happened a long time ago

65 years ago, people needed money to go to hospital. People without money could only hope a kind hospital would let them in and make them better — but for a lot of people, that didn’t happen. Instead they lived in pain or died early. People with less money died sooner and were sicker than people who had a lot. Some people said this showed we thought their lives mattered less. They had a point.

During the second big world fight, all the hospitals worked together for the first time. People said this was good and the hospitals should keep on doing it. After the fight ended, a lot of hospitals needed money or they would have to close. Something had to be done.

At the same time, we decided never to let money get in the way of making sick people better again. We would all pay a bit every month — everyone would pay what they could — and all the hospitals and doctors would be free when we needed them. Doctors would never need to ask how much we had, only how sick we were. The hospitals would talk to each other too, and work together to make the sick people better faster. By working together, they would make sure they didn’t spend more than they had to.

So, people would help each other, and hospitals and doctors would help each other too, and all the hospitals would have enough money to help everyone.

Most of us were very happy and felt good about what we had done together. We had made something new and exciting, and made a better place to live. Not many people in the world had that.

Some people, especially the people who had money and had never had to worry about paying the doctor, couldn’t understand why we had to help the people without money get better, or why they had to pay for it. Why couldn’t the people in small houses just work harder and pay for it themselves? Then they would live longer. Life is hard and they should be okay with that.

Things that have changed since then

Two things are different now. All in all, they are both very good things, but they do cause some problems.

The first thing is that by making more people better, lots more people lived longer. But because they didn’t keep working until they died, there was less money to go around from the young people who paid a bit each month to keep hospitals running. The number of old people got bigger a lot faster than the number of young people.

The second thing is that doctors with big brains figured out more ways to make us better, and because of this new stuff we spent a lot more money than we thought we would spend when the plans for all of this were first written.

The people in power had to decide what to do. Should we all pay more? They were scared to ask. Should people have to pay for doctors again, sometimes? They knew we would hate them if they did that, and not give them power again.

Then they thought, ah, here’s a bright idea. Let’s make hospitals work like businesses. We will give all the money to people in offices far away from hospitals, and they will make the hospitals play a game for it. By playing the game, hospitals will make the money go further.

It will also let sick people decide where to go, they said, and the best hospitals will make the most money. (But really, sick people just want to get better and know what is happening to them – and a lot of the time they don’t even know enough to decide well.)

(Important: the people who live up in the cold place, the people who live over to the left and the ones who live over the little bit of water who get rained on a lot thought this was crazy, so they did their own thing.)

The stuff that just happened

The people who were in power before did a lot of stuff to make hospitals work like businesses. They said this would save hospitals money, which they could use to help more people. The facts didn’t exactly agree. Not many of us were paying attention, so we let them do it anyway.

The people who came into power three years ago just did even more of that stuff. Even though they promised they wouldn’t, they said everything had to change. They took the way hospitals and doctors work together and broke it up into hundreds of little groups, all playing a game against each other, like businesses do. It was hard to understand and even harder to explain.

At the same time as changing everything, they said there would be no more money, even though there were more people to help and more ways to help them. In the next ten years, we would need a lot more money to give all the sick people what they needed to get better, but this wasn’t allowed. Instead we had to make hospitals even more like businesses, and make doctors run the businesses. Having doctors decide how to help sick people was a good idea — the people in offices didn’t really know what to do and didn’t care as much as doctors. But doctors didn’t train to be doctors because they wanted to manage businesses.

Making big changes to the way things worked was one problem. Having to get used to spending less money was another. Both problems together made one big and very bad problem that was too hard to do all at once. Not without hurting the sick.

There was also a third problem. The people who ran hospitals had already ended up being more interested in the business and numbers stuff than making sick people better and keeping hospitals safe. Some hospitals were not safe at all, and people who should have been helped died. More and more, people were telling lies.

Problem four was that the people in power said it didn’t matter who made the sick better as long as people got the care they needed without throwing away money. They said business people had big brains and would help everyone out by running bits they hadn’t been allowed to run before. For the first time, this meant some of the money we paid every month would go to helping business people buy nice houses instead of caring for the sick. The businesses could decide to run only the parts that made them the most money, so they picked the easy bits and left hospitals to do the hard stuff.

That was the most important change. The relationship between the people who manage hospitals, those who care for the sick and the sick people themselves would be different. Now money would come before care. Businesses would manage hospitals to make money for themselves, instead of putting that money back into making our hospitals better. They would cut everything they could get away with, not so they could pay to care for more people but so they could make their houses bigger and drive faster cars. It would be a race to the bottom.

What all this stuff means and why it was done

Businesses don’t always tell the truth or help each other, because they don’t want other businesses to do as well as them, and they don’t want to look bad in case people spend their money somewhere else. When hospitals do this, they stop working together for the good of the sick, and they throw away more money. The problem we already had with some bad hospitals not telling the truth and hurting the sick would only get worse.

Remember how all this started — hospitals had to work together. But they forgot. Lots of people did.

Having more businesses caring for the sick made it even harder to work together. Lots and lots of little parts each making cuts and trying to make the other parts pay instead is not a good way to save money. Hospitals, doctors and others who care for the sick need to work together as one big family, because that is the only way to put the money they have to best use.

Saying it doesn’t matter who makes sick people better is the first thing you need to do if you want give businesses a way of making money from running hospitals. It makes the job of caring for the sick less about helping people and more about making money. It makes it very easy for things to change one day so businesses can make doctors say, “This is how much care we can give you for the money everyone pays each month. Would you like quicker care, better care? We can do that, but only if you have money.” And then we will be right back where we started. People with less money will die sooner and be sicker than people who have a lot. The people with money will say, “Why couldn’t the people in small houses just work harder and pay for themselves? Then they would live longer. Life is hard and they should be okay with that.”

Eventually, the people in power want all hospitals to be run by their friends’ businesses. Their business friends gave them money to make sure this would happen, and are very happy about this first big step toward making that dream real.

The people in power say they are not making cuts, even though they have made cuts every year since they came into power. At the same time, they are making big changes, and this makes things very hard. We did need changes, but the changes we needed were ones to help us all work together to give the sick the best care and make the best use of the money we have. Instead, we got a big business game which makes that harder to do than ever before.

The people in power never believed in the idea of caring for people without money. They never liked the idea of doctors not having to think about how much money someone had, only how sick they were — they liked the way things were in the past.

They always wanted to do this, and now we’re letting them. And the place is getting less caring.

They were right about giving doctors more power to decide stuff though, so they did do one good thing.