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For a clear view of the NHS, look past the politics and promises of a cure For a clear view of the NHS, look past the politics and promises of a cure
(7 months later)
The NHS is a British glory, chosen by most as the best symbol of national unity. But it’s an eternal source of national anxiety too. Is it ever good enough? Born out of a fraught ideological contest, it can never escape the heat of the political battlefield.The NHS is a British glory, chosen by most as the best symbol of national unity. But it’s an eternal source of national anxiety too. Is it ever good enough? Born out of a fraught ideological contest, it can never escape the heat of the political battlefield.
The Guardian this month is taking its pulse – from top to toe, from head to heart, arteries, lungs and bowels – our journalistic scanner will run over it more thoroughly than we have explored any institution. We will find remarkable scenes of the best treatment there is. We shall also find greater organisational turmoil and financial strain than the NHS has ever known, a ligature tightening around its neck. Britain is tumbling down international tables for spending on health.The Guardian this month is taking its pulse – from top to toe, from head to heart, arteries, lungs and bowels – our journalistic scanner will run over it more thoroughly than we have explored any institution. We will find remarkable scenes of the best treatment there is. We shall also find greater organisational turmoil and financial strain than the NHS has ever known, a ligature tightening around its neck. Britain is tumbling down international tables for spending on health.
Related: The NHS may not survive this volcano of ideology | Polly Toynbee
The Commonwealth Fund, a private US foundation, has repeatedly judged the NHS the most efficient health system, delivering the best bang for buck of any country – but fewer bucks means the UK has more avoidable deaths than others. Money matters: countries get the results they pay for, spending matching outcomes (except the US, spending more privately for less). When Labour reached EU average spending, outcomes improved. The pernicious myth that the NHS is a “bottomless pit” comes from those who think costs can only be contained when people pay for themselves.The Commonwealth Fund, a private US foundation, has repeatedly judged the NHS the most efficient health system, delivering the best bang for buck of any country – but fewer bucks means the UK has more avoidable deaths than others. Money matters: countries get the results they pay for, spending matching outcomes (except the US, spending more privately for less). When Labour reached EU average spending, outcomes improved. The pernicious myth that the NHS is a “bottomless pit” comes from those who think costs can only be contained when people pay for themselves.
One problem with measuring NHS effectiveness is that no health service can compensate for social causes of ill-health: extreme inequality and poverty can’t be fixed by doctors. Nor can the NHS be efficient if failing community care tips more cases into its beds.One problem with measuring NHS effectiveness is that no health service can compensate for social causes of ill-health: extreme inequality and poverty can’t be fixed by doctors. Nor can the NHS be efficient if failing community care tips more cases into its beds.
Alarm bells are now ringing in the Department of Health, as trusts clock up mounting debts. Latest figures – for November, before the cold weather – show 34,000 A&E patients on trolleys for over four hours; 200,000 operations delayed; and waiting lists growing by 1,100 a day. The response of Jeremy Hunt, the health secretary, on Friday was to send an unprecedented threat to NHS boardrooms: “Providers who fail to balance their books without compromising patient care … could result in the entire board of a trust being dismissed.”Alarm bells are now ringing in the Department of Health, as trusts clock up mounting debts. Latest figures – for November, before the cold weather – show 34,000 A&E patients on trolleys for over four hours; 200,000 operations delayed; and waiting lists growing by 1,100 a day. The response of Jeremy Hunt, the health secretary, on Friday was to send an unprecedented threat to NHS boardrooms: “Providers who fail to balance their books without compromising patient care … could result in the entire board of a trust being dismissed.”
Where would brilliant new boards come from? Hunt demands £22bn of savings by 2020, but debts are expected to rise, with a swelling population and escalating numbers of elderly people. Despite a promised £8bn, the spending increase will stay at the same flat 0.9% a year from 2010 to 2020 – 10 years at its lowest: compare that with the near 4% average increase the NHS has been used to since 1948. Meanwhile, the social care crisis in local authorities is blocking more NHS beds than ever.Where would brilliant new boards come from? Hunt demands £22bn of savings by 2020, but debts are expected to rise, with a swelling population and escalating numbers of elderly people. Despite a promised £8bn, the spending increase will stay at the same flat 0.9% a year from 2010 to 2020 – 10 years at its lowest: compare that with the near 4% average increase the NHS has been used to since 1948. Meanwhile, the social care crisis in local authorities is blocking more NHS beds than ever.
Our reports will undoubtedly hear that “morale is at rock bottom”. In my experience it always is: clever, dedicated NHS people are never satisfied, always frustrated by obstacles to better care. Short-staffed and over-inspected, are they now under greater pressure? New technology and social change mean the NHS, often accused of institutional inertia, does need to be kept on its toes. But too often the balance tips from necessary reallocation of resources to pointlessly disruptive “reform”.Our reports will undoubtedly hear that “morale is at rock bottom”. In my experience it always is: clever, dedicated NHS people are never satisfied, always frustrated by obstacles to better care. Short-staffed and over-inspected, are they now under greater pressure? New technology and social change mean the NHS, often accused of institutional inertia, does need to be kept on its toes. But too often the balance tips from necessary reallocation of resources to pointlessly disruptive “reform”.
Reporting on the NHS since I wrote a book about it in 1977, I have watched each health secretary seize a scalpel and begin to operate, all declaring that they are the first to open up this “monolith, unreformed since 1948”. Yet these perpetual political cures are applied before diagnosis or evaluation of the medicine. The Thatcher era brought the internal market, with “competition” the magic bullet. Coming and going there have been regional health authorities, areas, districts and then strategic authorities; community health councils, GP fundholders, foundation trusts, independent treatment centres, primary care groups, primary care trusts, clinical commissioning groups, and now semi-devolution to councils.Reporting on the NHS since I wrote a book about it in 1977, I have watched each health secretary seize a scalpel and begin to operate, all declaring that they are the first to open up this “monolith, unreformed since 1948”. Yet these perpetual political cures are applied before diagnosis or evaluation of the medicine. The Thatcher era brought the internal market, with “competition” the magic bullet. Coming and going there have been regional health authorities, areas, districts and then strategic authorities; community health councils, GP fundholders, foundation trusts, independent treatment centres, primary care groups, primary care trusts, clinical commissioning groups, and now semi-devolution to councils.
No one counts the wasted productivity as staff reapply for old jobs with new names. Managers under various terror-and-targets regimes often survived no longer than Spitfire pilots. Labour health secretaries Alan Milburn, Patricia Hewitt and John Reid bought into the internal market and were similarly prone to bullying NHS staff with their own cherished nostrums. The terror of Jeremy Hunt’s Monday morning meetings to review trusts’ debts and waiting lists forces managers to put satisfying the health secretary above patients.No one counts the wasted productivity as staff reapply for old jobs with new names. Managers under various terror-and-targets regimes often survived no longer than Spitfire pilots. Labour health secretaries Alan Milburn, Patricia Hewitt and John Reid bought into the internal market and were similarly prone to bullying NHS staff with their own cherished nostrums. The terror of Jeremy Hunt’s Monday morning meetings to review trusts’ debts and waiting lists forces managers to put satisfying the health secretary above patients.
Every new health secretary arrives with “the answer”, and most get only two years to cut open the NHS: that’s how long Andrew – now Baron – Lansley lasted, before following too many predecessors into lucrative private health jobs. Simon Stevens, the NHS England supremo, is left to stitch the service back into cooperating mode, after Lansley sliced it into competing fragments in by far the most haphazard and catastrophic “reform” yet.Every new health secretary arrives with “the answer”, and most get only two years to cut open the NHS: that’s how long Andrew – now Baron – Lansley lasted, before following too many predecessors into lucrative private health jobs. Simon Stevens, the NHS England supremo, is left to stitch the service back into cooperating mode, after Lansley sliced it into competing fragments in by far the most haphazard and catastrophic “reform” yet.
No wonder NHS toilers sigh at politicians. Staff are the automatic stabilisers through every “transformation”. Why the perpetual motion? Because the puzzle is a fascinating intellectual challenge. Because a plethora of research keeps pointing to theoretically possible improvements, with no manual on how to implement them. Every other country torments itself over its health system: each feels dysfunctional in its own way. Ideological politicians pull on levers marked competition, privatisation and fragmentation. Others simply search for efficiency: if only we could bring the worst unit up to the standard of the best. Can’t they all be above average?No wonder NHS toilers sigh at politicians. Staff are the automatic stabilisers through every “transformation”. Why the perpetual motion? Because the puzzle is a fascinating intellectual challenge. Because a plethora of research keeps pointing to theoretically possible improvements, with no manual on how to implement them. Every other country torments itself over its health system: each feels dysfunctional in its own way. Ideological politicians pull on levers marked competition, privatisation and fragmentation. Others simply search for efficiency: if only we could bring the worst unit up to the standard of the best. Can’t they all be above average?
Every election brings new political promises plucked from the air, empty of evidence. Take the latest: no one counted the cost of David Cameron’s “seven-day NHS” pledge – it’s a prime example of what drives NHS staff mad. Up came one alarming report that “11,000 more die” at weekends, assuming a 10% increase. Is it true? John Appleby of the King’s Fund has read every paper and doubts it: too many differences in the types of weekend cases, despite attempts to account for that. This variation turns out to be across four days not two – Friday-to-Monday care, compared with Wednesday care. The same is found in many countries and no one knows why.Every election brings new political promises plucked from the air, empty of evidence. Take the latest: no one counted the cost of David Cameron’s “seven-day NHS” pledge – it’s a prime example of what drives NHS staff mad. Up came one alarming report that “11,000 more die” at weekends, assuming a 10% increase. Is it true? John Appleby of the King’s Fund has read every paper and doubts it: too many differences in the types of weekend cases, despite attempts to account for that. This variation turns out to be across four days not two – Friday-to-Monday care, compared with Wednesday care. The same is found in many countries and no one knows why.
Causes of weekend variations differ between hospitals, so no single solution would work. Put the numbers in perspective and the risk rises from 1.6% midweek to 1.7% on Saturdays, a bit less alarming. “Even if you knew the cause, is the improved treatment worth the huge cost of fixing it? It exceeds Nice’s limit for each QALY [quality adjusted life year],” says Appleby – while Nigel Edwards, of the Nuffield Trust, says the government “plays fast and loose with data”. Politicians are not statisticians and often their value for money lies in a good headline, not alleviating suffering.Causes of weekend variations differ between hospitals, so no single solution would work. Put the numbers in perspective and the risk rises from 1.6% midweek to 1.7% on Saturdays, a bit less alarming. “Even if you knew the cause, is the improved treatment worth the huge cost of fixing it? It exceeds Nice’s limit for each QALY [quality adjusted life year],” says Appleby – while Nigel Edwards, of the Nuffield Trust, says the government “plays fast and loose with data”. Politicians are not statisticians and often their value for money lies in a good headline, not alleviating suffering.
Cameron regularly abuses Welsh health outcomes, because Wales is Labour-run – but he never compares it with parts of England that have the same rural, poor and aged populations. That’s why clever clinicians and managers grind their teeth at politics.Cameron regularly abuses Welsh health outcomes, because Wales is Labour-run – but he never compares it with parts of England that have the same rural, poor and aged populations. That’s why clever clinicians and managers grind their teeth at politics.
The NHS will always be in the political frontline. Oppositions will always claim it’s on its last legs and promise magic remedies. Shroud-waving is the weapon of choice for staff negotiating contracts and ministers warning of staff self-interest. Rational discussion of priorities, effectiveness and cost gets lost, as all cry wolf. This time the Guardian will be asking if the wolf really is at the door – or already inside the house.The NHS will always be in the political frontline. Oppositions will always claim it’s on its last legs and promise magic remedies. Shroud-waving is the weapon of choice for staff negotiating contracts and ministers warning of staff self-interest. Rational discussion of priorities, effectiveness and cost gets lost, as all cry wolf. This time the Guardian will be asking if the wolf really is at the door – or already inside the house.