When the Government announced an extra £500m for NHS accident and emergency services in England, the response from the medical establishment was unanimous. The money would be no more than a “sticking plaster”, a vain effort to “paper over cracks”. The inference – what else could you expect from some of the best-paid medics in Europe? – was that far more than this would be needed to make overburdened A&E departments anything like equal to their task.
Only a few days before, we had been treated to Professor Don Berwick’s government-commissioned review of the NHS in the wake of the Stafford hospital scandal – and the nurses’ disappointed response. They had wanted (of course) a definition of “safe” staffing levels to include actual numbers, but Berwick had declined to count. His central conclusion was that patient safety had to be the top priority in the NHS – which left strangely open the question of what other health service priorities the American professor uncovered on his travels.
And a few days before that, the High Court had ruled that the Health Secretary, Jeremy Hunt, exceeded his authority when he decided to downgrade casualty and maternity services at London’s Lewisham hospital. This was a big victory for local campaigners who had objected to their well-run hospital being, as they saw it, plundered, to help save a bankrupt hospital nearby. The downgrading had been just the latest Solomon’s judgement decreed by Hunt, who must reconcile insolvent hospitals and fierce local sentiment.
Each of these examples, in its own way, exposes a deep-seated malady, and the only reasonable response is the doctors’ talk of “sticking plaster” – but not as they meant it. The additional money, as David Cameron himself recognised, is at best a stop-gap; after all, no government wants to see dying patients left on trolleys in mid-winter. What almost no one in the system seems ready to accept is that the NHS needs much more radical treatment than has mostly been broached.
In its organisation and buildings, it is stuck in several time-warps – that of the 1940s when it was founded; that of the 1960s when it indulged in its first great building programme, and that of the 1990s, when the Private Finance Initiative precipitated even more new building and the Labour government’s injection of money allowed the NHS to keep doing what it was doing, in the way it was doing it, only more extravagantly. Only the philosophy – a universal service, free at the point of delivery – remains valid, and even that looks a little frayed in this age of mass travel.
A few clear-sighted individuals have a grasp of what is wrong. Jeremy Hunt – who reportedly volunteers at a hospital once a week – may be one of them, though the High Court ruling calls into question his power to do anything. Another is Sir Bruce Keogh, the medical director of the NHS for the past six years, who has been outspoken about the way politicians front campaigns to keep local hospitals open, even though they know that a different configuration of medical services could be an improvement.
A third is Lord Darzi, the cancer surgeon and former Labour health minister, who planned and – no less important – implemented the reform of stroke care in London in the face of widespread hostility. That reform, which concentrates emergency stroke treatment at specialist hospitals, has – according to the British Medical Journal – saved more than 400 lives in three years at a cost per patient that is lower than under the old, dispersed, arrangements. Let me repeat that. This is a system that results in fewer deaths and lower costs. It is not an impossible combination.
It is fashionable to decry the frequent, and seemingly contradictory, reforms of the health service. But these changes reflect not just budgetary strictures or new political priorities, but a compromise with one vested interest or other. It is tempting to conclude that the NHS has not really been reformed, ever, since its foundation in 1948. It has been tweaked, blown this way and that by the political wind, but never brought into the present day.
Why else do we still have big wards, even in new hospitals? Why is “team nursing”, where no one takes ultimate responsibility, still a model? Why were mixed wards tolerated for so long? Why is there not a mix of accommodation, so that patients can choose to pay a supplement for privacy, as in most of Europe? The answer to all these questions is the idea that universal, healthcare, should mean egalitarian. And who authorised the building of enormous, energy-inefficient new hospitals, when it was already known that fewer, better hospitals were needed? Who vetted the PFI contracts to ensure that the mortgages were affordable (which many are not)? The same people, perhaps, who are now paying out compensation for mis-sold insurance. And – an old chestnut this – who negotiated the contract that paid GPs so much more for less?
I have rarely seen more glaring examples of wastefulness, not just of space and facilities, but of food, medicine, appliances and – yes – staff, than in the NHS. I have seen expensive equipment piled up against walls, rendering handrails useless. I have seen medicine sent for disposal as being beyond their use-by date. I observe with incredulity the spread of nurses’ 12-hour shifts that suit everyone except confused and neglected patients. Amazingly, even after all the furore over Mid-Staffs, I have had to ask for a spoon so that my husband could eat the food provided and move his trolley so that he could reach it.
Outside hospital, the huge – financial and institutional – wall that separates health and social care still stands. No one, it seems, has either the will or the clout to demolish it, and so smooth the transition from hospital to home. With GP services, it is often hard to believe they are run for our benefit, rather than theirs. No wonder many young people – not, as often believed, ailing grannies – increasingly prefer the one-stop immediacy of even understaffed A&Es. Home services for the elderly and ill are patchy at best, while purpose-built housing often manages to be both primitive and expensive compared with elsewhere in the world. In Australia, 65,000 people live in comfortable modern retirement complexes. In the UK, the figure is 5,000.
This time last year most Britons, so it seemed, were re-running in their mind’s eye the inspirational scenes from the Olympic Opening Ceremony: the sepia-tinted pictures of happy children bounding on their hospital beds and cheery nurses going about their duties. All this was consoling, but it represented our self-image more than our reality. It has taken 12 months, which included publication of the Francis report into the scandal at Mid-Staffs, more examples of appalling hospital neglect and an expose of the dysfunctional watchdog, the Care Quality Commission, to dilute some – but by no means all – of that nostalgia. It is not GP-led commissioning, nor the delegation of some services to private companies, nor yet “the market” we should worry about, but making the NHS, at 65, fit for this century.