The Colchester hospital crisis shows the NHS is in need of major surgery

Intense, forensic scrutiny is part of the future for the NHS. Poor managers must go

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The Independent Online

Even the healthy in and around Colchester must be anxious. Anyone from the Essex town might need urgent medical treatment but at the local hospital urgency has a narrow meaning. A statement from the hospital pleads that only those with serious or life-threatening conditions turn up to Accident and Emergency. The plea assumes a degree of informed self-awareness on behalf of the suddenly ill. Should I not add to the impossible burdens on the hospital? Or am I about to die?

Meanwhile inspectors arrive at the hospital to discover that in addition to the A&E crisis, all is not satisfactory in relation to the treatment of some patients. There appear to be some echoes with the terrible findings at Mid Staffs.

Those dependent on the services of the particular hospital will not be the only ones who are nervy. The Government cannot afford the “NHS in crisis” to become an urgent issue so close to the election. Already the Health Secretary, Jeremy Hunt, has found some additional cash for A&E departments, but that will not mark the end of his hyper-activity.

Last winter, wholly understandably, Hunt was known to make direct contact with managers of specific hospitals to check up on how they were coping. As it turned out, the winter was mild and there was no immediate crisis. This year it seems the crises are not weather-dependent. The Colchester emergency takes place during a mild autumn.

The claims of poor treatment, the inability of the hospital to meet increasing demand for emergency cases, and the need for Hunt to neuter the NHS as a pivotal election issue are part of an increasingly familiar sequence with deep lessons for the future of health provision.

One lesson is already being partially learnt. The reforms required in the NHS are far wider than those that obsessed Tony Blair and David Cameron in his early days of leadership. Those reforms were largely about internal competition, other market-based changes, and theoretical patient empowerment that would raise standards while allowing the government to step back from direct involvement. Cleverly Blair insisted that any opponent of his proposals was “anti-reform”, implying that there were no other options for change and that critics were backward-looking defenders of the status quo.

By implication Cameron himself challenged the crude simplicity of the “reform versus anti-reform” juxtaposition. In a statement last year, following the investigation into the Mid Staffs scandal, he outlined a series of sweeping changes that focused more on scrutiny, accountability and the enforcement of higher standards. He called for hospital boards to be suspended for care failures, performance-related pay for nurses, a new chief inspector of hospitals modelled on the Ofsted inspection agency for schools, and an inquiry into hospitals with the highest mortality rates nationwide.

Far from standing back from the fray, the Prime Minister sought to pull several new levers simultaneously from the centre, a marked change of gear, even if other reforms sought greater de-centralisation. Indeed so many contradictory moves are being made that while some welcome reforms place new light on poorly performing hospitals, other changes make it difficult to identify precisely who should ensure that improvements are made.

The fact that Colchester hospital is under scrutiny arises partly from the inspection carried out by the Care Quality Commission, accountable to the Government. The scale and rigour of the inspections mean that hospital managements are more fully held to account, and patients are better informed about the qualities and deficiencies of their local hospitals. Its website is crammed with detailed analyses of individual hospitals. When the ominous verdict “requires improvement” is applied, the hospital under inspection has no choice but to raise its game. The even more damning verdict “inadequate” sends shivers down the spine of this reader of the website, and will hopefully lead to a more practical response from the hospital concerned. Scrutiny and accountability through inspection are important tools. With good cause Hunt has expanded inspections to GPs and points out that they can be as powerful a form of accountability as the targets favoured by the previous government. We await the detailed report of what the CQC discovered at Colchester, but any possible mistreatment of patients will now get the widest possible publicity. Intense, forensic scrutiny and accountability is part of the future for the NHS. Poor managers must go. The good ones must show other poorer performing hospitals how it is done.

The more complex dimensions of the Colchester saga relate to funding and structure, the familiar unmet challenges. Demand for NHS treatments of all types is soaring. A&E crises are partly connected to the difficulty in seeing a GP quickly, and also have quite a lot to do with the growing pressures at weekends when drink and drugs play their part in the hell that hospital waiting rooms can become on Friday and Saturday nights.

The head of NHS England, Simon Stevens, recently estimated that the NHS would require an additional £8bn a year by the end of the decade, an assumption based on sweeping efficiency savings. There will need to be tax rises and the introduction of co-payments to pay for a modern NHS, along with a renewed focus on preventative measures and personal responsibility. Stevens estimated the funding shortfall as part of his impressive vision for the NHS over the next few years, one for which he got the peak time slot on the Today programme for nearly 20 minutes, an honour usually reserved for a Prime Minister rather than a non-elected official. But is he in charge of the NHS? It is the Health Secretary who will be held to account at a general election, not an official.

NHS England is rather like the independent Bank of England but without the independence. Sometimes there are tensions between the Health Secretary and Stevens as to who pulls the levers. Cameron has been known to ask Hunt to act in relation to a particular sensitive issue.

Hunt has pointed out politely that his government gave away the power to act to NHS England. The blurring of lines at the top is straightforward compared with the convoluted line of command below, where it can be impossible to identify who is precisely responsible for what.

Until the funding gap is bridged and the hierarchy of responsibility is clear, those living in Colchester – not to mention a Health Secretary with an election to fight – will not be alone in having cause to be nervy.

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