Over management and bureaucratic targets have distorted surgery and General Practice. It is “fundamentally dishonest and “No one is willing to admit publicly what so many inside the service privately understand..” Mr Hunt is the current Billy Liar, but he has had many predecessors..
The NHS is in crisis. Yes, it’s always in financial trouble, but now it finds itself in the critical care ward. It’s running a combined budget deficit of more than £2.3 billion with three quarters of hospitals and other providers in the red.
Dame Julie Moore, the respected chief executive of the University Hospitals Birmingham trust, was asked last week to explain why the NHS was in such difficulty. A lot of it, she believed was down to leadership failure and incompetence on every level. “We’ve created a culture of people who are terrified of making decisions because you can’t be held to account for making no decision but you can if you make a decision,” she said.
Much of the blame lay with previous governments who had centralised power, leaving many of her colleagues “waiting for a command from God on high” instead of taking the initiative.
What Dame Julie describes is typical of highly politicised bureaucracies. In the NHS, this entails a culture of fear from the health secretary downwards. What are they all so frightened of? In essence, that the veils of illusion surrounding the NHS will be torn away and it will be seen to be the failure that it is. Yes of course there are dedicated staff doing magnificent work. Nevertheless, a recent study by Imperial College found that death rates in British hospitals were 45 per cent higher than the best performing country, the US.
Last year, the Patients Association reported that in most hospital trusts there were patients waiting longer than the NHS limit of 18 weeks between referral and surgery. In some, there were too few nurses to properly feed or care for patients.
The fiction has to be maintained that healthcare is getting better all the time. This is to mask the fact that the NHS’s core aim — to provide all with the same level of state healthcare free at the point of use — is an impossibility. It creates an inexhaustible demand for funding.
The NHS in England spends £116 billion per year. It’s still not enough. Hospitals are now being told to shed staff to dangerously low levels. This was entirely predictable.
As a panic response to the Mid Staffordshire scandal three years ago in which hundreds of patients endured appalling standards of care, the health secretary vowed that staffing levels must rise and to hell with the cost. Clearly, there would be a day of reckoning. That day has arrived.
Measures designed to deny reality go back to Margaret Thatcher. Even she was not prepared to declare the NHS unfit for purpose. Instead she decided to run it like a business. This merely piled on new layers of dysfunctional management. Today the service boasts no fewer than 16 directors of “transformation and corporate operations” alone.
Targets, the bureaucrat’s principal means of demonstrating improvement, create a plethora of perverse incentives. A report by the Nuffield Trust found that thousands of patients are dying because the focus on high-profile conditions has distorted the way NHS surgery is organised. Waiting lists and cancer care are measured nationally which means that hospitals structure surgery around them. Yet elderly patients admitted in the middle of the night with a burst appendix or gallstones are not measured, and often get poorer treatment.
No one is willing to admit publicly what so many inside the service privately understand. The result is that successive governments, swearing undying loyalty to the NHS, have quietly shuffled off responsibility for it to the market.
Some of these privately provided services are notably better. The issue, however, is the way this is fragmenting the NHS. Private health companies tend to do what is straightforward, leaving the NHS with the more complicated and expensive stuff.
The point is that this is fundamentally dishonest. The government pretends the NHS is delivering, while stripping it of coherence, responsibility and accountability so that it is no longer the thing it purports to be.
Ministers cannot admit this because the health service is one of the few remaining institutions of which voters feel they can be proud. As the former chancellor Lord Lawson once observed, the NHS is “the nearest thing the English have to a religion”. They believe the choice is between state control, which channels compassion, and heartless private health insurance.
Not so. In Europe, social insurance schemes predominate, covering even the poorest. They provide choice, accountability and, crucially, patient control and leverage. Even at their most basic level, their standards are far higher than the NHS.
Countries have many different types of social insurance but the common feature is that people pay into a scheme that covers healthcare provision for all. Because purchasers can choose to leave one scheme for another, competition drives up standards. Paying for care is thus viewed as both equitable and value for money.
All healthcare systems are having to grapple with the insoluble problem of inexhaustible demand. Surely, though, the public should be credited with some intelligence. The NHS model has expired. It has ceased to be. Time to ’fess up, end the deceit and move on.