A former editor of this magazine, Nigel Lawson, once described the NHS as ‘the closest thing the English have to a religion, with those who practise in it regarding themselves as a priesthood’. He meant to imply that blind faith tends to take over from observation. But there are other likenesses: bickering cardinals, grandiose PFI cathedrals that suck money from the pockets of believers — and now, finally exposed after being covered up for years, a shocking scandal of abuse.
Hospital managers like to commission paintings of the premises to hang in their corridors. In the case of Mid Staffordshire Hospitals Trust, William Hogarth would have been a suitable choice of artist. If the scenes of ‘routine neglect’ exposed by Robert Francis’s report were described in a charity campaign for a developing country, it would have tens of thousands of concerned Britons stuffing tenners into envelopes.
It is now clear that this was not a unique tragedy, but an egregious example of a systemic problem: what happens when the NHS goes wrong. As Francis reveals, poor care was bred into the system, with managers and medical staff responsible for it allowed to take up jobs elsewhere in the NHS. His central recommendation — that medical staff be put under a ‘duty of candour’ to report poor care — may open a very large Pandora’s box. According to a survey by the Nursing Times, one in four nurses believes their NHS hospital is ‘at risk’ of suffering a similar scandal to Mid Staffordshire. One in eight say hospitals are already experiencing a similar collapse in the standard of care.
Even the Conservative ministers who answer every challenge to the NHS by saying that more cash than ever before is being poured into its coffers should by now realise that this is not a question of money, but of organisation. The Francis report shows that the failure to take a clear-eyed view of the NHS and confront its failings has a human cost. Any dispassionate assessment would show that even when it is not showing callous bureaucratic negligence, the NHS performs remarkably poorly for a national treasure which is supposedly the envy of the world.
British health spending more than doubled under Labour, yet still our cancer survival rates are mediocre. To take one example, the five-year survival rate for colo-rectal cancer in the UK is 53 per cent for men and 54 per cent for women, compared with an OECD average of 59 per cent and 62 per cent respectively. Hospital-acquired infections have fallen since they peaked five years ago, but remain scandalously high. The latest figures, for 2011, show that a staggering 2,200 NHS patients died after acquiring superbugs in hospital. Patients are twice as likely to acquire such fatal infections in the NHS as they are in private clinics.
The Mid Staffs scandal is all the more shocking because it is so at odds with the NHS that we hear about at political conferences. In this NHS no bedpan ever went unemptied, no patient ever went unfed, no one — unlike the 800 at Mid Staffordshire — ever died unnecessarily. This NHS is staffed entirely by selfless Florence Nightingale types who devote their lives to healing the sick: nurses who, in the words of David Cameron’s 2006 speech, ‘do everything to make you comfortable’ and doctors ‘who desperately want to get to the truth’.
Of course, many NHS staff are indeed dedicated and good at their jobs. But probably no higher a proportion than car mechanics, cleaners, and other occupations whom we rely upon but who rarely get showered with praise from politicians. As Lord Lawson said, working for the NHS is seen as a higher calling. The self-imposed censorship which prevents political leaders from ever doing anything other than praising doctors and nurses has a serious consequence, as it leaves ministers shorn of the ability to speak objectively about NHS failures.
Like any other trade union, the ‘Royal Colleges’ of doctors and nurses fight to preserve their comfortable little empires — and deploy the added leverage of public emotion. Any kind of involvement of the independent providers in the NHS is denounced as the precursor to fully privatised US-style insurance-based healthcare system.
There is unquestionably in Britain a (justified) fear of such a system, which is hugely expensive and tends to have a very poor outcome for those who, either through poverty or self-employment, have fallen through the insurance net. But surely what attaches the public to the NHS is the principle that it is free at the point of delivery — not that it is run as one state-owned monolith. The trick of the British Medical Association and other professional bodies is to try to confuse the two things, making out that you must either have a fully state-run, state-owned NHS or a fully privatised healthcare system.
The goal of health reformers, including many in the NHS, is to advocate a third way: having an NHS which pays for the medical services, but having a network of clinics and physicians providing the services in independent clinics. That the patient, rather than being told where to go, is given the power to choose — and can go to the hospital with the best reputation. Given that the NHS has more employees than Estonia has people, such reforms were always going to be a British answer to perestroika — fiercely resisted by those who like the status quo. The severity of internal NHS opposition is that market-based reforms are doomed to be compromised.
If David Cameron’s Health and Social Care Act didn’t start off as one of the ‘pointless reorganisations’ he denounced in opposition, it has certainly ended up that way. After trying to force the greater part of the NHS budget into the hands of reluctant GPs, we have ended up with a system whereby the money will be handled by Clinical Commissioning Groups chaired by GPs but staffed by pretty much the same people who ran the Primary Care Trusts that preceded them. Whatever they are supposed to achieve, it won’t make any difference to agonised patients trying with great frustration to make an appointment at their local surgery. Several generations of ‘market’ reforms for the NHS have done pitifully little to offer patients a choice of GP.
While Cameron was bogged down in his legislation, the most promising development in the NHS happened almost by accident, without new legislation. Hinchingbrooke Hospital in Huntingdon was handed over to be run by the private-sector provider Circle Healthcare.
While health unions protested — Karen Jennings, head of health at Unison, called it a ‘very serious and worrying development’ — public disapproval was muted for the simple reason that the alternative was closure. The hospital had run up £39 million in debt, while simultaneously sliding to the bottom of patient satisfaction surveys.
The deal with Circle Healthcare was a last desperate throw of the dice. Yet the results have been remarkable. Within six months of its takeover in February last year, Hinchingbrooke had climbed from the bottom to the very top of the 46 NHS trusts in the Midlands and East Anglia in A&E waiting times and patient satisfaction surveys. Even satisfaction with the food had improved to 94 per cent — and since April 2011, it has only found two cases of MRSA. It is still an NHS hospital, but no longer part of the largest bureaucracy in the free world.
The Hinchingbrooke secret was to trust doctors, not bureaucrats. It ditched the corporate management culture which so bugs medical staff elsewhere in the NHS. A tier of managers was removed and clinical staff were put at the heart of running the hospital. They were made a majority on the board, and the hospital’s operations divided into 12 clinically led units. Nurses talked about being better valued and being taken seriously when they made suggestions. The Hinchingbrooke experience shows that excessive management has been the biggest ailment afflicting the NHS.
Hinchingbrooke Hospital is not yet out of the woods. As of last November, Circle was making slower progress on the financial front than it had hoped: it was by then £4.1 million in the red rather than the £1.9 million which it had budgeted to be by that stage. And as expectations have risen, patient satisfaction has fallen. The experiment may yet fail. But even if it does, at least some innovation will have been injected into the running of an NHS hospital.
As well as providing ideas for how to run a hospital, the Hinchingbrooke experiment provides a political model for successful NHS reform. If you announce wholesale upheaval, and then appoint civil servants to design a system which will govern the entire NHS — subsuming the good as well as the bad — you are inviting doctors’ and nurses’ groups to line up against you. How much better to pick out parts of the NHS which have obviously failed and to concentrate reform on those, when staff and patients can see that there is no alternative other than failure. There is every chance that, as in the Hinchingbrooke case, the results might overcome the prejudice of NHS bureaucrats hostile to the notion of independent management.
This is the approach which has worked so well in education. Academies began as replacements for failing schools which were facing closure. Not every academy has proved successful, but because a sufficiently large number have, better-performing schools, too, are choosing the freedom of life outside local authority control. Parents who still have an ideological commitment to the idea of councils running schools can find one if they want to, but there is now greater diversity. We see schools approaching education in a variety of ways, which can be tested against each other. At no point has this ‘creeping privatisation’, as left-wing critics put it, put under any kind of threat the principle of school education that is free at the point of delivery.
Ultimately, it would be better for everyone if the ideological battle for the British health service could be carried out in a similarly competitive marketplace of ideas. If public sector managers are running something well, let them carry on. But where they have failed — and there are plenty of examples — let the NHS hospitals be put under independent control. Over time, the NHS may naturally evolve into the sort of service which Cameron would not have dared even to try to legislate for: a buyer of services from a variety of public and private providers, with patients themselves, not GPs, being the ultimate commissioners of services.
As for now, how about handing Stafford Hospital to an independent provider, as Hinchingbrooke was? Yes, reform brings its risks. But the brutal lesson of Mid Staffs is that leaving the NHS alone does not mean that patients won’t be killed. ‘The suffering undergone by the patients and those close to them in Stafford demands that the lessons to be learned are not considered for a day or two, and then forgotten,’ Mr Francis said when presenting his report. He says, in terms, that the extent of failure uncovered in the NHS system ‘suggests that a fundamental culture change is needed’, and this does not mean yet another bureaucratic reorganisation. Good luck to anyone minded to set up a ‘save Stafford hospital from privatisation’ protest group. It is clear that the principle of a monolithic NHS run from Whitehall is not one worth trying to save.