On the Critical List: How the NHS is being killed by politics and bureaucracy

13 April 2012

The NHS is 60 today. But a writer who's spent a year investigating it at every level says it's now in terminal decline - being killed by politicians, bureaucrats and the madness that's seen 30,000 beds disappear despite all the billions.

The brass band from Yorkshire Main Colliery trooped up to a doctor's surgery in Edlington, South Yorkshire, and began to play.

The doctor hung a Union flag out of the window and gave all the players a drink. The NHS had arrived.

A whole new world: The first babies born on the NHS under the 1948 Health Act

A whole new world: The first babies born on the NHS under the 1948 Health Act

That was exactly 60 years ago. Ever since, the NHS has exerted a powerful hold on the nation.

Its fairness defines us. It is a source of pride and comfort that people receive free medical care.

The NHS has always been far more than a health service. Former Tory Chancellor Nigel Lawson described it as 'the closest thing the English have to a religion'.

Nick Bosanquet, Professor of Health Policy at Imperial College, talks of the 'important human commitment' the NHS represents.

But strip away the nostalgia, the brass bands and drinks all round, and how effective is the NHS today?

Does it offer value for money? Is it efficient and flexible enough to keep the nation healthy over the next 60 years?

Will it be able to deal with an ageing population? Will it be able to satisfy an increasingly well-informed public with new and expensive drugs and treatments, just as the British taxpayer has almost certainly decided enough is enough? 

In decades to come, will we still celebrate the NHS with the same pride, affection and sense of wonder displayed that summer morning in Yorkshire 60 years ago?

I spent 11 months in hospitals around the country in order to investigate a report on management in the NHS.

I shadowed health care staff and interviewed a range of people from porters and cleaners to chairmen and chief executives. It is clear that on its 60th anniversary, the NHS is at a crossroads. 

No longer is it the envy of the world. Compared with the services provided across the Channel, NHS patients are less likely to survive cancer and more likely to die from a stroke, while our MRSA rates are the highest in Europe. The NHS also fails to offer value for money.

Health advisor Lord Darzi: His report 'does not address the fundamental problems facing the NHS'

Health advisor Lord Darzi: His report 'does not address the fundamental problems facing the NHS'

This week, to celebrate the 60th anniversary, ministers have published an NHS Constitution, establishing a patient's 'rights and responsibilities'.

Health minister Lord Darzi set out his vision for the service in a report which reiterated the founding principles of the health service: 'Care is to be universal, free and based on clinical need.' 

Such principles sound wonderful but do not address three fundamental problems facing the NHS. The first is bureaucracy. At its inception, the NHS was a very British compromise.

State- owned, centrally planned and centrally financed and run, it was a socialist revolution in a market economy. It was designed to emulate the state collectives of Stalinist Russia.

Sir William Beveridge, the architect of the NHS, promised that his proposals would take the country 'halfway to Moscow'. Sixty years on, Russia and China are shedding their monolithic state industries. We still have the giant NHS. 

The NHS too often puts the interests of those who work for it above those who use it. That is the nature of state bureaucracies. They are self-perpetuating.

They take on a life of their own. Any attempt at reform has unexpected and often unwelcome consequences.

Like any large bureaucracy, the NHS has a history of hijacking policies that are supposed to benefit the patient for its own purposes.

Look at what happened to the record amounts of money splurged by this government  -  doubling in the past five years to £100billion a year. 

For every £10 spent last year, for example, £9 went on increased pay for NHS staff and prices while productivity fell by 10per cent.

Nurse numbers rose by 22per cent, but 'a disastrous failure of workforce planning', according to the Commons health select committee, saw senior managers increase by a staggering 62per cent.

Dr Maurice Slevin, Senior Consultant Medical Oncologist at St Barts, examined how that affected patient care. He compared an NHS hospital with the private hospital he attended.

The NHS hospital had four and a half times as many managers, administrators and support staff to nurses as the private hospital.

For the private hospital to have the same ratio as the NHS, it would either have to recruit a further 143 administrators or sack 186 of its 240 nurses.

So the fact remains that without reform of the NHS, all the good intentions from this government came to one end  -  to expand and strengthen what Alan Milburn, then Secretary of Health, called 'a culture where the convenience of the patient can come a poor second to the convenience of the system'. 

The dedication and professionalism of many NHS staff mean some people get excellent service some of the time. But it is despite, not because of, the system.

In our attachment to the principle of the NHS, we have allowed a vast bureaucracy to replicate itself at the expense of our health.

There is another major obstacle to achieving a health service fit for future generations: politicians. They simply have to get out of the health care business.

At the top of the NHS sits the Minister of Health, answerable to Parliament. From the beginning, Nye Bevan understood the political implications of this unique set-up.

A month before the service was launched, he told the Royal College of Nursing: 'Every mistake which you make, I shall bleed for.' 

While Bevan ran a relatively small, manageable NHS, politicians ever since have stage-managed it for their own ends.

This week's anniversary is a marvellous opportunity to free the health service from political control but the Government has rejected the idea.

As the chief executive of one hospital told me sadly: 'More and more, I realise my job is really about politics. We are an extension of the Civil Service.'

The NHS's first priority is to make the Government look good  -  even at the expense of patient care.

The political nature of the NHS prevents management addressing the third, and greatest problem: capacity and the need to plan for more patients with more complex needs.

This was the issue raised by every senior manager I interviewed. For the unpalatable truth is that Britain faces an 80 per cent rise in the elderly population in the next 43 years and a reduction in younger taxpayers to support them.

As a senior non- executive director explained: 'With our ageing population, we've got to plan long-term.'

But the very political nature of the NHS condemns it to short-term fixes. As she described bitterly: 'Just as you try to plan for the future, along comes another new government initiative designed to garner good headlines which, once again, sweeps you off your chosen road.'

A chairman of an acute hospital trust explained how a lack of capacity combines with politics and bureaucracy to toxic effect.

With the best of intentions, the Government introduced a target of no more than a four-hour wait in A&E.

As a result, at three hours 59 minutes, doctors must make a snap decision whether to admit or not. As the majority of patients are elderly, it is safer to admit them.

And the outcome? Patient admissions in his trust shot up a 'mind boggling' 10 per cent every year.

This put 'alarming pressure' on the beds. But over the same period the Government had cut hospitals beds in his trust from 2,000 to 1,600.

Across the country it is the same story. Government targets with a lack of beds have contributed to a rise in hospital acquired infections.

Overcrowded wards are difficult to clean and staff too busy to wash their hands or clean properly between one patient leaving and the next arriving.

According to the Office for National Statistics, deaths from C. difficile have trebled in three years.

Graham Tanner, chairman of the National Concern for Healthcare Infections, estimates 230,000 patients catch C.difficile and MRSA each year, with an average mortality rate of 15per cent.

The chairman shakes his head, saying: 'Politicians don't understand what they have unleashed,' he went on, 'I was passionate about the NHS. That passion is hard to justify.'

As long as they refuse to address the problem of capacity, every government initiative will remain, at best, a wish-list  -  at worst, catastrophic for patients. 

Take just one example  -  the pledge from this week's Darzi review to give patients drugs on the basis of clinical need rather than cost.

This is meant to end the so-called 'postcode lottery'  -  but at what cost elsewhere in the NHS? The Government gives no indication of how it will pay the estimated £100 million worth of extra prescriptions. 

The truth is that ministers refuse to address the problem of capacity in a system with finite resources.

It is telling that, despite intense pressure from unions, the Government refuses to enshrine the new NHS constitution in law.

The Department of Health, apparently, feared law suits. It was right to be fearful. The constitution is a pact with the electorate the government knows it cannot keep.

On July 3, 1948, the Daily Mail stated the terms of the new NHS clearly. 'On Monday morning you will wake up in a new Britain,' it told readers, 'with free doctoring, dentistry and medicine.'

This would cost 4 shillings and 11 pence out of the weekly pay packet. The paper went on: 'You begin paying next Friday.'

The Mail understood the NHS was a vast, compulsory insurance scheme. It takes money in taxes in exchange for care.

But there is one vital difference between the NHS and other schemes. The politicised NHS is under no obligation to keep its side of the bargain.

The result, as Dr Michael Dixon, chairman of the NHS Alliance (which represents NHS trusts) commented recently, 'is that rationing is the great unspoken reality' of the NHS.

Saga magazine published a survey suggesting that one in six people over 50 have been denied treatment on the grounds of cost.

Moreover, 16 per cent of doctors questioned in a survey by Doctor magazine said their patients had died as a result of not being treated.

More than half said patients had suffered unnecessarily, a figure considerably up from a similar survey nine years ago.

Dr Dixon put the blame on the political nature of the NHS and 'the politicians who continue to promise everything for everyone in order to win elections'. 

The easiest way to ration health care is to prevent the patient getting into a hospital bed in the first place.

So, on one hand we have a government promising choice, quality and 'a patient-centred service', and on the other, the removal of hospital beds as fast as it can.

Since Labour came to power, the number of hospital beds has fallen by 32,000  -  from 199,000 in 1997 to 167,000 in 2007.

More than 8,450 were lost in the year ending March 2007 alone  -  the biggest cut in 14 years.

The official policy seems to be 'remove capacity and you remove demand'. As one consultant commented: 'None of us want more patients  -  we can't cope as it is.'

Only this week, the Government castigated GPs for failing to offer patients a choice of doctor, even though doctors claim it is impossible since surgeries are 'bursting at the seams.'

What private insurance company could get away, after a lifetime of collecting premiums, with refusing or delaying treatment? Its directors would end up in court. 

Debbie Hirst is a typical victim. She was left to die after an NHS trust refused to let her top up NHS care with a cancer drug not approved by the National Institute for Health and Clinical Excellence. 

As she remarked: 'I'm a person who left school at 15 and I've worked all my life. I've paid into the system and I'm not going to live long enough to get my pension from this government.'

On this anniversary of the NHS, we are in dire need of transparency and honesty. We need to know exactly what we are getting for our money.

It is time to admit that even the best-managed health service cannot pay for everyone to have every treatment all the time.

The Government must start a debate on what a health service on a limited budget can provide. It must stop confusing the idea of saving our health with saving the NHS.

Other European countries manage to provide universal access without the need for a highly-centralised state structure.

It must put aside ideology and do everything humanly possible to increase capacity. It must exploit private insurance companies more boldly.

We want a health service with the ethos of the NHS, free medical care for all, combined with all the advantages of the private sector: efficiency, value for money, quality and innovation through competition.

To achieve that would be an act of political courage as brave and visionary as the founding of the service 60 years ago. 

  • Harriet Sergeant is author of Managing Not To Manage  -  Management In The NHS' published by the Centre For Policy Studies

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