We are in danger of loving the NHS to death

Universal healthcare is the least citizens should expect. To make the NHS better for patients, politicians, press and public alike need to cultivate a healthly scepticism towards it, not give it unlimited adulation.

When Gary Walker broke the terms of a non-disclosure agreement to reveal the impact on patients of excessive target-setting at the United Lincolnshire Health Trust over which he used to preside, he revealed a great deal more. Most obviously, he lifted the lid on a culture of fear of that still pervades much of the NHS, a culture in which whistle-blowers stand to lose reputations and careers, in which silence is commonly bought through the use of legal gagging clauses that break the spirit and perhaps the letter of the Public Interest Disclosure Act. It's significant that when the BBC put Walker's allegations to the NHS, the response of the trust's lawyers was to write to the former manager threatening him with the loss of his £500,000 severance package, rather than to deal with the substance of his allegations.

But what's equally striking is that the story was presented as one about whistle-blowing, about the morality and legality of non-disclosure agreements, rather than about the horrendous overcrowding and patient neglect that caused Walker to blow his whistle. The fact that United Lincolnshire is one of fourteen NHS trusts currently under investigation for hundreds of excess deaths seemed of less significance than a debate about management practices. And of course it is important. A corporate culture that discourages and punishes whistle-blowing is one in which failures and abuses go unchallenged, one that breeds complacency and in which those responsible are rarely held to account. What is truly shocking, however, is that vulnerable people in our hospitals are spending their last days in squalor and dying needless deaths through dehydration and neglect.

At least it should be shocking. But perhaps, following years of revelations about dirt, mistreatment and neglect in hospitals - elderly patients left wallowing in their own waste, deprived of food and water while staff are sitting in offices filling in forms, beds parked in corridors while their occupants are treated with contempt - such tales have ceased to shock.

It's now two weeks since the release of the second report by Robert Francis into Mid Staffordshire hospital trust, where almost 1,200 excess deaths occurred between 1996 and 2008, years when the Labour government was pumping unprecedented amounts of cash into the NHS and boasting loudly about having transformed standards of treatment. By any standards, this is one of the biggest scandals of recent years - bigger than Savile, bigger than MPs' expenses, certainly bigger than the horsemeat saga that has largely relegated Mid Staffs to the inside pages. Bankers can steal your money, the press can invade your privacy, but only the NHS can kill you. Yet no-one has been forced to resign, and at this stage criminal charges seem an unlikely prospect. Yes, there have been ritual expressions of regret. But where is the outrage, where is the raw anger?

The Labour party, which was in government in the period covered by the Francis reports, prefers to talk about the Coalition's forthcoming reforms (or about horsemeat). The Conservatives, for whom Mid Staffs ought to represent an open goal, if only as evidence that their radical measures are needed, have been if anything even more reticent. David Cameron has contented himself with expressing his full confidence in Sir David Nicholson, the bureaucrat who presided over the Mid Staffs debacle and who now runs the entire NHS, dismissing calls for his resignation as "scapegoating."

For both main parties, where the NHS is concerned there's a fear of treading on sacred ground. It's especially acute for the Tories, fearful of detoxifying the brand by saying anything that might be construed as critical of the NHS. For Labour, meanwhile, the NHS is the great shibboleth. The Labour attitude is an unfortunate combination of sentimentality and a defensive sense of ownership. Its problems can be acknowledged only as unrepresentative and untypical; the only possible cure, more funding.

As for the public? The picture here, I suspect, is rather more mixed than often assumed by politicians or the press. The NHS regularly tops surveys of the things that make people proud to be British. At the same time, whenever the topic of hospital treatment features on a radio phone-in there's a huge response from people with bad experiences to share.  A talk by Christina Patterson on Radio 4 about the poor quality of nursing care she experienced while in hospital resonated hugely with audiences. Last summer, even as Danny Boyle brought a patriotic tear to many an eye with his vision of dancing nurses a survey recorded the biggest ever drop in public satisfaction with the NHS.

Few, though, are yet willing to contemplate any alternative. The former chancellor Nigel Lawson once said that the NHS was the closest thing this country has to a national religion. And indeed, the reverence with which the NHS continues to be treated is not entirely rational. Its devotees believe in the NHS despite all the evidence to the contrary, because to do so is an act of faith. The idea of state provision, "free at the point of need" (even while, much of the time, it isn't) is a powerful sustaining myth, a moral ideal whose purity negates the inconvenient fact that the provision itself is frequently worse than it is in countries with mixed systems. Belief in the goodness and inevitability NHS persists alongside the grumbling, alongside the equally widely held belief that the NHS is "failing", underfunded and fraying at the seams.

Universal healthcare isn't just a noble ideal, it is the least that citizens of an advanced society should expect. But there are many ways of providing it. When it was first established after the Second World War, the NHS one of the world's first experiments in nationalised medical care. It's still often said that the NHS is "the envy of the world"; but few other countries have copied it, and while it compares well with other systems in terms of cost efficiency it does much less well in terms of outcomes. Cancer survival rates, for example, are among the worst in the developed world.

What other countries took from the pioneering British example was the idea that universal health coverage was possible, and desirable; and they proceeded to build their systems in their own way, usually by mixing private insurance with public provision, ensuring that the most vulnerable didn't slip through the net.

All systems have their drawbacks. With the NHS, the main problem is lack of transparency, which allows abuses such as those in Mid Staffordshire and United Lincolnshire to fester. I see a direct connection between the lack of transparency and the NHS's sacrosanct place national life, certainly in political debate. Other countries may provide more of the people, more of the time, with better healthcare; they may protect the vulnerable more effectively, and be less unequal; they may keep more patients alive. But they will never be loved, as the NHS is loved. People who can see a connection between their financial contribution and the care they receive don't have this same superstitious reverence for their healthcare system, so in other countries it has been easier to introduce reforms.

"Each man kills the thing he loves," as Oscar Wilde once wrote. The NHS is in danger of being loved to death, by politicians, press and public alike. We should not love the NHS, any more than we should hate the NHS. We should, rather, cultivate a healthy scepticism about the NHS. We should appreciate that, however great the NHS's achievements in the past, it was built for a different age, an age of far greater social conformity and far less sophisticated (and thus expensive) medical care, when "one size fits all" represented a liberation not a straightjacket. We should try to separate the institutions and bureaucracy from the many tremendous people who work in it - who would, after all, continue to care for the sick and injured under whatever system happened to exist. And we should remember that, in the end, the patients are the only people who matter.

 

Danny Boyle's Olympics opening ceremony coincided with a survey recording the biggest ever drop in public satisfaction with the NHS. Photograph: Getty Images
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Trade unions must change or face permanent decline

Union membership will fall below one in five employees by 2030 unless current trends are reversed. 

The future should be full of potential for trade unions. Four in five people in Great Britain think that trade unions are “essential” to protect workers’ interests. Public concerns about low pay have soared to record levels over recent years. And, after almost disappearing from view, there is now a resurgent debate about the quality and dignity of work in today’s Britain.

Yet, as things stand, none of these currents are likely to reverse long-term decline. Membership has fallen by almost half since the late 1970s and at the same time the number of people in work has risen by a quarter. Unions are heavily skewed towards the public sector, older workers and middle-to-high earners. Overall, membership is now just under 25 per cent of all employees, however in the private sector it falls to 14 per cent nationally and 10 per cent in London. Less than 1 in 10 of the lowest paid are members. Across large swathes of our economy unions are near invisible.

The reasons are complex and deep-rooted — sweeping industrial change, anti-union legislation, shifts in social attitudes and the rise of precarious work to name a few — but the upshot is plain to see. Looking at the past 15 years, membership has fallen from 30 per cent in 2000 to 25 per cent in 2015. As the TUC have said, we are now into a 2nd generation of “never members”, millions of young people are entering the jobs market without even a passing thought about joining a union. Above all, demographics are taking their toll: baby boomers are retiring; millennials aren’t signing up.

This is a structural problem for the union movement because if fewer young workers join then it’s a rock-solid bet that fewer of their peers will sign-up in later life — setting in train a further wave of decline in membership figures in the decades ahead. As older workers, who came of age in the 1970s when trade unions were at their most dominant, retire and are replaced with fewer newcomers, union membership will fall. The question is: by how much?

The chart below sets out our analysis of trends in membership over the 20 years for which detailed membership data is available (the thick lines) and a fifteen year projection period (the dotted lines). The filled-in dots show where membership is today and the white-filled dots show our projection for 2030. Those born in the 1950s were the last cohort to see similar membership rates to their predecessors.

 

Our projections (the white-filled dots) are based on the assumption that changes in membership in the coming years simply track the path that previous cohorts took at the same age. For example, the cohort born in the late 1980s saw a 50 per cent increase in union membership as they moved from their early to late twenties. We have assumed that the same percentage increase in membership will occur over the coming decade among those born in the late 1990s.

This may turn out to be a highly optimistic assumption. Further fragmentation in the nature of work or prolonged austerity, for example, could curtail the familiar big rise in membership rates as people pass through their twenties. Against this, it could be argued that a greater proportion of young people spending longer in education might simply be delaying the age at which union membership rises, resulting in sharper growth among those in their late twenties in the future. However, to date this simply hasn’t happened. Membership rates for those in their late twenties have fallen steadily: they stand at 19 per cent among today’s 26–30 year olds compared to 23 per cent a decade ago, and 29 per cent two decades ago.

All told our overall projection is that just under 20 per cent of employees will be in a union by 2030. Think of this as a rough indication of where the union movement will be in 15 years’ time if history repeats itself. To be clear, this doesn’t signify union membership suddenly going over a cliff; it just points to steady, continual decline. If accurate, it would mean that by 2030 the share of trade unionists would have fallen by a third since the turn of the century.

Let’s hope that this outlook brings home the urgency of acting to address this generational challenge. It should spark far-reaching debate about what the next chapter of pro-worker organisation should look like. Some of this thinking is starting to happen inside our own union movement. But it needs to come from outside of the union world too: there is likely to be a need for a more diverse set of institutions experimenting with new ways of supporting those in exposed parts of the workforce. There’s no shortage of examples from the US — a country whose union movement faces an even more acute challenge than ours — of how to innovate on behalf of workers.

It’s not written in the stars that these gloomy projections will come to pass. They are there to be acted on. But if the voices of union conservatism prevail — and the offer to millennials is more of the same — no-one should be at all surprised about where this ends up.

This post originally appeared on Gavin Kelly's blog