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
Belief, disbelief and beyond belief
Nicola Sturgeon and Tony Blair. Photo: Getty
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Nicola Sturgeon's SNP, like Tony Blair's New Labour, is heading for a crash landing

The fall of Tony Blair should be a set text for anyone wishing to know what happens next to the SNP.

If there was one thing the SNP and New Labour had in common, it was the hope. Both offered themselves as a burning torch of optimism to publics that had become tired of the same old gang running things in the same old way. Both promised a fairer, more equal society and a fearless embrace of the modern world with an appealing freshness and energy. The voters bought it: both won big, repeatedly.

The thing is, if you’re elected on a mandate to be different, you’d better be different. In many areas, for a long time, New Labour managed to be just that. The smiling PM with the huge majority pushed through radical policies, some of which even worked. Tony Blair’s methodology was so successful and so convincing that the Conservatives and the Lib Dems reshaped themselves in his likeness. Arguably, a form of New Labour won in 2010 and 2015.

But, as they say, it’s the hope that kills you. When the inevitable attritional realities of governing start to weigh, when you make, as you will, bad decisions, when the list of enemies grows long, when you’ve just had your time, you’ll fall like all the rest – only, when you’ve soared so close to the sun, you have that much further to plummet.

The fall of Blair and of Labour should be a set text for anyone wishing to know what happens next to the SNP. Sunday night’s debate between the Scottish party leaders was, I think, a foretaste of what’s coming – a public that until recently was politically and emotionally invested in the Nats is growing restive. In time, this will turn to disenchantment, then anger, then revenge at the ballot box. This is the unbreakable cycle of democratic politics.

Some of us have warned since the start that the SNP had over-promised and could only under-deliver. Its raison d’etre is independence; everything else - literally everything else - is just another brick to build the path. And so education reform cannot be either radical or unpopular, even if it needs to be so to work, because the SNP cannot afford to alienate teachers or the teaching unions or parents. Bricks, you see. Same with the NHS and doctors and health unions and patients. All the separatists have done – all they could have done, given their nature - is deploy the rhetoric of the radical while in reality body-swerving hard choices and conflict at any cost. And where they have found themselves taking flak, they’ve pointed south to Westminster: "it’s no’ our fault, it’s theirs".

But voters show signs of wearying of the predictable blame game and waking up to the time-limited strategy of show-over-substance. Middle Scotland is either ignored or maligned by the middle-class socialists who drive the nation’s political debate, but it is where elections are won. The SNP has secured the support of enough of these people to win every recent election in style, but somewhere along the way the party seems to have forgotten this was a mandate not for independence, but for good government. Ten years in to SNP rule, each new audit of public services seems to wail like a warning siren – things aren’t just not improving, they’re getting worse. The SNP is not keeping its part of the deal.

So, during Sunday night’s debate it was Nicola Sturgeon, not Ruth Davidson or Kezia Dugdale, who found herself in the audience’s cross-hairs. It will have been a strange experience for a woman more used to public adulation and a clamour for selfies. There were the teachers, who complained about the damp squib that is the Curriculum for Excellence, the SNP’s flagship education policy; who pointed out that a fifth of primary pupils are leaving without basic literacy and numeracy skills; and who warned that lowering the standard of exams in order to push up the pass rate was not a mark of success.

Then there was the nurse who said she had been forced to use a food bank (the existence of which has been used repeatedly by the SNP as a stick with which to beat the Conservatives and Westminster): ‘I can’t manage on the salary I have [which is set by the Scottish Government]. You have no idea how demoralising it is to work in the NHS. Don’t come on your announced visits, come in in the middle of any day to any ward, any A&E department and see what we’re up against.’ She delivered the evening’s killer line: ‘Do you think your perceived obsession with independence might actually cost you… in this election?’

The list of reasonable criticisms is growing and will grow further. The ideological obsession with free university tuition for Scottish students is increasingly seen as a sop to the better-off, while in England the fee-charging regime has seen the number of students coming from poorer families climb. Ms Sturgeon’s demand for a quick second independence referendum, when a worried middle Scotland was focused on what Brexit might mean for its future, was tone deaf.

The SNP has another problem (one that New Labour, for all its flaws, didn’t face): its doctrine of infallibility. The Nats’ constitution explicitly prohibits its elected members from criticising the party, its policies or each other. While total unity is useful when you’re on the climb, it starts to look bonkers when the cracks are showing. Allowing public self-criticism, far from being a sign of weakness, is a necessary vent for inner tensions and a sign to voters that a political party is something more than a cult.

That ‘cult’ word has long dogged the SNP and its supporters. The party has tried hard to normalise its electoral appeal while keeping the flame of independence burning bright, but it has been a difficult balancing act. The pro-independence mob is an ugly thing when it is unleashed (and it has suited the leadership to open the cage at times). Claire Austin, the nurse who criticised the First Minister on Sunday, has found herself at its mercy. Immediately after the debate, the Nats briefed (wrongly) that she was the wife of a Tory councilor. The SNP branch in Stirling said Tebbitishly that if she was having to use food banks "maybe she needs to tighten her belt a bit more?" Joanna Cherry, a QC, MP and the SNP’s Home Affairs spokesperson, was forced to publicly apologise for spreading "Twitter rumours" about Ms Austin.

The ravening horde has largely kept its head down since the 2014 independence referendum, but we now see it hasn’t gone away - it is not enough for the SNP’s critics to be debated, they must be destroyed. This isn’t the behaviour of a normal political party: it’s the behaviour of a cult.

I might be wrong, but I have a feeling that when the SNP does fall it will fall quite quickly. Its belief in its infallibility, its inability or unwillingness to do self-deprecation or apology, will increasingly aggravate voters. There is nothing to suggest the current public policy failings will be addressed, and plenty of signs that things will get worse. How, then, do you arrest your fall?

The SNP offered hope and promised it was different, and the voters believed. The sense of betrayal could make for a very hard landing indeed.

Chris Deerin is the New Statesman's contributing editor (Scotland). 

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