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The NHS is Britain’s beating heart – don’t let it flatline

After 30 years of meddling with the NHS, are we now at risk of destroying our most precious public s

I have hazy memories of my parents getting their first telephone. It was the late 1960s, and telecommunications was a public service. There was a waiting list but, in time, we got to the head of the queue. An engineer from the General Post Office installed the necessary equipment and we were connected - or at least, connected any time our neighbours weren't using their phone: ours was a "party line". I don't recall any grumbles about the tortuousness of the process, nor about having to share with the people next door. The sense of wonder at what was now possible must have mitigated any frustration. It was marvellous to be able to speak to relatives and friends from the comfort of home, without having to trudge to the phone box.

The National Health Service was viewed in much the same way. My father developed cancer when I was two years old. He was swiftly cured but irrevocably damaged, and he struggled thereafter with chronic ill-health. His illnesses had knock-on effects on various members of our family, myself included. Between us we saw a lot of the NHS. At the centre of it (to my eyes) was our GP, a good-hearted man with half-moon glasses and a somewhat distant manner. When he needed expert assistance, a referral would be made. Waiting times were sometimes long but were accepted with stoicism: the professionals we eventually saw did their best. Looking back, I recognise the profound comfort in those experiences for my parents, who had grown up knowing what medical care could be like - and its financial implications - before the advent of the NHS. No matter how threatening or scary things got, no matter what time of day or night, this health service was there to help and asked nothing in return.

In the mid-1980s, I entered medical school in Nottingham. Like most aspiring doctors, I knew what I was going to be: a public servant, working extremely long and often antisocial hours, the whole arduous endeavour sustained by a powerful sense of doing something important and worthwhile. I would be joining an unquestionable force for good, grouped under the fluttering blue-and-white standard of the NHS.

But even as I embarked on my training, society was changing under the Thatcher government. The emerging citizen-consumer was increasingly exasperated by the inefficiency of state monopolies; no longer could we tolerate waiting months to have something as commonplace as a phone line installed or repaired. Margaret Thatcher's solution was privatisation and exposure to market forces. British Telecom was sold off in 1984, two years after a licence had been granted to its first competitor, Mercury Communications. British Gas and British Petroleum soon followed. It was only a matter of time before government attention turned to the biggest state monopoly of them all.

I was nearing qualification as a doctor when the then secretary of state for health, Kenneth Clarke, published his 1989 white paper, Working for Patients. The huge, sprawling, multicellular organism of the NHS would be cleaved in two, hospitals becoming providers, wooing and responding to the demands of purchasers in a so-called internal market. Competition, survival of the fittest, would deliver a patient-centred NHS, something even the new breed of health service managers, ushered in by the 1983 Griffiths report, was failing to achieve.

The white paper was greeted with consternation in Nottingham. The city had two general hospitals. Each had the full complement of acute care services and they shared the emergency work, alternating days "on take" for admissions. Specialised departments were located at one or the other site. Co-ordinated by the health authority, they supplied virtually all hospital care for the local population between them, with little unnecessary duplication. Now they were to become independent trusts, no longer co-operating, but competing for each other's business.

The central dilemma with the model was: who, in practice, would the purchasers be? In any normal market, they would be the consumers. But in an era when most people's access to medical information was limited to the family copy of Home Doctor, patients could not realistically make informed decisions. The That­cher government's response was to invite GPs to become purchasers, controlling budgets on behalf of their patients. Generous management allowances and the freedom to reinvest savings provided incentives for uptake. Wave after wave of practices signed up, until eventually about 50 per cent of GPs - covering 60 per cent of the population - were fund-holders.

The Labour opposition was incensed by the scheme, arguing that it was creating a two-tier service. By this stage, I was working as a junior hospital doctor in a surgical speciality and the evidence was stark. The admissions office had a card system along the length of one wall, with a slot for each patient on the waiting list. The nearer a card moved to the left, the closer the admission date. Patients from fund-holding practices were flagged with red stickers. When any were in danger of exceeding the eight-week treatment time specified in the fund-holding group contract, they were simply bumped along, displacing those from non-fundholding practices who had already been waiting longer.

Unfair advantage

There were other perversities. A fund-holding practice's budget was set according to its activity in the year before entering the scheme. GPs routinely maximised referrals and prescribing in the run-up to budget-setting to ensure a decent allocation. It was not hard to make savings that could be reinvested. I spent a year working at a fund-holding practice in Oxfordshire in the mid-1990s. A consultant orthopaedic surgeon was contracted to run a clinic at the health centre every fortnight; patients had in-house physiotherapy and counselling. A handsome meeting room had been built and computers upgraded. Other practices opened branch surgeries; elsewhere NHS osteopathy and acu­puncture were made available. Fund-holding GPs and their patients had never had it so convenient or so good. Non-fundholding surgeries, such as the Oxford city practice I went on to join, were being left behind.

The 1997 election result was a great relief. True to its reputation as the party of the NHS, New Labour soon scrapped fund-holding and the internal market. Budgets were returned to health authority control in the form of primary care trusts (PCTs). I remember listening to the closing flourish of Gordon Brown's first Budget speech when he pulled from his metaphorical hat £1.2bn extra funding for the health service. Labour backbenchers sent up a raucous cheer, their reaction to the announcement reflecting my own surge of elation. Here at last was a government prepared to back the NHS with proper resources. The rhetoric of Blair's first term was about ensuring excellent health care for all, regardless of where you lived or who your GP was. New Labour, it seemed, was a party that understood our public service values.

National Service Frameworks (NSFs) began to spew from the Department of Health, dictating to doctors every aspect of the care they must provide for common, important conditions. I took the lead in my practice for the heart disease NSF; we welcomed it as a template against which to assess our standard of care.

All too soon, however, the rigid, controlling instinct of the New Labour regime emerged. The National Institute for Health and Clinical Excellence (NICE) was founded, its remit to abolish postcode lotteries in NHS treatment and further to promulgate a centralised vision of health care. Targets for hospital waiting and for access to GP care were imposed, spawning unintended consequences that inconvenienced or adversely affected more patients than they helped. The NSFs became incorporated into the 2004 GP contract as the tick-box-obsessed Quality and Outcomes Framework (QOF), straitjacketing doctors' ability to tailor treatment according to patients' individual needs. More and more managers were employed to survey and to audit and to enforce compliance with these various initiatives.

My GP colleagues and I have become press-ganged into the role of pill-pushers, the tyranny of QOF subjecting patients to bewildering and sometimes injurious choices of drug, irrespective of circumstances. The only way to practise holistically is to "exception-code" patients, removing them from QOF. But exception-code too many, and the managerial thought-police are quickly on to you - you're incompetent, you're a maverick, or even worse you are setting out to defraud. The distrust and disempowerment of dedicated professionals have been a kind of poison, choking off the immense goodwill that was the lifeblood of the NHS.

To compound matters, at some point during Tony Blair's second term, the decision was taken to revisit the Thatcher experiment. The language had to be distinct, so commissioners rather than purchasers would call the shots. And there could be no return to a two-tier service; all GPs were expected to become involved in the new, practice-based commissioning. Audaciously, Blair went where Thatcher had never dared to tread. The provider market was no longer to be internal: it was opened up to the private sector, treatment reimbursed at fixed-tariff rates. To kick-start the process, New Labour guaranteed returns to a number of independent-sector treatment centres (ISTCs), whose staff are often brought in from overseas, with qualifications, training and experience that are unfamiliar to local practitioners.

ISTCs have proved popular with many patients, who appreciate the plush facilities and short waiting lists that overgenerous block contracts have endowed. But, for the local NHS, there is uncertainty over clinical quality. One of my patients was given an inappropriate orthopaedic operation two years ago. The pieces are still being picked up by an experienced consultant at the local district general hospital. Nor is this an isolated case. Several other patients had to have camera examinations of their bowels repeated as part of a review of 1,800 procedures carried out at our local ISTC, following allegations of failure to diagnose cancer.

Even where quality of care is good, patients who have investigations that detect significant pathology then have to be referred on to consultants at the district general hospital, fragmenting their care and generating additional stress and anxiety, because ISTCs are not contracted or able to manage the conditions they diagnose. ISTCs have destabilised the existing NHS hospitals they rely on for safety-netting, cherry-picking patients at lowest risk and leaving the old providers to deal with complex, high-risk patients whose care is, as a consequence, more expensive. Training the next generation of doctors has been rendered problematic by the skewing of case-mix (patient categories) in medical teaching centres.

Franchised out

Allegedly to disrupt vested interests, New Labour also opened up general practice to the private sector. PCTs were compelled to award an increasing proportion of primary care contracts to commercial organisations. Under Lord Darzi's NHS Next Stage Review, every PCT was forced to commission a new "8-till-8" health centre - funded at levels a conventional practice could only fantasise about - the thinly disguised agenda being to expose existing surgeries to the white heat of (unfair) competition. The fluttering blue-and-white flag of the NHS to which I had once rallied has become a mere franchise, something to be waved by any organisation granted entry into the health-care arena, no matter its motivation.

In spite of the resources New Labour squandered to open up the provider market, practice-based commissioning proved an abject failure. By the time the policy was launched, PCTs had become mature, self-sustaining bureaucracies. With a few notable exceptions - where enlightened PCTs granted GPs substantial freedom of commissioning, and where some impressive innovations and efficiencies were achieved as a result - practice-based commissioning barely drew breath, smothered by managers unwilling to relinquish control.

The relief I felt last May when Labour was finally evicted was every bit as strong as that I'd experienced in 1997. Andrew Lansley appeared to be offering us the opportunity to reinvent the NHS as a modern public service - GP commissioning consortiums collaborating with consultants and other stakeholders to deliver joined-up, efficient, patient-centred care pathways. We had seen our efforts bear fruit in the few places where practice-based commissioning was allowed to flourish and there was an appetite to restore the public-service ethos that New Labour had so wilfully destroyed.

At what price?

Yet, in the months since the white paper was announced, clinician enthusiasm has been ever declining. Recent polls find only a minority of GPs continuing to back Lansley's plans and there has been an extraordinary convergence of concern among virtually every body representing the NHS, from unions such as the BMA, Unite and Unison, to the royal colleges of every medical and nursing discipline, to the NHS Confederation and various independent think tanks such as the King's Fund. There is anxiety about the pace and scale of the reforms, and disquiet about shifting responsibility for rationing on to doctors whose time-honoured role is to do their best for each patient. The show-stopper, though, is the picture that has recently emerged of Lansley's version of the provider market.

This is to remain external, with "any willing provider" (AWP) allowed to pitch for business under the NHS franchise. We have had more than enough experience with New Labour to appreciate the downsides, but the profession could probably live with AWP, relying on the commissioning process to factor in holistic care, were it not for Lansley's completely unexpected determination - smuggled into a brief mention when the Health and Social Care Bill was published on 19 January - to permit providers to compete not just on quality (as now), but also on price. The NHS regulator, Monitor, will be tasked with compelling this price competition. Far from collaborating with providers to design holistic, patient-responsive care programmes, GP consortiums will be bound by competition law and could face legal challenges, should they seek to work organically with selected organisations.

This surprise emphasis on price competition might at first seem reasonable, given the pressures on public spending. But the evidence strongly suggests that price competition lowers quality of care. One need only consider the NHS's single, disastrous experiment with it. Under the terms of the 2004 GP contract, PCTs were handed responsibility for commissioning out-of-hours care for patients, with no national tariff to adhere to. In order to win contracts, many commercial organisations bid low - either as a loss-leader to eliminate local, GP-led competition before increasing contract costs, or in the sincere belief that they could provide adequate care at bargain-basement prices.

In my own area we are all thankful that the PCT has continued to commission out-of-hours services from a not-for-profit company run and staffed by local GPs, which recently achieved second place nationally in a survey of quality. Elsewhere in the country, cut-price out-of-hours providers - by definition often dealing with patients with acute or life-threatening conditions - frequently depend on non-medical staff working to inflexible protocols, or on agency doctors who have little knowledge of local services, and whose language and communication skills can be markedly deficient.

At best, these apparently cheaper services consume more resources as inappropriate admissions multiply. At worst, patients needlessly suffer and die. All these services looked good on paper when the tenders came in. It takes a long time, and a lot of harm to patients, before deficiencies of quality become apparent; and it can be legally difficult to break a contract even when the provider seems to be failing.

Crossed wires

My family moved house recently. BT royally loused up the redirections we had commissioned on our old phone numbers. Innumerable operatives in call centres around the globe were unable to rectify matters, some simply hanging up when the going proved too difficult. In the end, even the high-level complaints manager we were allocated admitted it was beyond her power to put things right.

Disgruntled and nonplussed by BT's failure to make amends, we investigated switching providers, only to find that our contracts render any move prohibitively expensive. We are stuck, at least for the next year. Never mind, it really doesn't matter - it's only phones. But what if it did matter? What if this was a matter of life and death, or of life-enhancing care? What price would we then put on a health service that was there for us - not for profit - no matter how threatening or scary things were, no matter the time of day or night, and which asked nothing of us in return?

Phil Whitaker is a novelist and GP working in the south-west of England

This article first appeared in the 28 February 2011 issue of the New Statesman, Toppling the tyrants

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The New Times: Brexit, globalisation, the crisis in Labour and the future of the left

With essays by David Miliband, Paul Mason, John Harris, Lisa Nandy, Vince Cable and more.

Once again the “new times” are associated with the ascendancy of the right. The financial crash of 2007-2008 – and the Great Recession and sovereign debt crises that were a consequence of it – were meant to have marked the end of an era of runaway “turbocapitalism”. It never came close to happening. The crash was a crisis of capitalism but not the crisis of capitalism. As Lenin observed, there is “no such thing as an absolutely hopeless situation” for capitalism, and so we discovered again. Instead, the greatest burden of the period of fiscal retrenchment that followed the crash was carried by the poorest in society, those most directly affected by austerity, and this in turn has contributed to a deepening distrust of elites and a wider crisis of governance.

Where are we now and in which direction are we heading?

Some of the contributors to this special issue believe that we have reached the end of the “neoliberal” era. I am more sceptical. In any event, the end of neoliberalism, however you define it, will not lead to a social-democratic revival: it looks as if, in many Western countries, we are entering an age in which centre-left parties cannot form ruling majorities, having leaked support to nationalists, populists and more radical alternatives.

Certainly the British Labour Party, riven by a war between its parliamentary representatives and much of its membership, is in a critical condition. At the same time, Jeremy Corbyn’s leadership has inspired a remarkable re-engagement with left-wing politics, even as his party slumps in the polls. His own views may seem frozen in time, but hundreds of thousands of people, many of them young graduates, have responded to his anti-austerity rhetoric, his candour and his shambolic, unspun style.

The EU referendum, in which as much as one-third of Labour supporters voted for Brexit, exposed another chasm in Labour – this time between educated metropolitan liberals and the more socially conservative white working class on whose loyalty the party has long depended. This no longer looks like a viable election-winning coalition, especially after the collapse of Labour in Scotland and the concomitant rise of nationalism in England.

In Marxism Today’s “New Times” issue of October 1988, Stuart Hall wrote: “The left seems not just displaced by Thatcherism, but disabled, flattened, becalmed by the very prospect of change; afraid of rooting itself in ‘the new’ and unable to make the leap of imagination required to engage the future.” Something similar could be said of the left today as it confronts Brexit, the disunities within the United Kingdom, and, in Theresa May, a prime minister who has indicated that she might be prepared to break with the orthodoxies of the past three decades.

The Labour leadership contest between Corbyn and Owen Smith was largely an exercise in nostalgia, both candidates seeking to revive policies that defined an era of mass production and working-class solidarity when Labour was strong. On matters such as immigration, digital disruption, the new gig economy or the power of networks, they had little to say. They proposed a politics of opposition – against austerity, against grammar schools. But what were they for? Neither man seemed capable of embracing the “leading edge of change” or of making the imaginative leap necessary to engage the future.

So is there a politics of the left that will allow us to ride with the currents of these turbulent “new times” and thus shape rather than be flattened by them? Over the next 34 pages 18 writers, offering many perspectives, attempt to answer this and related questions as they analyse the forces shaping a world in which power is shifting to the East, wars rage unchecked in the Middle East, refugees drown en masse in the Mediterranean, technology is outstripping our capacity to understand it, and globalisation begins to fragment.

— Jason Cowley, Editor 

Tom Kibasi on what the left fails to see

Philip Collins on why it's time for Labour to end its crisis

John Harris on why Labour is losing its heartland

Lisa Nandy on how Labour has been halted and hollowed out

David Runciman on networks and the digital revolution

John Gray on why the right, not the left, has grasped the new times

Mariana Mazzucato on why it's time for progressives to rethink capitalism

Robert Ford on why the left must reckon with the anger of those left behind

Ros Wynne-Jones on the people who need a Labour government most

Gary Gerstle on Corbyn, Sanders and the populist surge

Nick Pearce on why the left is haunted by the ghosts of the 1930s

Paul Mason on why the left must be ready to cause a commotion

Neal Lawson on what the new, 21st-century left needs now

Charles Leadbeater explains why we are all existentialists now

John Bew mourns the lost left

Marc Stears on why democracy is a long, hard, slow business

Vince Cable on how a financial crisis empowered the right

David Miliband on why the left needs to move forward, not back

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times