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30 May 2022

Zero: Jeremy Hunt’s book on the NHS is well intentioned – but misses 90 per cent of the story

Candid on short-staffing and underfunding, ministerial memoir Zero omits the healthcare that happens in the community.

By Gavin Francis

There’s a moment near the beginning of Zero when the former health secretary Jeremy Hunt states that the NHS has survived as an institution not because voters like it or benefit from it, or even because they recognise the justice of its principles, but because its values are “entwined with what it means to be British”. Three pages later, Hunt is at Margaret Thatcher’s funeral, and we get another glimpse of what Britishness means: “It was of course no ordinary funeral. As a member of the cabinet I was sitting in a row behind Gordon Brown, Tony Blair and John Major. I remember singing ‘I Vow to Thee My Country’ and thinking it must rank as one of the most British moments of my life.”

The eulogy was delivered by Thatcher’s friend Bishop Richard Chartres, who, among other anecdotes, recounted how the former prime minister responded personally to a letter sent in by a nine-year-old boy. “I sat there and thought: in my seven months as health secretary I haven’t read a single letter from an NHS patient. If Margaret Thatcher had found the time to do personal replies as prime minister, couldn’t I?” Inspired by Thatcher, Hunt began to ask for a complaint letter a day to be brought to him, for a personal response.

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Department of Health officials would bring further details, and he’d sometimes meet with the complainants and CEOs of the hospitals involved. Those letters, conversations and stories form the backbone of Hunt’s new memoir, a book about his time as health secretary. It is ostensibly about eliminating unnecessary deaths, often using analogies from the nuclear or airline industries (though Hunt concedes people are not uranium, and hospitals can’t be closed the way planes can be grounded).

Death, of course, is eventually necessary for everyone. But Hunt means lives that have been shortened through avoidable harms. His top three culprits for the latter are blame culture, short-staffing and underfunding, each illustrated with examples and with a measure of calculated candour about his own party’s culpability in defunding the NHS, abysmal workforce planning and stripping resources from social care. He then explores the paradoxical effects of target cultures, stiff hierarchies, litigation and “groupthink”.

A side effect of Hunt’s focus on dramatic failures is that his book is dominated by the kind of stories that threaten the front pages of the tabloids, but that clinicians only very rarely encounter. Uninformed readers of Zero will be astonished to learn that 90 per cent of the clinical encounters in today’s NHS take place in the community – they are with district nurses, practice nurses, GPs and community mental health workers. These 90 per cent of encounters are paid for with just 10 per cent of NHS funding – the rest of the money goes to hospitals, about which Zero is more preoccupied.

The fact of money – saving it, spending it – gleams beneath the swift-flowing surface of every story. Hunt is honest about having set up the NHS’s Cancer Drugs Fund for otherwise prohibitively expensive chemotherapies not for clinical reasons, but because cancer treatment was an election issue. Such funds can never be enough, and in the end Hunt diverted money from “vital areas” to keep it flowing – an admission that essential services were cut to keep his election issue solvent. He’s frank, too, on the eyewatering cost of system failures, the botched surgeries and tragic stillbirths that found their way to his desk (60 per cent of NHS legal settlements are paid out for maternity cases; 7,000 doctors could be employed annually with the money the NHS pays out in legal fees).

[See also: “Frankly, people are dying”: The NHS spring crisis your higher taxes can’t solve]

Most of Hunt’s interviewees are trust CEOs and management clinicians who have long ago hung up their stethoscopes. Zero’s cover is spangled with adulatory quotes from a Who’s Who of the medico-political establishment – CEOs, presidents of colleges, two Dames and a former prime minister (Blair, of course; Major, Brown, Cameron, May and Johnson must all have declined). I wondered when in the book Hunt would have a conversation with a district nurse, GP or other community clinician, and hear concerns or even ideas about how pressure on hospitals might be eased.

The answer is page 161: “Dr Ronan Moran was perhaps the most down-to-earth doctor I ever met. The place I met him, though, was far from down to earth: at the glitz of a black-tie gala dinner at the Marriott in Grosvenor Square. The occasion was the Daily Mail Health Hero Awards.” I was glad Hunt had found time to hold a conversation with a GP, albeit in Mayfair, though the subsequent quotations from Dr Moran are credited not to their conversation that night, but to a later newspaper feature written about the ceremony.

The Conservative Party resisted the creation of the NHS with vigour, as did the British Medical Association in England (but not in Scotland), and it is to Hunt’s credit that he has realised what a calamitous mistake his party made. In 2016, four years into Hunt’s tenure as health secretary, the King’s Fund charity estimated that the UK would need to increase spending by 30 per cent, or £43 billion a year, to bring its health service in line with European averages. Hunt makes much in Zero of his negotiation with George Osborne to secure less than a fifth of what was needed (£8 billion), and recounts the tense discussions between Theresa May and Philip Hammond (“Let’s face it Philip, the NHS does need more money!”). It’s safe to say it still does. But after five years in the job, Hunt was beginning to feel affectionate and patriotic towards the NHS, even as he compared it to Oliver Twist – always asking for more. Dickensian starvation is an unfortunate if appropriate analogy – the NHS fobbed off with gruel instead of being fed properly.

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A dispiriting revelation of Zero is that Hunt made pledges he never expected to have to fulfil, such as making the NHS paper-free by 2018. When his third child was born that year, the cardboard folder of notes at the end of his wife’s hospital bed told him he’d failed. Another upsetting revelation is that during the junior doctors’ strike in 2015-16 over the imposition of a new contract (which threatened to spread an already threadbare workforce even thinner) he was lobbied by Conservative Party donors to soften his position. This was largely, he writes, because these donors had sons or daughters who were junior doctors. Hunt declined their requests (which is perhaps why he included the story) but for the reader outside the Whitehall bubble the fact that such approaches took place seems appalling. There’s a name for the practice of paying political parties in the hope of influencing policy, and that practice is apparently so widespread that Hunt notes it without blushing. If I took money from people who hoped to influence my professional decisions, I’d be struck off.

Patient safety is central to good clinical practice, and Hunt’s book is well intentioned, but all those boardroom meetings and ministerial audiences have given him a view of the NHS and its priorities that I barely recognise, and I longed for him to get out of the boardrooms and into more clinics. Its focus on rare, tragic deaths means that structural problems impacting the greatest numbers of patients go largely unaddressed. He says the NHS is “middle of the pack” internationally in terms of quality of care and accessibility, but doesn’t engage with its rating on value for money, at which it excels. After six years in the job, he was the longest-serving health minister in British history; six years of medical school wouldn’t even qualify him to prescribe paracetamol on a drug chart without supervision.

But then Hunt isn’t a clinician. He is a self-professed “amateur”, a former entrepreneur, an expert on Britishness and now a backbench MP. He has been promoting Zero on the media circuit, and each interview I’ve read has mentioned his leadership ambitions. His prescriptions for the NHS include more staff as well as greater transparency, accountability and continuity at all levels. They are all good ambitions. If he ever becomes prime minister, I look forward to his insistence on the same values among his MPs.

Gavin Francis is a GP in Edinburgh and author of “Recovery: The Lost Art of Convalescence” (Wellcome)

Zero: Eliminating Unnecessary Deaths in a Post-Pandemic NHS
By Jeremy Hunt
Swift Press, 320pp, £20

[See also: The born-to-rule Oxford Tories]

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This article appears in the 08 Jun 2022 issue of the New Statesman, Marked Man