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  1. Politics
25 December 2000

Tidings and joy? Not at the NHS

NS Christmas - For doctors and patients, Christmas is the worst of times. The government's

By Phil Hammond

I have to admit, I’m a tad jealous of Lord Winston. While he makes babies, I treat verrucas. While my modest little show (Trust Me, I’m a Doctor) has been axed by BBC2, he has just breezed through another multimillion-pound Superhuman epic on BBC1. And when I complain about the state of the NHS in the Express or Private Eye, no one bats an eyelid. But when he does it in the New Statesman, Tony Blair goes into meltdown and promises an alleged £26bn in extra funding. OK, so I don’t want to be a Labour peer, and I’d look stupid with the moustache, but it’s a tough life being an also-ran media medic.

So it is with some trepidation that I take on the annual NS “NHS in Crisis” Lord Winston Memorial Article. The Secretary of State for Health, Alan Milburn, has already fired the opening salvo, claiming that calling the winter crisis a “crisis” is an exaggeration. “Crisis is an overused word when it comes to the NHS,” he says. “It does not accurately reflect what goes on day after day.” Milburn would prefer us to use the term “winter pressures” to describe lying on a trolley in a draughty corridor for 36 hours.

It is at times like these that I long for the return of Frank Dobson. You couldn’t put a Rizla between their intellects, but at least Frank was frank. He wasn’t afraid to call a crisis a crisis. Not that he had much choice in 1999. The previous November, he had announced £250m extra to avoid it, but a “mild flu epidemic” (Frank’s words, not mine) soon scuppered that plan, and we were treated to some vintage headlines. “Agony of doctors at breaking point” (Daily Mail); “Hospital has to turn away ambulances in flu crisis” (Birmingham Post); “Doctors started Jake’s birth, then stopped. They’d run out of beds” (Mirror); and, the clear winner, “A CRISIS-HIT hospital has hired a refrigerated truck as an overflow MORTUARY” (Daily Star).

Dobson blamed NHS difficulties on the “serious underlying problems” that the Labour government had inherited, especially a shortage of nurses. He then fired an ill-advised broadside at nursing education, claiming that the emphasis on the academic element was putting off those who just want to wipe arses for £3 an hour. Or something like that.

Professor Chris Ham, the director of the Health Services Management Centre at the University of Birmingham and now a member of the Department of Health’s strategy unit, provided a more sanguine appraisal. “It’s not just money, it’s more fundamental. There are shortages of staff in some areas, and there’s very little slack in the system. So, to that extent, you might say that some parts of the NHS have been in crisis. The way I’d put it, using medical terminology, is that we’ve got an acute problem on top of a chronic problem, and what the papers pick up on is the acute problem.”

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This is clearly bad news for such a media-obsessed administration, and the spirit of open government is hardly likely to be furthered by reports that the BBC has set up a crack squad to cover the “NHS crisis at Christmas 2000”. At the time of writing, there appears to be less crisis around than the BBC had hoped for, and this year’s NHS plan for the “winter pressures” does seem to contain excellent examples where local services have got together to ease the burden. In Liverpool, a “paediatric outreach nursing” initiative makes for far more than a silly acronym. Nurses have been despatched into the community to help treat babies and children with minor illnesses and prevent hospital admission, saving an impressive “588 inpatient bed days” in the first year alone.

More ambitious is an intensive care outreach scheme at the King’s Mill Centre in Mansfield, which uses an Augmented Care Assessment Tool (ACAT) as an early warning system. “If the patient’s condition begins to deteriorate, they are identified quickly and senior medical staff are contacted. This helps prevent further deterioration and ultimately prevents avoidable intensive care admissions and further complications.”

There are plenty more examples in this vein, but none of them is supported by references to allow me to check out the validity of the claims. The few “big ideas” that the government has come up with to reduce the pressure on the NHS are still, at best, unproven. NHS Direct has gone nationwide for Christmas and is likely to field thousands of calls at great public expense over the winter break. To a politician, its superficial popularity may be justification enough but, as with most of the NHS, there is precious little scrutiny of the quality of advice offered and not much evidence that it is taking the heat off GPs or casualty departments.

Every doctor has a horror story about NHS Direct. One night, a relative of mine phoned the GP with chest pain that strongly suggested a heart attack (it was). He was diverted to NHS Direct, and had to wait for more than half an hour while the nurse checked her flow chart and consulted a colleague before calling an ambulance. But doctors and their untrained receptionists are equally prone to dispensing suboptimal telephone advice. A far more constructive way of introducing the service would have been to run it out of existing GP surgeries and health centres, so that grass-roots staff could see it in action, develop it and evaluate it. Instead, it is viewed with deep scepticism as separate, threatening and unproven by doctors who feel the money would have been better spent elsewhere.

The same criticism is being levelled at the new NHS walk-in centres. I’m spoilt for choice here – there is one in both Bath and Bristol – but the local press are sharpening their knives and demanding evidence that the centres are providing value for money. Certainly, the Bristol centre is an impressive multi-floored, multimillion-pound refurbishment, with nurse practitioner consultation suites, a dental suite and a conference suite (available for hire). However, on the few occasions when I have walked past, it has been empty.

Contrast this with the sexual health clinic at the United Bristol Healthcare Trust, as fine an example of first-class staff holding together third-world facilities as you could hope to find. The service operates out of cramped “temporary” accommodation in a rubbish-strewn yard, and it has to be sprayed for fleas every year. If ever a building put off patients seeking help, then this is it. And yet, if they make it through the door, they are met with highly dedicated and expert staff. “There’s a huge pool of unmet need in Bristol, and we’d like to advertise the service,” said one consultant. “But there’s already a ten-day waiting-list for treatment, and we just couldn’t cope with the extra demand.”

The irony of the beautiful empty NHS walk-in centre is not lost on the clinic staff, who already have to pick up the pieces for the butchering of excellent NHS family planning clinics and the patchy service provided in general practices. The walk-in centre may pride itself on prescribing the morning-after pill, but these patients, often vulnerable, are not fully assessed and diagnosed, and are never followed up. There is no substitute for a properly equipped specialist sexual health service and, with the UK facing record levels of teenage pregnancy and chlamydia-induced infertility, as well as a rise in HIV, it is grossly negligent to throw money at a white elephant when there are so many more worthy causes. The pragmatic solution – for the two services to swap buildings – seems almost too obvious.

In Bristol, the sexual health crisis is a year-long thing. If you want a truthful insight into the NHS, don’t listen to the British Medical Association, the Department of Health or media doctors. Instead, seek out the words of unknown, full-time, politically unmotivated staff who are driven to speaking out by sheer frustration. In October, Michael Joy, a cardiologist at St Peter’s Hospital in Chertsey, wrote a letter to the Times. “This morning I led the post-emergency ward round at our hospital. Most of it was conducted in the accident department because we no longer admit patients directly to the wards, as there are no beds.

“There were 23 patients awaiting admission, six had been waiting for up to two days. Ten more were awaiting review. Some were very ill indeed. There are only 21 trolley slots in the department, so many of the patients were two to a cubicle, making it almost impossible to get between trolleys. It is impossible to practise medicine, let alone safe medicine, in these conditions . . .”

To be fair to new Labour, the NHS was ever thus, and was made considerably worse by the introduction, under the Tories, of the internal market. But Labour’s folly was to believe that all the woes of the NHS were down to a corrupt Conservative administration, and that a change of personnel and a removal of the more divisive elements of competition would be enough to improve it. Certainly, the culture is more open now, and even doctors are becoming more accountable. Ironically, it is this openness and the removal of contractual gagging clauses that has encouraged doctors such as Michael Joy to tell it like it is, giving the impression that the NHS may have got worse under Labour.

In reality, it just hasn’t changed much. Some ideas are good (for example, NHS frameworks and clinical governance), but none has yet been delivered in a way that improves the patient’s lot. This delivery was never achievable in a political term, and Labour was naive to promise it. But promise it did, and there is now cynicism among NHS staff towards the leadership. Indeed, perhaps the biggest problem facing the NHS is its almost total lack of credible leadership. This year, I have asked hundreds of doctors, nurses and managers to name their leader; very rarely has anyone felt able to nominate a person of vision and integrity whom they are willing to follow. Perhaps the NHS is just too big to lead, and it is time to give up on central control. Nobody takes much notice of it, and all the real innovations are down to dedicated staff, battling against the odds to achieve change in their little patch (or Portakabin). As Graham Garden remarked on its 50th anniversary: “The NHS is much praised around the world . . . but never copied.” Happy Christmas.

Dr Phil Hammond is a GP and a columnist for the Daily Express and Private Eye