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On the critical list Exactly ten years ago, Tony Blair told voters that if they didn't back Labour the NHS would die. Today? Billions have been spent but in many areas things are are worse than ever. HARRIET SERGEANT has spent the past year finding out why - Daily Mail, April 14, 2007 Ten years ago today, Tony Blair warned: "Two weeks to save the NHS." A vote for Labour in the forthcoming general election would save the Health Service from extinction and transform patient care. Ten years on, and what has that vote achieved? How has Tony Blair shaped out health care for the 21st century, and what legacy does he leave behind? In an attempt to answer the question, I have spent a year researching the management of the NHS, looking in particular at six different hospitals in different areas and talking to everyone involved, from hospital porters to chief executives - not forgetting, of course, the patients. What I found was that the dedication and professionalism of many NHS staff ensured that some people get excellent care some of the time. But it was despite the system, not because of it. A recent report from the Royal College of Radiologists sums up the present state of our Health Service. The Government considers the improvement in cancer services a success story - and in some respects it is right to do so. Funding each year has been 'staggering', says Professor Karol Sikora, clinical director of cancer services at Hammersmith Hospital and chief of the World Health Organisation's cancer programme. However, the Royal College of Radiologists claims that cancer patients who have had tumours successfully removed are still dying. This is because they are forced to wait so long for follow-up radiotherapy treatment that their tumours return. Professor Sikura says: "In some areas, people are getting scarcely any radiotherapy. They are often old, poor, uneducated and forgotten about." The report describing this situation remains unavailable to the public. Critics suspect the Department of health will suppress publication until is is ready to announce plans to improve cancer services in the autumn. Here we have it all: record investment; targets achieved in that the tumours have been removed; yet patients who are not getting proper treatment and a department that puts politics before patient care. Will the Labour government's legacy be merely to have created the illusion of progress while producing confusion, inefficiency and demoralisation? The huge amounts of money the Labour Government has spent on the NHS is certainly no illusion. Funding has risen from £35billion a year in 1997 when Labour came to power to £84billion today. By 2010 we are projected to spend £100billion a year on the NHS. The large sums have certainly made a difference. Patients have seen a 25% reduction in waiting lists since 2000 with an average wait of seven weeks and a 20% fall in cancelled operations. The number of new doctors has risen. So has the number of hospitals being built. But this is where the confusion begins. Record funding has at the same time produced a record deficit of £800million. One third of all NHS trusts have announced they are in the red. And Health Secretary Patricia Hewitt has ordered trusts to balance their books by the end of this month. The results of this financial fiasco are entirely predictable. Hospitals have sacked the staff they have newly taken on, closed wards and cancelled operations. Three out of four trusts are already restricting patients' access to treatments as they struggle to control deficits. Training budgets have been cut and newly qualified medical staff such as junior doctors suddenly find they are unable to get jobs. Meanwhile hospitals are having to make cuts, which are, of course, dictated by short-term financial need with little regard to the effect on patient care. Trusts are in so much trouble, points out a scathing report from the Commons Health Select Committee published last month, because of the 'reckless and uncontrolled' recruitment of new staff that took place as a result of the extra funding. Reckless and uncontrolled recruitment Between 1999 and 2005 an extra 260,000 employees were hired, an increase of almost a quarter. That included 17% more GPs, 22% more nurses, 37% more consultants and a staggering 62% more senior managers. But a 'disastrous failure of workforce planning' by the Government, says the committee chairman, Labour MP Kevin Barron, meant that trusts recruited far more staff than they actually could afford to pay. The Government compounded their difficulties by overgenerous pay rewards to GPs and consultants for which the Department of Health failed to budget correctly. In 2004/5 for example, the GP contract - the amount the Government had to pay GPs - came out at £250million more than the Department of Health expected, and the contract for consultants £90million more. The Agenda for Change package which concerned pay to nurses and other NHS staff came out £220million more than expected. The sad truth is that more and better-paid staff has not translated into better care for patients. 'We were very concerned by the failure to improve the productivity of the Health Service workforce,' said the select committee, 'particularly when investment in the NHS has been growing so rapidly.' In fact, in some cases the recruits have made patient care worse. In order to afford the extra salaries for new staff, hospitals are economising by postponing operations and cutting back on services. One consultant anaesthetist says: "At the moment I am doing nothing because, in order to save money, my trust has cancelled all my operations until the next financial year." This is hardly the legacy either Tony Blair or taxpayers hoped for. The problem is Mr Blair's original pledge was misguided. His mistake was to have confused 'saving the NHS' with better health care. The Government has splurged our money without first asking an important question. Should we be spending such large sums of money on an unreformed Health Service? Is it fit for purpose - to deliver health care in the 21st century? To understand what has gone wrong, look no further than the structure of the NHS. It is a vast state monopoly employing a staggering 1.3million people. It was designed to emulate the state enterprises of Stalinist Russia. Sir William Beveridge, the architect of the NHS, promised that his proposals would take the country 'halfway to Moscow'. The NHS too often puts the interests of those who work for it above those who use it. This is the nature of state bureaucracies. They take on a life of their own. Any attempt at reform has unexpected and often unwelcome consequences. Even Richard Titmuss, professor of social administration at the London School of Economics and a passionate lifelong advocate of the British Welfare State, admitted our public services had proved 'independent or impervious to the public they are presumed to serve'. Failure to reform the NHS is disastrous The NHS, like any large bureaucracy, has a history of hijacking policies that are supposed to benefit patients, for its own purposes. This is what has happened to the record funding. For every £10 spent last year, for example, £9 went to increase pay for NHS staff and prices. In the absence of reform, all the good intentions of government and the vast sums it has spent became the means to only one end - to expand and strengthen what former health secretary Alan Milburn once called 'a culture where the convenience of the patient can come a poor second to the convenience of the system'. What an irony it is that, 50 years on, Russia and China are shedding their monolithic state industries while we still put our faith in the NHS. But it is not just the structure of the NHS which is to blame for our wasted billions. The government made another crucial mistake. It failed to ask why politicians are in the business of health care at all. It failed even to consider extending the same reform to the NHS as it did to the Bank of England - in other words, independence. As a result, the NHS is, above everything else, a political organization. It was the chief executive of one hospital who told me with sadness: "We are an extension of the civil service." This means the first priority of the NHS is to make the Government look good - even at the expense of patient care. The select committee castigates trusts for hiring staff recklessly. But this is a disingenuous criticism of an organisation which is essentially political. Trusts did so for good reason. They were responding to the Government's desire to look busy and impress the electorate. Government targets and initiatives have dominated hospital business for the last ten years. The board meetings I attended in my year's research were wholly taken up with meeting those targets and complying with those initiatives. The job of every chief executive depends on this compliance. The effect is that it makes every one of them 'very jumpy', as one auditor put it. They employed 'anyone and everyone to collect data' in order to reassure the Department of Health that someone is in place monitoring the latest initiative. Targets are, of course, no bad thing if they improve the quality of health care. But unfortunately it was the achieving of the targets that became all-important. The results and data presented as evidence of this achievement were often, as one consultant told me, 'frankly fraudulent'. A manager in a North London hospital explained that 'decent, otherwise scrupulous people are pushed into conniving with the Government into hitting targets at the expense of patient care'. This corruption of hospital management is, to say the least, one of the more regrettable of Labour's legacies. In effect, the Government has created the surreal situation in which hospitals have taken on managers and bureaucrats to check on and evaluate all manner of services to patients - and the effect is that the quality of those services, far from improving, has actually deteriorated. The Government can point to targets reached and initiatives fulfilled. But how many of them have improved the patient's lot? I was told by one surprised chief executive that health and safety legislation, which is so powerful it can close down a hospital if targets are not met, does not cover the control of infections such as MRSA and other superbugs. In the rush to comply with this or that week's latest initiative from Whitehall, much important hospital activity gets overlooked. Managers complain that too often they are responding to demands from the politically driven centre of the NHS rather than to what is actually going on in their hospital. The failure of the Government billions to reform the NHS and transform our health care has been a disaster But it has had one unintended consequence. It has shown that funding alone is not the cause of the NHS's problems. It has revealed serious fundamental flaws of structure and management. It has exposed the fallacy that the NHS can be changed from the top down without unwelcome side-effects. And it is against this failure that Tony Blair's final initiative, Patient Choice, where money follows the patient and NHS funds pay for patients to attend private treatment is coming into its own. Choice is proving popular among patients. Support is highest, a social attitudes survey points out, among the poor and less well educated. The efficiencies that are associated with private business are bearing fruit. Staff at the independent treatment centres are 60% more productive that similar staff in NHS trusts. Theatres are better used and surgical times shorter. In the West Country, local trusts are copying the methods used by their private competitors to improve rehabilitation and discharge plans. Patient Choice is so exciting because for the first time, power is being transferred from the NHS bureaucracy to the patient. Until there is real competition between providers of treatment, patients cannot exercise choice. It is patient choice that will do more than any government policy to force good practice up through management hierarchy and free the NHS from the need for political interference. The only criticism of Patient Choice is that it is not going far enough fast enough. As one anaesthetist consultant complained: "I would love to open a pain management clinic and sell its services to the NHS. But I am not allowed to do so." How can we pay for an ageing population? But even with Patient Choice the Government still has to tackle the crucial issue it has so far ducked. How is a health service, however efficient and well managed, to pay for an ageing population and new and expensive medical advances? Professor Sikora has pointed out that at least six powerful cancer drugs will be available from next year at a cost of £60,000 a year per patient. How will the NHS respond? If it refuses to pay for the drugs, the only alternative is for patients either to go without or to top up their NHS care by paying privately. "There is now evidence of a growing use of co-payments to break through the access barriers in the NHS," Professor Sikora wrote recently in the Journal of the Royal Society of Medicine. But this is a step too far for the Department of Health. 'You cannot be both an NHS patient and a private patient at the same time,' a spokesman said. It is vital to start a debate on this and the wider issue of how much we are willing to pay for health. We are looking at an 80% rise in the elderly population over the next 43 years and a reduction in the number of younger taxpayers able to support them. Has the time come to admit that even the best-managed health service cannot pay for everyone to have everything all of the time? How do we as a society decide what a health service should and should not provide? To start that debate would be a brave and worthwhile legacy for a politician.
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