The former Granada boss Sir Gerry Robinson recently spent six months trying to reform Rotherham general hospital. The result was shown in three hours of fly-on-the-wall television on BBC2 last week. It was rightly put after the watershed: as politics it was certificate 18. At the end of each day Robinson could be seen slumped in the back of his car, his face buried in his hands. A tycoon sobbing in a limousine is the perfect icon of Labour’s health service.
So die all who try to reform the National Health Service. They have been doing so since a despairing Margaret Thatcher appointed Roy Griffiths, boss of Sainsbury’s, to the task in 1983. The NHS is the North-West Frontier of the public sector. If the health union Tajiks don’t get you, the Pashtun consultants will. You can throw as many men into the Khyber Pass as you like but they never return.
The one laugh in the programme was Robinson’s conclusion that the NHS was “unmanaged”. Yet each frame was crammed with managers falling over each other, with clipboards, pagers, consultancy reports and meeting agendas. There were nursing managers, surgical managers, recovery managers, manager managers, chief executive managers. The one thing they did not do was manage but that, of course, was not their fault.
Through this jungle wandered a charismatic megaspecies, the consultants, whom everyone agreed were “unmanageable”. They were like the weather, an immutable constant. It did not matter what the NHS or its patients wanted, the consultants ruled, which enabled everyone else to be equally obtuse. They seemed to regard their first duty as to the heraldic privileges of their specialist tribe, be it paediatrician, anaesthetist or ophthalmologist.
We watched the consultants, often in league with “health and safety”, blocking rationalisation of a system that had some of them doing three operations a morning and some seven. They demanded their own anaesthetists, who in turn demanded their own schedules. Surgeons wandered in and out of their private practices as waiting lists stretched over the horizon. NHS productivity would not improve because the fruit machine never yielded oranges in a row. There was always a lemon in the way — unless you were lucky enough to have Robinson and a television camera to move it.
The message of Robinson’s inquiry was devastating and explains the ostensibly terminal chaos enveloping the NHS under Patricia Hewitt. The central arm of government, the Treasury, has clearly given up on NHS reform. No government, Labour or Tory, has the guts to break the consultants’ restrictive practices, the GPs’ “lifestyle” demands or the healthcare unions. The Treasury itself capitulated to the unions by rubber-stamping the ridiculously expensive 2004 NHS pay deal, depriving Britons for the first time of proper out-of-hours GP cover.
After a quarter century of seeing money piling up in the upper echelons of the NHS, and being wasted on management consultants and useless computers, the paymasters have had enough. While Thatcher hoped for reform by shoving the private sector into the NHS, Gordon Brown is shoving the NHS into the private sector. If Rotherham hospital can do only half a dozen cataracts a session when it has capacity for 20 or 30, why not give the job to a bunch of South Africans in a caravan in the car park? Outsource routine operations. Switch a few regional general hospitals to accident and acute care and let the public drive to find them. Hence the decision to subcontract 40% of NHS operations to something called a “partners’ network” (Blairism for the private sector). We can hear a muffled cheer rising over the Thatcher home in Chester Square.
Treasury loss of faith in the corporate NHS has all but collapsed public investment in the hospital service, switching some £12 billion of it to private finance. This will be astronomically expensive, consuming reserves that would previously have gone on healthcare. The new Woolwich hospital must find £100m a year from its revenue budget and the Royal London and Barts £120m to service private loans forced on them by the Treasury in the fond belief that private money is more “efficient”.
More alarming is that internal pricing and payment-per-treatment will leave these mastodons financially exposed through loss of business to the private sector. In an attempt to favour this sector, the Treasury and Hewitt are refusing to allow NHS hospitals to cut tariffs to compete. Small wonder James Johnson, the British Medical Association chairman, parodied Blair’s 1997 battle cry, “24 hours to save the NHS” by saying there was now “one year to save the NHS”.
Many hospital trusts are building up large deficits that they cannot possibly cover; 29 are contemplating some 60 “reconfigurations”, code for closures, at a time when Hewitt is also talking of somehow building 50 cottage hospitals. She must also now contend with 11 of her ministerial colleagues declared to be in open opposition. Meanwhile manpower planning is in disarray, with hiring cuts or freezes almost everywhere and a reported surplus of 3,200 expensively trained NHS consultants by 2010.
How this has been achieved despite five years of 7% annual real rises in health spending is no mystery. A lethal coalition of medical staff and private financiers is walking away with the money. Few demoralised managers will bother to imitate Robinson’s efforts at Rotherham when the lead from Whitehall is to capitulate. Since many trusts are supposedly free-standing — which means bankruptable — it is possible that swathes of the NHS will end the decade in the notional ownership of City banks. Yet even this, for Brown, is preferable to the existing NHS.
The Robinson programme showed what amounted to the collapse of the “public service ethos” in Britain. The government would ideally like to privatise not just the bulk of the NHS but the Post Office, the probation service, the jobcentre network and, it was reported last week, most care of the elderly.
It has clearly lost confidence in the capacity of public officials to administer services (as opposed to regulate and form policy in Whitehall). That this should be the work of a Labour government is ironic since the purpose is to circumvent those classic legacies of socialism: trade unions and the risk aversion of large organisations.
Nothing better illustrates this than the shambles at the Home Office where privatisation is of limited application. Its capacity to administer a service, be it immigration, drug treatment or prisons, has all but failed. Its boss, John Reid, has rewritten the rulebook of corporate accountability. He will take no collective responsibility for the actions of his forebears as home secretary, though he sat in the same cabinet as them. Nor will he take blame for any decision if he can prove he was “not told about it”. Bang goes the theory of corporate negligence.
The catalogue of Whitehall organisations no longer fit for purpose is lengthening by the week. It embraces the farm payments agency, the child support agency, the immigration service and the criminal assets recovery agency.
In the old days such fiascos would have led to parliamentary uproar and heads rolling. Nowadays they are part of the tragic Whitehall soap opera, cause for rejoicing only among civil servants leaving to join management consultancies and parastatals such as Capita and Serco.
It is hard to imagine what morale must be like among officials in the Home Office or health department. Perhaps the public service ethos is out of date, irretrievably polluted by trade unionism and bureaucratic protectionism. Perhaps it is true that only the hope of personal gain will induce Britons to help their fellow men and women.
I am reluctant to reach that conclusion. The boundary between public and private action must be redefined and the former remoralised. It was a failing of Thatcherism to throw out the baby of social duty with the bathwater of socialism. Between the charitable sector and the private there has always been a tier of “public servants”, moved in part by philanthropy and in part by patriotism. The title has conferred honour and status but not riches on those who serve their country in peace and war. One day we will miss them.
Although i had admired Gerry Robinson's efforts with various commercial organisations, the presentation of his experience with the NHS left the impression that he did not understand why all surgeons (for example) do not have indentical time tables and performances. Perhaps the programme's producers were at fault, but one gained no knowledge of why there are differences even at the simplest level from differing commitments (teaching, ward rounds, differing levels of experience,
patient mix etc...,..) and he simply wanted a production line as in a factory. He even thought that all the members of a team could be replaced
or were interchangeable with others without affecting that team. It is a pity he did not go further into the absurd fairytale accounting system which now informs a hospital of whether or not it can afford to carry out ops. Given the constant reorganisation without rationale I thought the doctors were remarkably tolerant to accommodate him and the cameras.
David, Stockport, UK
I can identify with the comment about the arrogance of some NHS consultants. On asking my spinal consultant about a newer alternative treatment to a risky disc decompression, he jumped down my throat as if my question was a personal affront. It is high time NHS consultants were subject to truly independent peer review such as that practiced in academia so that the lame ducks can be prevented from ruining the lives of those that they are unable to treat properly for whatever reason. I cannot think of any other profession which would tolerate such a lax approach to health and safety. Someone once said that a doctors loyalty is to their colleagues first and their family second and I can testify to that. When my mothers GP prescribed aspirin and nearly killed her due to her history of ulcers, my own sister, a consultant radiologist, also jumped down my throat when I suggested the GP should be made to answer for his actions. Who will rid us of these turbulent sawbones?
Jon Brooks, Lancaster, UK
According to The Economist "Pocket World in Figures 2005 Edition", out of 233 countries England is number 42 for the number of hospital beds per capita and number 207 (26 from bottom) for the number of doctors per capita.
The power of the consultants comes simply from the lack of supply.
France spends about the same percentage of its GDP on health as we are now doing and has exactly twice the number of beds and 65% more doctors for the population size.
Peter Angelo, Southall,
Unfortunately my family have required the services of the NHS to a very considerable extent over the last few years so I could provide an official guide to the Hospitals of London, Hampshire , Wiltshire, Berkshire and Kent.
Whilst iI have nothing but praise for the treatment and after- care of acute illnesses when it comes to treating chronic conditions such as spinal problems and Crone's Disease there appears to be a lack of joined- up thinking. There seems to be a lack of co-ordination between Departments and I would suspect a touch of arrogance by Consultants who are not prepared to consider alternative diagnoses. Perhaps we are suffering from too much democracy and should bring back the role of a general factotem like that of the erstwhile Matron.
Gerald Spencer, Andover, UK