I grew up hearing stories of life on the wards. My beloved great-aunt was a nurse in the era when there was camaraderie, heroic doctors, and everyone was scared of matron. No question of contracting out cleaning: you did it yourself, with matron hovering over you to check there wasn’t a smidgen of dust. Tea and solace were not hived off to charities or junior staff — she did it all, and spoke lovingly of many of her patients, with huge knowledge of their lives.
So when I fell pregnant in 2002, I looked forward to having my baby in the same hospital where I had been born: a respected London teaching hospital. I was surprised to be told, with other expectant mothers at the antenatal clinic, that we should on no account have a bath or shower unless we brought our own Dettol and scrubbed.
But nothing prepared me for the trauma of the birth itself: a protracted labour during which all pain relief failed because of a midwife’s mistakes, ending with an emergency caesarean on the Monday, when the consultant showed up: at the weekend, the most senior doctor had been a junior registrar. Even in the operating theatre, the consultant turned furiously on a nurse for using the wrong anaesthetic. And afterwards, recovery on the wards was “like Bedlam”, my consultant joked. My mother-in-law, who had been a midwife, burst into tears at seeing the state of the ward, me and our baby.
The thing that frightened me most that weekend was the feeling that no one was in charge. Later, I was to discover that no one really is in charge.
The NHS is not the monolith of media imagination: it is a crazy series of fiefdoms, ranging from hospitals to GP surgeries to mental health trusts and outpatient clinics, encircled by an alphabet soup of quangos. During the pandemic, when I was working in the Department of Health as a temporary adviser, a senior doctor rang me to ask about an interfering NHS agency that neither of us had heard of. “Oh,” he said finally. “I think some of us tried to abolish that years ago.”
The story of the NHS is one of good people being thwarted, in a disconnected landscape. Of directives raining down from on high as politicians try to keep a grip on something they pretend to control but don’t. In March 2020, I watched the health secretary Matt Hancock answering questions about Covid-19 on TV, while knowing that behind the scenes his staff were often frantically trying to find out what Simon Stevens, the then chief executive of the NHS, was actually doing. Stevens is a highly capable operator. But politicians have to be accountable to parliament for a service whose budget has grown more than fourfold in real terms since 1979-80, and are terrified of losing “grip”.
I have since become fascinated by the ecosystem of the NHS, of whose founding objectives we should still be proud. I have been lucky enough to travel through it in many different guises: as a journalist, a patient and relative, author of two independent government reviews, board member of the regulator, head of the Number 10 Policy Unit, and temporary adviser to the Department of Health in the pandemic. I still have only a partial view. But one of the most maddening things, for me, is that there are extraordinary people, doing world-beating things, almost everywhere. Yet the wider system won’t learn from them.
The disconnected landscape
The NHS was founded in 1948 to heal the sick and send them on their way. It was not built for a world in which we live for decades after retirement, many with a cocktail of chronic conditions that don’t kill us but need repeated treatment. About two-thirds of the NHS budget is spent on these long-term conditions (such as arthritis, diabetes and heart disease).
But the institutions have not adapted. The traditional divide between GPs and hospital consultants, and between the NHS and the local authorities, means people are shunted between different parts of an uncomprehending system. Mental health, public health and social care are regarded as remote backwaters, although the lack of investment in them is part of what is bringing the whole system down.
To bridge the divides, governments have spawned endless committees to oversee the commissioning of services: primary care trusts, clinical commissioning groups and now Integrated Care Systems. On visits to such entities, I have been amazed by how many people are usually sitting around the table, surely too many to get much done, and how many are frontline professionals who might otherwise be seeing patients.
Staff can feel disconnected, too. In 2011 I travelled around the country meeting junior nursing and care staff for a government review. These are the people that patients see the most, who can make the difference between feeling scared and feeling safe. Yet they are the worst paid and the least valued. I met healthcare assistants who were grieving when a patient died, but were left out of the ward debrief because they were not registered nurses.
Staff are treated badly
Nurses work shifts of up to 12 hours and often eat out of vending machines. Pension caps are driving some of the most experienced doctors out of the service. The clunky system of pay bands called “Agenda for Change” means that some of the most dedicated middle-ranking nurses, who have worked for decades, are not properly rewarded. Performance appraisals seem largely meaningless — hardly anyone is ever fired. Yet nothing demoralises good staff more than the reluctance of the system to root out poor performers.
When I sat on the board of the Care Quality Commission, which regulates hospitals, care homes and GPs, I started to wonder whether we should be regulating GPs at all. We inspected surgeries’ fridge temperatures (which matters, because medicines can go off) and a host of indicators such as the friendliness of the receptionist. But we didn’t have the data to tell whether doctors were diagnosing properly, which is what matters most.
Warped financial incentives
Things are equally frustrating at the top, partly because the worst-performing hospitals are routinely bailed out by taking money from the best. This removes incentives for both bad and good to improve. Annual budgets, and the yo-yo of politics, also make it impossible to plan.
Last year I went to see Bruno Holthof, chief executive of Oxford University Hospitals, who I’d heard was stepping down. He is an impressive Belgian who came to England after successfully bringing the Antwerp hospital system out of bankruptcy. The NHS has many bankrupt hospitals, he told me, but managers don’t get the five years it would take to turn them around.
“The NHS invents its own financial measures and incentive systems,” he said. “NHS finances are also difficult to explain to clinicians, so it is hard to engage clinicians in improving the financial performance of their hospital.” Managers are often blamed for NHS failures. But the NHS also fails good managers. And the media doesn’t help. Julie Moore, the formidable former nurse who became chief executive of University Hospitals Birmingham, once told me that if the media kept denigrating managers, she’d never get anyone to apply.
A culture of covering up failures
When I was appointed to the CQC board in 2013, the organisation was in turmoil, having failed to spot the unfolding scandal at Stafford Hospital, where between 400 and 1,200 patients are thought to have died between 2005 and 2009 because of substandard care. Mid Staffs was exposed not by well-remunerated oversight bodies, but by ordinary people who lost relatives, as was also the case with NHS scandals at Morecambe Bay, Shrewsbury and Telford, Nottingham and East Kent. James Titcombe, whose baby died after receiving poor care at a Morecambe Bay Trust hospital, and Julie Bailey, whose mother died at Stafford Hospital, had to fight lengthy battles to expose institutions intent on covering up their failures.
We the patients can be our own worst enemies
Julie Bailey didn’t just lose her mother to the Mid Staffs scandal. She was subsequently harassed by locals who feared the bad publicity might lead to the hospital being downgraded. People will fight to keep their local hospital, even if it literally kills them. MPs court popularity by pledging to “save” one maternity unit from being merged with another, even though it might make women safer by having an obstetrician available round the clock.
Public cynicism about change is understandable. We were told that fewer hospital beds were needed — and ended up with rampant shortages and hospital-acquired infections. We heard that the private finance initiative would build shiny new hospitals — but saw trusts in hock to crippling contracts. We know that billions were wasted on an IT system to join up the NHS that didn’t work. When saving money is part of the motivation, we fear that change is a conspiracy to save money at the expense of care.
I am guilty myself of having opposed the big and centralised. I was one of those who thought the “polyclinics” proposed by the surgeon Ara Darzi (mega-surgeries housing GPs, diagnostic scanners, and community workers in mental health and social care) sounded alien. I changed my mind after the success of London’s stroke centres. Taking patients to these specialist trauma centres, rather than to the nearest hospital, has significantly reduced death rates from stroke, and also from serious injury, because those patients can be seen faster by a specialist. Yet their creation was decried by some of the hospitals which weren’t selected as centres.
Politics prevents an honest conversation
At every election, parties promise to “save the NHS” from the other lot. It leads to politicians grandstanding about hiring more hospital doctors and nurses, and the media judging them on that, even if what’s actually needed is more physios, district nurses, geriatricians and psychiatrists. It stops politicians posing the kind of questions I get asked on public panels: should we keep very old people alive for months when there is no hope of recovery? Should 89 per cent of prescriptions be free, when some people don’t even bother to finish courses of antibiotics?
The pressure is also on to show that more money is going to the frontline. A former minister reflected to me recently that in the mid 2010s, “the Department of Health wanted to put out a press release every year claiming that the NHS England budget was going up. So they transferred money from Public Health England, Health Education England [the training body], NHS Digital and the capital budget, to be able to show more at the frontline.” I was working in Downing Street at the time. From there, it could feel as though the NHS just soaked up cash. But I now think the under-investment was a mistake.
Social care: out of sight, out of mind
Up to one in five hospital beds are currently occupied by an elderly person who is medically fit to leave but has nowhere to go, because there is no place in “social care”: the network of home-visiting agencies and nursing homes.
Social care is largely invisible, because politicians have quietly left it to local authorities (whose budgets were cut during austerity). In 2017, when Prime Minister Theresa May suggested that voters might have to pay more for social care, most reacted with horror at the very idea.
Hiring and training more care workers is probably the quickest and cheapest way to release hospital beds and help doctors tackle the waiting list. It would also help to attract recruits, and make care feel more like a career, if the NHS would stop looking down from a great height and instead allow capable care workers to administer insulin, take blood pressure and be involved in rehabilitation units.
The NHS has endless discussions about “discharge”. “It’s less of a problem at Christmas,” one doctor tells me darkly, “when families are happy to have granny to stay. But they don’t want her for more than a week.”
Why prevention doesn’t happen
It seems obvious that prevention is better than cure. But despite the appalling and growing gaps in healthy life expectancy between rich and poor, public health is a Cinderella service that no one, beyond cash-strapped councils, seems to feel responsible for.
When I arrived in Downing Street in 2015, I had become convinced that obesity was a national epidemic and that we needed to treat sugar like nicotine. Obesity correlates closely with some cancers, and with Type 2 diabetes, which costs the NHS £10bn a year. It reduces the life chances of some of the poorest children. But I found that many GPs in both the UK and US were reluctant to talk to patients about their weight. Some were embarrassed; others said they had no time; others didn’t think their patients would ever lose weight. Susan Jebb, the Oxford professor of diet and population health who is now head of the Food Standards Agency, once told me she thought weight loss would be of more interest to doctors if it involved “shiny new drugs” rather than group hugs with health coaches.
When he was prime minister, David Cameron authorised my team to write an obesity strategy that included bans on trans fats and the advertising of junk food. The only policy we achieved, before Cameron resigned, was the sugar tax on fizzy drinks. Far from raising the cost of drinks, as critics alleged, this was a smart tax that convinced most companies to reformulate, removing 35 per cent of sugar from all drinks sold. Yet even this was attacked by libertarians, who thought it was “nannying”.
Unless we keep people healthier, and treat them earlier, we will be locked into an ever-increasing cost of healthcare, in a society of two halves: those who are still energetic into their seventies and those crippled by chronic conditions at 50. I believe the UK could lead the world in public health. We have a good record on smoking. But that was brought about by a combination of cultural change, local clinics and the national ban on smoking in enclosed spaces. Government expenditure does not in itself guarantee results: it is the concerted effort across the media, government and local government that can change minds.
The system looks upwards
It’s hard to imagine my great-aunt waiting for a directive from London to tell her what infection-control rules to follow should there be an outbreak. Yet the Department of Health issues “guidance” on almost everything. To take just one example, the “NHS Safety Thermometer” was an attempt to eradicate hospital-acquired infections. It is an unreadable, 36-page document. This is the kind of thing that staff endure all the time.
What needs to be done
Today, the NHS is in its most perilous state since its formation. Waiting lists are gargantuan, and growing numbers of people are getting operations done privately. The crippling health inequalities exposed by Covid are a stain on society. Staff who worked tirelessly through the pandemic are burnt out and running short of hope. That loss of hope is an existential threat.
In response, there are calls for new funding models, such as a European-style social insurance system; and for new committees or a royal commission.
I support a social insurance system for social care, and wrote a report in 2020 about how I think social care could be “fixed”. But when it comes to the NHS, it seems to me that most of the answers are already there: in the Darzi plan of 2008, the NHS Five Year Forward View of 2014 and the NHS Long Term Plan of 2019. All envision a radical upgrade in “prevention”. All want to integrate GPs and hospitals, to connect up the landscape for patients with multiple conditions, to empower us to take charge of our own health in a world where genomics and AI will help pinpoint our individual risk.
The big question is why this hasn’t happened. One answer is that it’s hard to reshape a service into something new while you’re still running the old one, and that far more money is needed to ease the way. Another is that the financial incentives are not aligned. Hospitals are paid by “activity”, so have little interest in patients being kept healthier outside. In addition, the kind of people needed to staff the vision — district nurses, geriatricians, health coaches, physician assistants, data analysts — haven’t been hired. Despite being the lifeblood of community services, the number of district nurses almost halved between 2010 and 2018. The digitalisation of health records and the sharing of data have been incredibly slow, resisted by vested interests at every turn.
And social care remains stuck in the “too hard” box, after a decade of cuts to local authority funding, with the middle classes insisting that no one should have to sell their home to pay for care, and no one daring to challenge them.
The short-termism of our politics is a big barrier. To save the NHS, political parties need to agree a 10-year funded plan in exchange for reform. There must be an end to annual budgeting. Financial incentives need to be aligned: one way to do this would be for hospitals to take responsibility for primary care and community services. This happens in Northumbria, where the hospital trust is rated outstanding.
With the NHS England budget set at £180bn for 2022-23, taxpayers are spending a lot. Experts say that the service needs a year-on-year funding increase of at least 4 per cent just to survive in its current form; or more, given the pandemic and inflation. We probably need to pay that, while also finding reforms that produce a better service.
A clear philosophy is needed about how to drive up standards in what is effectively a monopoly. The Conservatives’ answer, under Ken Clarke, was the internal market. New Labour’s was “choice and competition”: waits for hip and knee replacements were slashed by giving patients a choice between the NHS and private providers. That policy was shelved after it had done its job of reducing waiting lists. But a similar approach could bring waiting lists down now. And Labour shadow health secretary Wes Streeting has, encouragingly, promised to be a “shop steward for patients”, who would rewrite the GP contract and let patients self-refer in some cases. This must mean measuring outcomes, not just inputs.
We also need a decisive shift towards greater autonomy for staff, and a proper workforce plan. The immediate need is to provide a sense of hope and momentum. In Tony Blair’s first term, he promised to raise spending to the EU average, with big annual cash injections. By spending so much, he and Alan Milburn, his health secretary, could face down those who claimed that funding was the sole problem and focus on reform.
We need something similar now: a big offer but with an insistence on reducing bureaucracy and increasing autonomy. We could expand the “virtual wards” that freed up hospital capacity in the pandemic, monitoring people at home. Build homes for nurses on spare public sector land. And change the visa regime, so that hard-pressed staff know the cavalry is coming. The current crisis must be an opportunity — or we are all sunk.
Camilla Cavendish is an FT contributing editor and columnist, and former head of the Downing Street policy unit under Prime Minister David Cameron
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