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The dire state of the NHS has led to predictable calls for a royal commission. But that would be a time-wasting distraction. The big secret is that there is widespread agreement, in the NHS and all political parties, on what needs to be done. The real question is why it still hasn’t happened.
You could fill Centre Court at Wimbledon with all the NHS strategies, plans, think-tank reports and independent reviews in the past 20 years (two written by me). The official plans — the Darzi plan of 2008, the NHS Five Year Forward View of 2014, the NHS Long Term Plan of 2019 — all envision similar things. A radical upgrade in public health to stop so many people getting sick. The integration of GPs, hospitals and community services because most patients are living with chronic conditions not a none-off injury. And more power and information for patients, in a world where genomics and AI will help pinpoint our individual risk.
Too little of this has happened, partly because of cuts and volatile budgeting; but also because of what Tony Blair once called “the forces of conservatism”. Over the years, I have watched dedicated GPs, consultants and nurses burn out in the struggle to improve things for patients, against the system. One GP spent years convincing his local hospital to let him have a clinic inside A&E, which was a huge success. When I sat on the board of the hospital regulator, we visited one hospital which had hired management consultants to game our inspection. Now, the British Medical Association is locked in a battle with NHS England to stop patients getting hold of their own electronic health records, although sharing data is critical to modernising the service.
We all know that frontline staff are under extreme pressure. But it felt arrogant for the BMA to attack the recent demand, by shadow health secretary Wes Streeting, that GPs give face to face appointments to patients who want them. This, said the BMA, was “divisive and disappointing”. What is disappointing is that my own GP practice has called me several times to offer me a health check I don’t want, while refusing to give one of my kids an appointment.
The sheer scale of the crisis, the acknowledgment that our population is ageing and the return of reasonableness to the Labour party, means the NHS could finally be heading into a decade of steadiness which will let leaders plan ahead. Rishi Sunak’s government laid the ground last week, when it broke a longstanding Treasury taboo by announcing a long-term plan for the NHS workforce with thousands more doctors and nurses. But while that may improve morale, more inputs won’t automatically translate into better outcomes without good management.
In pledging to increase frontline staff but not managers, health secretary Steve Barclay made a major mistake. The government is right that the service is drowning in bureaucracy. But it is wrong to equate bureaucracy with there being too many managers — academic studies tend to find that the NHS is undermanaged. The bureaucracy is largely the fault of the monstrous quangocracy which has been created by serial reorganisations. NHS staff are drowning in requests for information, many of them duplicative, from multiple agencies created by governments desperate to maintain their grip.
Doctors resisted the introduction of non-clinical managers in the 1980s, and nurses still sometimes joke about “going to the dark side” if they take leadership positions. Managers are blamed for the piles of paperwork which take doctors away from patients, despite these being largely the consequence of national policies.
What is needed is a step-change in management, with better training, more trust and more autonomy. It’s hard to keep great leaders running complex services with the ludicrous constraints of annual budgets and the best performing services plundered to prop up the worst. But without more of them, the NHS will continue what General Sir Gordon Messenger, in a recent review, called “an organisational instinct to prioritise the needs of the system and its hierarchy over . . . better patient outcomes”.
As directives and rules flow downwards from paranoid politicians, managers have become increasingly defensive. Staff surveys show endemic bullying, harassment and blame — but fear of lawsuits means performance appraisals are almost uniformly positive. Speaking to professionals about why they have left or are thinking of leaving the service, all cite pay but most are also deeply upset about the lack of respect from their own employers. Junior doctors are abused by patients and have nowhere to eat. Nurses work 12-hour shifts.
One experienced NHS leader told me recently that he thinks the service is more risk-averse than those it treats. Most of us would like to die at home, according to surveys, but almost half of us still die in hospital. One in five women want to give birth at home; but only 2 per cent do. We over-medicalise, he said, but under-manage.
Only a Labour government, it is often said, can radically improve the NHS because it is so much more trusted than the Conservatives. If Wes Streeting becomes health secretary, he has promised to put himself squarely on the side of patients. That is what Alan Milburn did under Blair — and patient outcomes improved.
Many of the NHS’s problems won’t be resolved by more committees, or a new charging system. They are classic management problems. The service’s future depends on resolving them.