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- Herausgeber: Biteback Publishing
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
"A truly insightful tour d'horizon" – Rt Hon. Jeremy Hunt MP, Secretary of State for Health, 2012–18 "Insightful and thought-provoking" – Rt Hon. Matt Hancock MP, Secretary of State for Health, 2018–21 "Brilliant" – Sir Stephen Bubb, director of Charity Futures and the Oxford Institute of Charity "A tour de force" – Niall Dickson CBE, former chief executive of The King's Fund, the General Medical Council and the NHS Confederation *** How good is the NHS, really? That is the question this book seeks to answer, as the health service emerges from the gravest crisis in its history with more money – but greater challenges – than ever before. During the pandemic, voters made extraordinary sacrifices to save the NHS from collapse. Thanks to these efforts and the dedication and bravery of the NHS workforce, hospitals were able to treat patients with coronavirus, but millions of others lost out. Now an exhausted and depleted NHS workforce faces a huge backlog. The gap between supply and demand for publicly funded healthcare has never been so wide. With record numbers waiting for treatment, the politicians' answer has been to spend ever more taxpayers' money. The question is whether throwing cash at the problem will work. Every day, millions of patients receive care that is fair, good or outstanding. In keeping with Nye Bevan's founding principles, the same treatment is available to rich and poor, free at the point of need. Public support for the concept remains overwhelming. Yet for every positive NHS experience there are negatives: care that is substandard, disjointed and arrives too late. A cult of secrecy surrounds errors and failings. Politicians on all sides dissemble and lie. This book seeks to strip away the spin and uncover the true state of the NHS: the good, the bad and the ugly. It explores an increasingly urgent question: in an era of pandemics, can the NHS provide the quality of service patients deserve?
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iii
CONTENTS
AUTHORS’ ROYALTIES
Lord Ashcroft is donating all authors’ royalties from Life Support to charities supporting the NHS in England.
viii
ACKNOWLEDGEMENTS
First and foremost, we would like to thank all the NHS doctors, nurses and other clinicians who generously gave their time and consideration to this project. Our investigation draws from interviews with several hundred such NHS sources, as well as many administrative staff at all levels. NHS Trusts exercise a very high degree of control over employees’ interactions with the media and do not encourage open dialogue. As a result, many of our most valuable sources felt unable to talk on the record for fear of reprisals. Nonetheless, their contributions were vital and much appreciated. Almost everyone we interviewed believes passionately in the founding principles of the NHS and wants it to thrive. Where they were critical, it was always in constructive spirit.
This book is as much about the politics of delivering healthcare as it is about the quality of that care. We are grateful that recent Secretaries of State for Health supported our research. We would particularly like to thank the Rt Hon. Jeremy Hunt MP, who held this most challenging of positions from 2012 to 2018, making him the longest-serving Health Secretary in history; the Rt Hon. Matt Hancock MP, who was Secretary of State during the peak of the pandemic; and Labour’s Andy Burnham, who was Secretary of State for Health in 2009–10. Many other MPs, peers and political xfigures with a particular interest in health were also very supportive, including former health minister Lord O’Shaughnessy; Lord Prior, of the NHS board; and Ed Jones, former special adviser to Jeremy Hunt.
Various think tanks went out of their way to help us, especially the highly respected King’s Fund. We are also grateful to Niall Dickson, formerly of the NHS Confederation; the distinguished American cardiologist Prof. Eric Topol; the Nuffield Trust; Prof. Sir Brian Jarman; Prof. Sir Michael Marmot; Rupert Soames, CEO of Serco Group; and Edward Davies, of the Centre for Social Justice.
The University College London Hospitals NHS Foundation Trust granted us special access to an operating theatre; Queen’s Hospital in Romford supported our research on delayed discharges and end-of-life care; the independent Princess Grace Hospital allowed us to shadow one of their consultants; and Babylon, which has an NHS contract to provide online GP services, contributed to our research in primary care.
While this book is highly critical of the standard of healthcare on the Isle of Wight, the local NHS Trust was very cooperative and keen to show how things have changed. We are grateful to chief executive Maggie Oldham and her team and recognise the significant improvement in services under her leadership.
On the very important (and frequently marginalised) issue of services for those with autism and learning disabilities, the campaigning journalist Ian Birrell and Sir Stephen Bubb, an expert in this field, gave us a great deal of their time and insights. We would also like to thank the team at the Cleveland Clinic for facilitating a research visit to their flagship hospital in Ohio. Special thanks to consultant urologist Prasanna ‘PS’ Sooriakumaran, who works for xithe NHS in London and at the Cleveland Clinic’s new UK hospital and allowed us to observe him performing robotic surgery.
This book was originally due to be published in autumn 2020. The manuscript had just been sent to the publisher when the pandemic started. As the health service was plunged into the biggest crisis in its history, it was clear we could not proceed as planned. Luckily, it was not too late to change the timetable. The project was delayed by more than a year until the worst of the pandemic was over, not only because it might be perceived we were criticising from the sidelines while heroic healthcare professionals were battling to save lives, but also because the lasting impact of coronavirus on the NHS was unclear.
Following the end of lockdown restrictions in summer 2020, we went through an exhaustive process of updating the manuscript and reinterviewed many of our original sources, as well as some new ones. Keeping pace with such a rapidly moving story was extremely challenging. We have done our best to incorporate and reflect the most important changes that have taken place since the pandemic, but in a work of this length and detail, some omissions are inevitable. Towards the end of the project, our researcher Josh Dolder worked very long hours assisting with fact-checking and updating statistics. Any mistakes that have nonetheless slipped through the net are honest ones.
Finally, we are grateful to Angela Entwistle, corporate communications director to Lord Ashcroft, and her wonderful team, and to everybody at Biteback Publishing, for making this project possible. xii
PREFACE
The coronavirus pandemic has posed the greatest challenge to the National Health Service since it was established in 1948. The heroic response of frontline staff from the outset was not lost on the British people, who congregated on their doorsteps each Thursday evening to clap, cheer and bang pots and pans in gratitude. NHS workers’ efforts were further recognised in July 2021 when, in response to a campaign I was pleased to have helped to instigate, the Queen awarded the NHS the George Cross. In a handwritten personal message, Her Majesty said: ‘Over more than seven decades, and especially in recent times, you have supported the people of our country with courage, compassion and dedication, demonstrating the highest standards of public service.’
The sentiment is one to which most people in Britain would subscribe. Indeed, the NHS is frequently compared to a national religion. At the same time, and even in the absence of a global health crisis, the health service is always among the public’s biggest concerns. When my political surveys ask about the most important issues facing the country, it often tops the list; even more so when we ask people what matters most to them and their families. Even at the 2019 election, dominated as it was by Brexit, my election-day xivpoll found nearly as many people saying the NHS had been a factor in their vote as Britain’s departure from the EU.
Naturally, people’s health will always matter a great deal to them, but so too do many things that never appear in the forefront of political debate. What keeps the NHS so close to the top of the league table of national preoccupations is the belief that it is fragile and vulnerable. There is a sense that it is fighting a losing battle to deliver the standard of care people deserve.
I have always been interested in the challenge of delivering a modern health service with limited resources, especially with my longstanding interest in the interaction between politics and public opinion. As in the field of defence, which my co-author Isabel Oakeshott and I tackled in our 2018 book White Flag? An Examinationof the UK’s Defence Capability, I see a national institution with a critical role struggling to keep up with public expectations as the world changes: a fascinating and important subject.
But there is also a personal reason that I have developed a keener interest in healthcare. In September 2015, during a visit to Gallipoli to explore First World War battlefields, I became unwell with what I thought at the time was a bad case of food poisoning. A few days later, by now in the Caribbean and still feeling decidedly grim, I was diagnosed with sepsis and flown to the Cleveland Clinic in Ohio, of which I was (and remain) a trustee, and where I received regular check-ups and underwent a heart bypass operation in 2001. Before long I was in intensive care, where I remained for nineteen days. During this period, my life was in the balance. In my lucid moments, I sent messages to loved ones I feared I would not see again and, I must admit, wondered how my obituary would read. After months of rehabilitation, and despite some setbacks, I made a full recovery.xv
I relate this story for three reasons. The first is that the Cleveland Clinic is one of the very best and most innovative health institutions in the world and has a great deal to teach us about delivering outstanding healthcare. A later chapter in this book explores this in more detail.
The second is that it gives me an excuse to make my regular plea to readers to find out about sepsis, a condition that is still unknown to many but which kills a staggering 50,000 people in the UK alone every year. It arises when the body’s response to an infection injures its own tissues and organs. The signs include slurred speech or confusion, shivering, severe breathlessness, mottled or discoloured skin and not urinating for a whole day. If someone you are with experiences these symptoms, seek medical help immediately and ask: ‘Could it be sepsis?’
The third is that you may think it’s all very well for me to talk about jetting off to my world-class clinic, but what about the rest of us? In which case, I agree with you. In fact, that is the point of this book. The NHS was set up to provide free healthcare for everyone in Britain at a time when medicine looked very different. Much of what can be achieved today could not even be imagined seventy years ago. The kind of treatment and care I was fortunate enough to receive in Cleveland should be available to everybody. At its best, the NHS can deliver it. But both within the NHS and outside it, many will say that the service has too much to cope with simply keeping the show on the road. We need a better understanding of what needs to change.
The widespread view that the NHS is in a sorry state, however, is not always based on personal experience. I conducted extensive research both at the outset of the pandemic in March 2020 and again in November 2021 when the crisis had eased (the full results xviare available to study at LordAshcroftPolls.com). In both surveys, people gave a more positive rating for their own most recent encounter with the NHS than they did when asked how good or bad they thought NHS services were in the country as a whole. Indeed, those who had had very frequent contact with the NHS gave a higher mark for their personal experience than those who had had no contact in the previous six months.
Curiously, in a development that says much about Britain’s relationship with its favourite institution, the perception that Britain had a deteriorating health service appeared to be turned on its head during the pandemic itself. The bleaker things got, the greater people’s adulation. In the spring of 2020, at the height of the emergency, the number of people in YouGov’s regular tracking poll who felt that NHS services were getting better briefly outnumbered those saying the opposite. This was highly unusual. As case numbers subsided, ‘worse’ took the lead again.1 In the early weeks, confidence in the UK health authorities to respond to the virus rose with the number of victims.2 The proportion saying that they thought NHS services were good nearly doubled as the crisis took hold, rising from 37 per cent in February 2020 to 69 per cent in April (and drifting back down to 45 per cent eighteen months later).3
In my own research, people were slightly more likely to think that the UK in general had handled the pandemic worse than other countries than to think it had done better. But asked how the NHS itself had done, people were four times more likely to say it had performed better than other countries’ health systems than the opposite. In my focus groups, people praised the way the service had responded to an unprecedented situation, with staff working around the clock and risking their own health to care for those suffering. Problems were acknowledged: shortages of personal xviiprotective equipment and other supplies, infected patients being returned to care homes, a faltering test-and-trace system, and widely varying rules and procedures between one hospital to another. Some wondered whether decisions like cancellation of non-Covid services and restrictions on hospital visits – including last visits to dying relatives – had been too severe. But these things were by and large blamed on the fraught circumstances of the time; or on other people. The general consensus was that the health service had acquitted itself admirably.
Together, these observations represent a microcosm of the public’s wider view of the NHS: gallant frontline staff doing their best to serve patients in the face of grim conditions, political blunders, cack-handed management, inadequate resources and overwhelming demand. Even so, they were more inclined to think that the pandemic had shown how good the NHS is and why it is the right health system for Britain than to believe it had highlighted the need for serious reform.
Nonetheless, there is a widespread sense that the pandemic has had a lasting negative impact on the health service. Most of those I have polled believed the NHS is now in a worse state than it was before the crisis began. Even though they recognised the logjam caused by Covid as the biggest immediate problem, few thought this simply amounted to short-term overload that would quickly clear. The prevailing view was that the pandemic had exacerbated existing problems and that things were unlikely to improve any time soon.
They believed – just as they did before the virus struck – that waiting times for appointments and treatment were foremost among these problems. While they understood that the crisis had created a huge backlog of postponed operations and consultations, xviiisome had begun to feel that Covid was sometimes being used as an excuse, rather than a genuine explanation, for delays. As always, many other satisfied customers spoke up for their experience of the NHS in recent months. But some said they were losing patience with services they needed still being unavailable because of Covid, even though the rest of society was returning to normal.
There was particular frustration among those who had tried to see their GP, with many complaining that they had had to wait weeks even for a scheduled phone call. In our poll, more than a third of those who had tried to make an appointment within the past year had had to wait what they considered an unreasonably long time for a slot or had been unable to get one at all. Of those who had managed to do so, fewer than four in ten said they had been seen in person; most appointments had been by phone. Some in our focus groups had no complaints about this, especially for routine or straightforward matters. But for many others, it had meant irritations including long waits for diagnosis of painful and possibly serious conditions; occasional misdiagnoses that would not have occurred had the consultation taken place in person; or the somewhat surreal experience of online physiotherapy. Some spoke of family members for whom late diagnosis or postponed treatment had allowed cancers to become inoperable.
The most common view in our survey was that while GPs had no choice but to hold remote appointments at the height of the pandemic, they should now be seeing patients face to face as far as possible. Only one in ten of those surveyed thought remote appointments were just as good, and even fewer believed the Covid situation meant traditional consultations were still unsafe. While most thought GPs were trying to protect themselves and their patients or to fit more appointments into a day, a quarter suspected xixthat they simply found remote appointments more convenient. Most in our groups agreed that GPs certainly seemed in no particular hurry to go back to business as usual and sometimes assumed that – like much of the rest of the country – they had found remote working rather enjoyable.
Beyond these issues, the biggest perceived problem for NHS patients was believed to be different standards of care between hospitals and areas of the country: nearly seven in ten said they thought the quality of NHS services varied a lot from one place to the next. Patients being denied drugs and treatment that could help them was next in line, followed by poor communication. Strikingly, new drugs and treatments not being approved quickly enough registered considerably less concern after Covid than before – doubtless a legacy of the impressive vaccine programme. The list of gripes was echoed and expanded upon in my focus groups, with a first- or second-hand anecdote to illustrate each shortcoming. But as often as not, people would conclude their story about a long wait in Accident & Emergency or a traumatic night on the ward by saying something like: ‘I didn’t complain, though, because I could see they were all rushed off their feet.’ Patients often excuse bad experiences, or at least the staff who eventually treat them, whom they often go out of their way to praise.
This is because they appreciate the pressure under which the service is operating. They believe that a shortage of doctors, nurses and other clinical staff – exacerbated by the post-Covid backlog – is chief among these burdens. The problem is aggravated by those who show up for trivial things or otherwise display a cavalier attitude to the scarce resources available. (One woman in our pre-pandemic research cheerfully confessed to making a GP appointment every fortnight, just in case she needed it.) xx
Others assume staff shortages must be one of the many consequences of continual underfunding. Even after the government’s post-election funding announcements, the £12 billion a year in projected extra cash from the new health and social care levy, and the torrent of public money unleashed during the pandemic, I found more people thinking NHS spending over the past five years had fallen than that it had risen (though by a smaller margin than was the case before the crisis). In group discussions, it was clear that many people simply did not know what to make of NHS funding, even when hard figures were attached. The issue now belongs squarely in the realm of political claim and counterclaim, and confusion reigns. There is a widespread feeling that even if the NHS budget is rising – a doubtful enough supposition for many people – demand for NHS services is rising even faster, while a growing population, longer life expectancy and expensive new drugs and technologies consume NHS funds at an ever-faster rate. When we asked specifically about the new levy – of which few had heard – people were sceptical that the revenue really would be spent on health and social care, and even more sceptical that it would lead to any improvement in the NHS. ‘I’ll believe it when I see it’ was the refrain. The conviction that the NHS is beset with waste and bureaucracy – a problem believed to be on a par with underfunding – is also widespread, with stories of garbled communication and lost paperwork supplied in abundant evidence.
Arguably, all these problems stem from the characteristic that British people most value about the NHS: that it is available to everyone and free at the point of use. Demand constantly outstripping supply, insufficient staff to keep up, missed but uncancelled appointments, overburdened GPs, long waits, administrative bungles and ever-rising costs with no mechanism for meeting them xxiother than the Chancellor’s political judgement – all these will be a perpetual challenge in a universal health system funded entirely from taxes.
An overseas observer might expect this to prompt a national debate as to whether such a system is really the best way of providing for the country’s health more than seventy years after it was invented. But to think this, the observer would have to be unfamiliar with the British, to whom the founding principles of the NHS are practically sacred. In both my polls, clear majorities agreed with the statement ‘It is more important to keep the principle of an NHS funded by taxation and free at the point of use, even if a differentsystem could mean improvements in treatment and better survivalrates for serious conditions.’ Only just over one in five agreed with the opposing contention that ‘it is more important to have the best possible treatment and improved survival rates, even if that means the NHS is no longer funded by taxation and free at the point of use’.
The point was illustrated in our focus groups by participants’ reactions to international comparisons. Presented with evidence that the UK achieves distinctly mid-table positions on certain measures – such as an OECD study4 putting us twenty-fourth in the world on five-year survival rates for breast cancer – some people were quite shocked, but very few would have expected to see us top the league. More often, they would ask what Britain could learn from countries that do better in terms of screening, early detection or follow-up care, or how they achieved their superior results. Seeing that the USA did markedly better than the UK on such measures does not prompt people to think there might after all be something in the American system. When people say they believe the NHS is the best health service in the world, which many do, they don’t xxiimean they are convinced it offers the best treatment and produces the best outcomes – just that they would rather have the NHS than any other system they can think of. In other words, people accept that having a free and universal system involves some compromises in terms of quality, but they are compromises they are prepared to make.
The reason may lie in what behavioural economists call prospect theory. When faced with choices that might lead to potential gains, people will tend to be risk-averse, preferring the certainty of keeping what they already have – in this case, what one of our participants called the ‘psychic assurance’ that the NHS will be there for them. ‘I could lose my job, I could lose my car, my house, my wife, but I will never lose my healthcare,’ as he put it. ‘It doesn’t matter what financial state I get into. Other countries don’t necessarily have that.’
This also explains why ideas for reform are always met with suspicion. Changes might bring improvements, but what if they make things worse? For example, many people’s unease about more private firms delivering NHS services is not down to ideological horror at the profit motive so much as the suspicion that this will somehow inevitably lead to patients one day having to pay. Government-imposed targets might bring down waiting times, but what if they just encourage corner-cutting and box ticking? Encouraging hospitals to innovate might lead to improvements, but what if it just makes services patchier? Giving patients more choice might drive up standards, but what if I choose the wrong place and lose out – and anyway, don’t we just want a reliably good service, reasonably close to home?
When talking to people in Britain about ideas for improving the NHS that have been put forward over the years, these are some of xxiiithe things you will hear. The public might be right about some or all of them, or it might not. But together, along with an understanding of the part the institution plays in Britain’s national psyche, they help explain why the NHS perennially tops the charts of voters’ worries, and why change is so hard.
For the right change to be identified, we first need to define where we are. This is what this book seeks to do. Some will be tempted to see what follows as an attack on the NHS. It is not. It is an objective study of how things really are, and the ways in which politics, bureaucracy, finances, skewed priorities, overstretched resources and even the unintended consequences of well-intentioned reforms have too often conspired to prevent those working in the NHS from delivering the kind of service they themselves want to provide.
Michael Ashcroft
November 2021xxiv
419
NOTES
1 ‘Is the NHS getting better or worse?’, YouGov, available at: https://yougov.co.uk/topics/politics/trackers/is-the-nhs-getting-better-or-worse
2 ‘Covid-19: Government handling and confidence in health authorities’, YouGov, available at: https://yougov.co.uk/topics/international/articles-reports/2020/03/17/perception-government-handling-covid-19
3 ‘How good or bad are national NHS services’, YouGov, available at: https://yougov.co.uk/topics/politics/trackers/how-good-or-bad-are-national-nhs-services
4https://stats.oecd.org/Index.aspx?QueryId=51882
INTRODUCTION: HEALTH CHECK
Just inside the main entrance to St George’s Hospital in south London is a brightly coloured doormat emblazoned with the words ‘Outstanding Care, Every Time’. This message must be reassuring for patients as they step through the sliding doors and head towards outpatient appointments. It is also encouraging for visitors as they make their way to see relatives on wards. Just one problem: this is simply not true.
No large hospital in the world provides outstanding care, every time: even the most prestigious clinics with the most eminent doctors occasionally slip up. As for St George’s, it may aspire to such standards, but it certainly does not achieve them. Most patients receive decent enough care, and some receive better. However, the reality is that many others are badly let down. We know this for a fact because the trust officially ‘requires improvement’, which is better than being rated ‘inadequate’, as it was in 2016, but is nonetheless an embarrassment to those who run it.1 What this official status means is that a lot is wrong, and despite the fact that managers have known this for some time, not enough has been done to put things right.xxvi
The most recent inspection report lays bare the failings, highlighting issues with patient record-keeping; infection control; cleanliness; staff training; the state of the building; and management.2 It says patients cannot always access the treatment they need and do not always receive the right care promptly. It says waiting times are too long for appointments with specialists and for operations. It says arrangements to admit, treat and discharge patients are not in line with national standards. It says some facilities need modernising and some departments and wards are ‘excessively hot’ in summer because there is no air conditioning. It says the place is not very well led. Despite the obvious areas for improvement, the trust is getting better, and services for children and young people were rated outstanding. However, this is a far cry from ‘outstanding care, every time’.
The propaganda on that doormat is a classic example of the way politicians and many of those who run the NHS wilfully deceive voters about the quality of service they receive. The aim of this book is to strip away such spin and paint a picture of the NHS as it really is: the good, the bad and the ugly.
St George’s is, like many other hospitals up and down the country, staffed by talented, hard-working people struggling to provide a good service. But it does not take an inspector to observe that it is not a model trust. On a typical ward in the St James Wing, so many patients are crammed into such a small space that it is impossible to fit chairs on both sides of the beds. Synthetic blue curtains that can be drawn round each bay offer the pretence of privacy, but still everything can be overheard. It is messy, airless, noisy, strip-lit, patently short-staffed and the food looks like prison slop. On the hospital website, this particular area is described as a ‘short stay acute medical ward’ catering for patients with a range xxviiof conditions, including respiratory, gastroenterology and cardiac problems, but it is hard to imagine anyone making a rapid recovery here. It looks third world. Nonetheless, a noticeboard on the corridor wall is covered in ‘thank-you’ cards from grateful patients and relatives.3 Regulators do not consider services at St George’s entirely safe, nor entirely well led, nor entirely effective, nor entirely responsive to patients’ needs, but in common with most other substandard hospitals, staff are caring.4
What is depressing for voters is that there is nothing particularly unusual about this trust. Around fifty-five trusts in England are officially deemed to ‘require improvement’, while a further two are rated ‘inadequate’ and seventeen are in the Recovery Support Programme.5 There have been scandals at St George’s, including a toxic feud between warring heart surgeons which apparently left staff feeling that poor performance was ‘inevitable’,6 but it is not notorious, like the Mid Staffordshire NHS Foundation Trust became before it was broken up.* It is just another hospital that’s not that great.
Zooming in and out from the detail to the bigger picture, this book seeks to identify the truth about one of this country’s most cherished institutions, identifying where the challenges and opportunities lie. We take as a starting point that the NHS is one of this country’s greatest assets. It would be mad to let it wither away. We believe Nye Bevan’s vision of providing all patients with healthcare free at the point of delivery, based on need and not on ability to pay, remains the right principle today, more than seventy years after he created the NHS. We take as a given that the majority of the NHS workforce works tirelessly. There is no doubt that millions xxviiiof patients receive care that is good, and thousands receive care that is outstanding, every single day. The trouble is that millions of others do not, and the number of those who are failed is growing at the very same time as taxpayers are pouring billions more into the system. That is where an honest conversation about the state of the NHS begins.
When the NHS was established in 1948, it had an annual budget of today’s equivalent of around £15 billion. Average life expectancy for men was sixty-six years, while women could expect to live to the age of seventy. Today, NHS England has a budget of £129.7 billion† and rising,7 but male life expectancy is just under eighty, while female life expectancy is almost eighty-three years. In 1948, when the National Health Service Act nationalised more than 2,700 hospitals previously run by charities and local authorities, the UK population was around 50 million. Today, it stands at just under 70 million.
Pre-coronavirus, the NHS was dealing with over 1 million patients every thirty-six hours, with over 17 million hospital admissions and around 96 million outpatient attendances every year.8
This is a whole new ballgame. Maintaining the standard of care that everyone who works for the NHS would like to provide is becoming ever more challenging, and the effort is exhausting the workforce. Many people will be familiar with the most frequently cited sources of pressure on GP and hospital services: the ageing demographic which has seen people living longer but with many more years of poor health; soaring rates of obesity; diabetes and xxixother chronic diseases; and antibiotic resistance.9 Though this book will touch on some of these issues, they are well-covered ground. In any case, it is all too easy for politicians to reference such challenges as if they are the only problems. Our aim is to delve deeper, looking at other critical factors in the ability of the NHS to continue to provide the level and range of service that patients need or have come to expect. It sets out to answer a highly sensitive question: how good is the NHS, really?
It is not just all the propaganda that makes this difficult to answer but the depth of public affection for, and commitment to, the NHS as an institution. In recent years, satisfaction levels have fallen dramatically,10 but the health service still regularly tops polls of what makes the British most proud. Such is the depth of attachment to the institution, whether ideological or as a result of positive personal experiences, that there can be a wilful deafness to its flaws. Most people realise the service is imperfect but prefer to imagine that any shortcomings or failures are either sporadic misfortunes which occur in spite of a great system or that they stem from a shortage of funding.
The perception that we are lucky to have the NHS remains widespread, along with a sense that while it is acceptable to complain about individual mishaps, criticising it more generally is not only somehow ungrateful but also represents an attack on the tireless army of doctors, nurses, healthcare assistants, porters and other NHS workers who keep it going. This attitude permeates every debate about its merits and shortcomings.
Yet the real reason it is so difficult to get to the truth is politicians. As we shall see, the cynical exploitation of the NHS by representatives of all parties completely warps the debate, especially during election campaigns. Following three UK general elections xxxin the space of four years and the heightened emotions surrounding the pandemic, reality has become ever harder to separate from fiction. This book seeks to cool the temperature. It seeks to show how politicians, aided and abetted by vested interests, deliberately distort the picture. The aim is to arm voters with the information needed to make their own judgements.
It is important to make clear that we are not attempting to assess how well the NHS performed during the pandemic: that will be exhaustively examined during the wider public inquiry. Our interest is in the fundamental state of the NHS. We will of course look at what the response to the pandemic revealed about the NHS, and at the long-term impact of the pandemic on its ability to provide non-coronavirus-related care, but our primary focus is on the state of the NHS in normal times, rather than on how it coped during this particular unprecedented crisis.
By way of a plot spoiler, we are not going to recommend that the NHS be dismantled, privatised or funded in a completely different way. There might be both pragmatic and ideological arguments for a radical change in the way the system is paid for, replacing general taxation with some kind of insurance scheme while maintaining Bevan’s vision of care that is free at the point of need, but we do not seek to make that case here. There is simply no public or political appetite for change of this nature, and the descent of so much political debate about the state of the NHS into a row over public versus private provision does voters a huge disservice. It is deliberately polarising, diverting attention from the true nature of the challenges faced and the many other potential methods of improving the system. Nevertheless, those who care about the NHS and are deeply concerned about its future must work with the political world as it is, not as they would like it to be. xxxi
This is a huge subject, and some aspects are beyond our scope. One of our biggest challenges has been the pace of change in the NHS. Every day, fresh inspection reports are published, new statistics are released and policy changes are announced. Some things improve, while others deteriorate. Facts and figures were updated until the point the manuscript was sent to the publisher in October 2021, after which changes could not be reflected. We have concentrated on the state of the NHS in England, as opposed to in the devolved administrations, because health services in Scotland, Wales and Northern Ireland have their own unique features. They also operate in a very different political context. We have also not explored the state of dentistry, medical training and education or the state of the pharmaceutical industry. Throughout this exercise we have been led by the evidence, but our investigation does not purport to be scientific. The problem for those interested in the state of the NHS is not a shortage of facts and figures, though we supply them where appropriate, but the opposite. The volume of statistics and specialist reports on individual aspects of the service is quite overwhelming, and of little help to the layperson who is interested in the overall picture. So, we combine quantitative and qualitative evidence, drawing from official data and observations from expert witnesses. To provide some depth, we decided to carry out a special investigation into the state of health services in one particular part of the country. Prompted by disturbing evidence about standards of care, we selected the Isle of Wight for this research. The challenges this trust faces are similar to those faced by many other low-profile trusts, particularly outside cities.
The health service is changing every day, and it is impossible to capture everything. Our hope is that we offer enough to give a real sense of the status quo and the direction in which things are xxxiiheading. Naturally, people’s perceptions are very largely shaped by their own experience. Ask anyone what they think about the subject and they almost invariably reference the care – whether good or less so – that they or a relative have received. It is commonplace for individuals to proclaim that the NHS saved their life or the life of a loved one. Though it is tempting to write a book such as this through patient stories, at an early stage in our research we realised that such accounts are of limited value in terms of our objective. Every week millions of patients have wonderful experiences, while very many others receive care ranging from mediocre to dangerous. Paradoxically, their individual stories are almost all both entirely representative and unrepresentative of the NHS today. So, we have focused on the evidence of those who have a broader perspective, either because they work for the NHS or have observed it in a professional or political capacity for very many years. They are clearly better placed to make the sort of generalisations that illuminate the debate than individual patients who are personally grateful or aggrieved. We do make some exceptions to the rule, one of which immediately follows this introduction. It has been chosen not because the story is remarkable but because it is precisely the opposite. It touches on many themes that will recur throughout the book.
While some of what follows is unsparing, our aim is not to denigrate the NHS but to act as a critical friend. It is only by knowing the truth that the country can demand better.
NOTES
1 ‘St George’s University Hospitals NHS Foundation Trust: Inspection report’, Care Quality Commission, 18 December 2019; ‘St George’s University Hospitals NHS Foundation Trust: Quality report’, Care Quality Commission, 1 November 2016.
2 ‘St George’s Hospitals NHS Foundation Trust: Inspection report’, op. cit., pp. 19–20.
3 Research trip to St George’s Hospital.
4 ‘St George’s Hospitals NHS Foundation Trust: Inspection report’, op. cit., p. 16.
5 ‘Recovery support programme’, NHS England, available at: https://www.england.nhs.uk/system-and-organisational-oversight/national-recovery-support-programme/; ‘Care directory with ratings’, CQC, available at: https://www.cqc.org.uk/about-us/transparency/using-cqc-data
6 Prof. Mike Bewick and Dr Simon Haynes, ‘Independent review of St George’s Hospital NHS Trust’, August 2018, p. 14.
7 ‘Budget 2021: Protecting the jobs and livelihoods of the British people’, HM Treasury, March 2021, p. 32.
8 ‘Hospital admitted patient care activity 2018–19’, National Statistics, 19 September 2019; ‘Hospital outpatient activity 2018–19’, National Statistics, 10 October 2019.
9 ‘Chapter 1: Population change and trends in life expectancy’, Health Profile for England: 2018, Public Health England, 11 September 2018; Carl Baker, ‘Obesity statistics’, Briefing Paper No. 3336, House of Commons Library, 12 January 2021, p. 3; ‘Number of people living with diabetes doubles in twenty years’, Diabetes UK, 27 February 2018; ‘Antimicrobial resistance (AMR)’, available at: https://www.gov.uk/government/collections/antimicrobial-resistance-amr-information-and-resources
10 ‘Satisfaction with NHS falls to lowest level for a decade’, The Guardian, 7 March 2019. 420
* For more information on this, see Glossary.
† This is the budget for NHS England. The total core budget for the Department of Health and Social Care is £148.7 billion. This includes funding for other responsibilities of the department including Public Health England. In addition, the department received £63.4 billion in emergency Covid funding. This brought the total Department of Health and Social Care budget to £212.1 billion in 2020/21.
1
RESURRECTING THE DEAD: A DARK TALE OF RECURRING NHS THEMES
There is a week between Glorious Goodwood and the Glorious Twelfth when the Isle of Wight is a fashionable place to be. Hot on the heels of one of the highlights of the British racing calendar and ahead of the first day of the grouse shooting season is Cowes Week, one of the UK’s longest-running and most successful summer sporting fixtures.
The famous sailing regatta attracts 8,000 competitors from all over the world, along with 100,000 visitors. For eight days in August, the narrow streets of Cowes throng with yachties, and the seafront is a blizzard of colourful sails. Among those involved in the event in 2019 were Prince William and the Duchess of Cambridge, who took part in the inaugural King’s Cup sailing race. The visitors generate huge sums for Cowes and are vital to the local economy, but along with the 2 million or so other tourists who come to the Isle of Wight every year, they are also a problem. With a permanent population of just 141,000, the island has just one small hospital, which already struggles. The sudden arrival of an additional 100,000 people during what is already peak tourist season is a massive additional strain.12
Permanent residents of the Isle of Wight love its pristine beaches, hidden coves and rugged Jurassic coast – a rich source of dinosaur fossils. They love it for its rolling countryside, its quirky towns, its red squirrels and its haunted houses. They love it for the weather, too: it is one of the sunniest places in the UK. Queen Victoria said it was ‘impossible to imagine a prettier spot’ than her island holiday home, Osborne House.
What locals do not love it for is the health service – especially during holiday season. They are frightened of falling ill during Cowes Week. Indeed, they are frightened of falling ill any time in August. Nor do they want to fall ill over Christmas and New Year, a period when all NHS Trusts are short-staffed but doctors and nurses are in particularly short supply on the island. They know from local media reports of coroners’ inquiries that it’s also a bad idea to fall ill at weekends. It is said that the hours between 10 p.m. and midnight, any day of the week, are another danger zone.
In fact, there really is no good time to be ill on the Isle of Wight, especially for the very elderly or those with mental health conditions. Out of sight of the happy holidaymakers, the cheery working families who flock to caravan parks and the smart London set who drop in every August in their tasteful nautical wear, there is a dark side to this special place.
Patients unfortunate enough to find themselves heading into St Mary’s Hospital in Newport are supposed to be temporarily distracted from their fate by a gigantic art installation by the entrance. Up to a point, the trick works. Perched on a scrubby hillock outside A&E, the gaudy 27ft conical structure looks like a cross between a gigantic traffic cone and a fairground ride. You’d have to be very poorly not to notice it and wonder what it is.
Known as ‘The Koan’, the sculpture towers incongruously over 3 the sprawling NHS site. Back in 1997, when it was installed, it must have looked quite cheerful. It was designed to revolve and was illuminated at night. Within months, however, it was bust. The lights went out, it stopped turning and islanders launched a petition to have it removed. They told the council that they would prefer the money to be spent on their health – as well they might.2
Delivering good healthcare in rural locations is always more challenging than it is in cities. There are even more logistics issues on an island, and demographics are a further problem for health bosses on the Isle of Wight. There are lots of old people, a higher than average rate of unemployment and a shortage of white-collar jobs.3 Only 40 per cent of the population describe their health as ‘very good’, relative to 47 per cent on average in England. Some 6.5 per cent of residents consider their health ‘bad’ or ‘very bad’, compared to an average of 5.5 per cent across England. Local NHS bosses complain that NHS-wide recruitment and retention problems are magnified in a place where ambitious young doctors and surgeons will not see enough cases to develop and enhance specialist skills, and there is not a ready supply of agency staff to plug gaps.
So much for excuses: there is plenty to offset these disadvantages. Crossing the Solent is quick and easy, meaning the island is much less isolated than swathes of Yorkshire, the Peak District, Cornwall and the Lake District. A squat blue-and-white Hovercraft zooms between Portsmouth and the town of Ryde in just ten minutes, while the exotic-sounding catamaran crosses the Solent in just over twenty minutes. Car ferry services are regular and efficient.
Meanwhile, the island has none of the challenges associated with a large migrant population, and property is relatively cheap, meaning NHS salaries go further. All over the world, there are examples of isolated places with small populations providing 4outstanding healthcare.* Yet until very recently this was one of the worst-performing NHS Trusts in England and a dangerous place to be seriously sick. For a considerable period, an average day in the Coroner’s Court, which investigates unexpected deaths at St Mary’s, was testament to that. Failures by the hospital were a constant feature of the narrative, and trust officials were summoned to explain themselves with such regularity that the judge was on weary first-name terms with hospital bosses and lawyers.
The risks associated with ill health on the island are laid bare in official reports. The 2017 assessment by the Care Quality Commission (CQC), which carries out regular inspections of all hospitals and GP surgeries, makes particularly grim reading. It concluded that the trust was failing on multiple levels and was guilty of an array of safety breaches.4 Inspectors ruled that there were insufficient staff; medical care was inadequate; and the place was so disorganised that patients were routinely being shunted around the hospital in the middle of the night to make way for new admissions. They described end-of-life care as dire. There was a huge backlog of incidents requiring investigation: some 400 open cases, an alarming figure for a hospital with fewer than 250 beds. The trust’s chief executive Karen Baker resigned on the eve of publication of the report. Apologising for the state of the trust, she said: ‘It is true that the NHS on the Isle of Wight – like elsewhere – faces many big challenges and it is clear to me that we have not always provided the quality of care the public expects. I am very sorry about that.’5
The following year, the CQC returned for another look. Things were no better. Of the twenty-three services provided by the Isle of Wight NHS Trust, seven were rated ‘inadequate’ and eleven 5required improvement.6 Overall, the trust was labelled ‘inadequate’. Standards of emergency and end-of-life care had further deteriorated. The report declared that safety systems were ‘not fit for purpose, or were not implemented sufficiently, across many services’. Staff training was patchy, with very low levels of completion for mandatory courses. Infection control was poor. There were still not enough clinicians, leading to frequent gaps in rotas. The biggest worry was the A&E department, where there were nowhere near enough nurses and frequently no consultant on duty at all. Patient record-keeping was poor, and the leadership of the department was still recovering from the resignation of the CEO the previous year.
The CQC made crystal clear what needed to be done and announced that inspectors would return again soon. But when they came back in January 2019, standards remained dismal. A total of eight nurses were supposed to be on duty in the accident and emergency unit; only six were present. Officials were appalled by what was being asked of the nurse in charge.
[She was] having to assess newly arrived ambulance patients, look after patients requiring care in the corridor, assist in the resuscitation room, take over from nurses on meal breaks as well as co-ordinate the care of all the patients in the department. It was not possible for one nurse to do all of this and we found several aspects of patient care had not been completed.
There were periods of time during the evening when there were no nurses in the major treatment area, the minor treatment area or the rapid assessment area.
Initial assessment (triage) of ambulance patients did not take place according to guidance produced by the Royal College of Emergency Medicine and the Royal College of Nursing. Although 6a handover generally took place within fifteen minutes of arrival, there was no face-to-face assessment of these patients by an experienced nurse. Subsequent observations and assessments were often undertaken by a healthcare assistant.7
One patient had been in the department for fifteen hours and spent three of those hours being seen to on the hospital’s main thoroughfare as passers-by stared.
St Mary’s was not just having a really bad day, of the sort that can affect even the best-run places when several things go wrong at once. Such scenes were normal. Inspectors looked at nursing staff levels for twenty random shifts over a three-month period and found that agency staff were a vital component of almost every shift. In eight of the twenty shifts investigated, temporary staff made up 40–50 per cent of personnel on duty. A formal review into nursing levels in 2018 had revealed that the department needed forty-four nurses to provide an acceptable level of care, yet only thirty-three were employed. Money-wise, the trust was in crisis, registering a £30.1 million deficit in March 2019. This was £12.9 million more than expected.8 In March 2019, it was placed into ‘financial special measures’.9
Of course it was not all negative. Even the worst-run NHS services are staffed by brilliant, dedicated people, without whom standards of care would be very much worse. The Isle of Wight NHS Trust regularly scores highly for kindness.10 Under a new chief executive, Maggie Oldham, much has improved. But that is of cold comfort to relatives of the many patients who meet an untimely end at St Mary’s and many more who receive sub-optimal care. In 2018/19, there were thirty-five unexpected deaths.11
Focusing on the state of A&E, the CQC’s 2019 report identified three major breaches to safety regulations and set out the 7improvements required. The trust was told it must provide a sufficient number of ‘suitably qualified, competent, skilled and experienced nurses to meet the needs of patients’. It was told crowding must be reduced so patients are no longer forced to wait on trolleys in corridors. Finally, inspectors made clear that patients whose clinical condition is at risk of deteriorating should be ‘rapidly identified and monitored appropriately’.
The last of those three demands – that medics waste no time in spotting the signs that patients who arrive at A&E are dangerously ill and do whatever it takes to prevent them getting sicker – sounds like the core function of an emergency room. On the Isle of Wight, however, there are many bereaved relatives with tales to tell about the way standard procedures are not routinely followed – often with fatal consequences.
• • •
James Byrne was never a doctor botherer. A great big bull of a man, he was overweight and smoked but was as physically fit as his job as a builder demanded – or so it seemed. He was fifty-nine when he died, and save for the stack of hospital notes about the last twenty-four hours of his life, his entire medical record only ran to a page or two. ‘He was literally never ill,’ according to his wife.
Byrne was from a solid, salt-of-the-earth sort of family, the kind of folk who look after their own and owe everything they have to old-fashioned hard graft. He worked seven days a week, saving enough money over the years to acquire 40 acres of land near Ryde in east Wight as well as several horses. One way or another, he was always busy. Family life ticked along in a comfortable enough fashion until the night of Saturday 4 August 2018, when Byrne suddenly developed 8a very sore stomach. It all happened very fast. One minute he was feeling fine, about to put his feet up at home following a quick pint in the pub with friends; the next he was doubled up in pain.
The events that followed epitomise the sort of low-level bad care that takes place every day in the NHS alongside care that is fair, good or outstanding (often all in the same place). Byrne’s care showcases more than fifteen themes that crop up with depressing regularity during official investigations into unexpected deaths at St Mary’s – almost all of which are also recurring themes throughout the NHS. Taken individually, the lapses are not very dramatic. Combined, they point to an organisation that lacks the basic systems and structures to guarantee a decent standard of care. Little wonder that Mrs Byrne now tells everyone she knows that the safest course of action for those who fall seriously ill on the island is to head for the ferry to hospitals in Portsmouth or Southampton.
Byrne had a high pain threshold, so when he told his wife he was in agony she didn’t hang around. The paramedics who arrived at the house at 22.12 asked him to rate his discomfort on a scale of one to ten, with ten being the worst pain imaginable. He gave it a ten. The paramedic thought it might be peritonitis, an inflammation of the inner lining of the stomach, or possibly gallstones, and gave him some morphine. He was taken to hospital as a ‘Priority Two’ patient, meaning his condition was considered potentially serious but not so critical that he required the immediate attention of a doctor.
It was the first day of Cowes Week, meaning A&E was even busier than usual. All the patient bays at St Mary’s were occupied, so Byrne was deposited in a place hospital bosses euphemistically describe as a ‘sub-waiting area’, and which everyone else calls a corridor. (Recurring theme No. 1: overcrowding.)
When he was handed over to staff nurse Samantha by paramedics 9at 23.20, he was in a stable condition. It would not be until 02.28 that a patient bay became available, and he would not see a doctor for more than five hours following his arrival. (Recurring themes two and three: breaching A&E waiting-time targets; doctor shortages.) Samantha would later tell the Coroner’s Court that she logged the excessive waiting times and understaffing at A&E that night on the hospital’s patient safety and incident reporting system. She made clear that this was a regular occurrence.
When Byrne was finally admitted to a bay, he came under the care of a nurse called Betty, who was originally from Kenya but qualified to practise medicine in the UK. She had worked in more than ten different NHS hospitals and was with a temping agency called ID Medical at the time. (Recurring theme No. 4: use of agency nurses.) Betty carried out a number of routine medical checks on Byrne, taking his blood pressure, heart rate and temperature. At 02.45, his heart rate seemed higher than it should be for someone who was sitting down. Betty said that no formal handover had taken place between her and a person she referred to as the ‘corridor nurse’. (Recurring theme No. 5: poor staff communication; recurring theme No. 6: overcrowding so normalised that job descriptions like ‘corridor nurse’ come into use.) However, she was able to read Byrne’s notes. What she could not ascertain was how much morphine he had been given; it appeared that the dosages provided by the paramedics had not been officially recorded on hospital IT systems. (Recurring theme No. 7: poor medical record-keeping.)
At the inquest into Byrne’s death, various figures were thrown around by different witnesses, including 37mg, 22mg and 17mg. The discussion was not helped by a language barrier between the coroner and Betty. At one point, Betty even appeared to suggest that she was unaware that Byrne had already been given any morphine 10at all. One way or another, it became apparent that while morphine doses were recorded on the patient’s hand-written notes, they were not entered on the hospital’s electronic system (recurring theme No. 8: discrepancies in patient records linked to multiple record-keeping systems), leading to confusion all round. The coroner was shocked that there was no definitive record.
At 03.15, Byrne was still in agony. Betty administered more morphine, taking his total dosage up to 22mg since 22.40 – more than the standard recommended amount of 20mg. During a heated debate at the inquest, the coroner suggested that medical staff should have been trying to identify the source of the pain as opposed to simply masking it. The hospital’s lawyer disagreed, arguing that it was the nurse’s duty to relieve pain.
At 03.59, Byrne was finally seen by a doctor. Her name was Monica, and she had trained in the Czech Republic. She had only qualified a year earlier, in 2017. (Recurring theme No. 9: reliance on inexperienced doctors.) It was her second shift on the Isle of Wight. At this point in the inquest, there was a long debate about staffing levels. Amid more confusion, what seemed to emerge was that between 20.00 and 22.00, it is not unusual at St Mary’s Hospital for no doctors to be on duty at all. (Recurring theme No. 10: clinical staff shortages.)
