The NHS was an integrated care institution, until the politicians began to meddle with it.
Norman Fowler started the rot when he set aside the area health authorities (AHAs) in 1982, after being health secretary for less than a year. The AHAs had been running for eight years and were on the verge of integrating with local government to balance regional demand and supply. The management system was key. Local management teams integrated the hospitals, family medical clinics and community health centres; and decisions were made by consensus. Sounds like integrated care systems to me.
Fowler’s intervention was a major disruptor, opening the way for the top down, ‘efficiency’-driven fragmented encumbrance that Jeremy Hunt and Simon Stevens (former chief executive of NHS England) have left us with today.
The first ministerial flaw – experience
What was Fowler’s qualification for this key role? Just like Michael Gove’s for education – journalism! How much did he know about how large service organisations work best? Did he visit the Marriott or Taj hotels, famous for their service, or John Lewis, or even another successful health service?
No, his opinion was sufficient. He clearly had never heard of continuous improvement, a policy used by the finest companies in the world, e.g. Toyota. In 50 years, Toyota has never reorganised; but it obliterated General Motors in less than 10 years in the 1970s, with a little help from Honda and Nissan – not on price, but on customer satisfaction.
Here we have the nub of the problem: ministers are put in charge of vital services like the NHS, transport, justice, and probation (the last three all fell under the egregious Chris Grayling) with no understanding of them as systems. Instead, they arm themselves with neoliberal ideology, and with command-and-control management style. The extent of their ignorance is only matched by the degree of cognitive dissonance, which means they refuse to acknowledge any evidence that shows their policies are not working.
The second ministerial flaw – humanity
This is where the health activists have gone wrong. In the case of the NHS, they have presented moving examples of very sick patients in corridors, nurses at the end of their tether, grieving families etc. This approach is not effective in challenging a money-driven government.
The empathy in the political world, especially of the Conservatives, seems negatively correlated with the seniority and significance of the post, e.g. Priti Patel at the Home Office, Chris Grayling at justice and probation, Jeremy Hunt as health secretary. In summary, those with the thickest skins get the posts requiring the greatest humanity.
The extent of the damage
A mark of the destruction the Tories have wrought on the NHS can be found in the Covid 19 pandemic. The most haunting image I have seen in a long time was Professor Kevin Fong, former national clinical adviser in emergency preparedness resilience and response, in tears while giving evidence to the Covid Inquiry, saying the “scale of death was truly, truly astounding”.
He told the inquiry he was on the scene of the Soho bombing in 1999 and worked in A&E during the 7 July London bombings, “but nothing that I saw was as bad as Covid was every single day”. To prevent another NHS calamity at the scale of the pandemic requires not just change, but positive change.
How we drive positive change for the NHS
What we need to do is point out clearly their failures as ‘executives’ in their jobs and the subsequent waste and increased costs. We need to relate these consequences to their flawed organisational model, i.e. targets, cost-cutting, outsourcing, privatisation, and, most subtly malignant of all, excessive governance and compliance.
The new Labour government should be directing its efforts to replace the Tory public sector disaster with a state economy based on Bevan’s In Place of Fear (1952). This will resurrect the model of excellent service the NHS provided before the destructive tampering. It will then be applicable in all public services as they are brought back into the public domain, working hand in hand with a new green economic strategy.
What we must not do is go about saying that ‘the NHS is broken’. It is not. The system may be broken (deliberately); but the NHS is more than the sum of its parts. The people, the intellectual value and the institution are still in place. Stop talking of ‘reform’. Fix the system and value the people. A little bit of love goes a long way.
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