At the British Olympics in 2012, 200 million people across the world watched in delight and amazement (and not a little envy) as 2,000 NHS staff danced and mimed their way through routines that showed off the NHS at its finest. And the NHS was at its finest. But the worm had already begun to eat into the apple. It was called the Health and Social Care Act and was the most extensive reorganisation of the NHS ever.
The NHS in 2022: sick and tired
The plan emerged in 2010 when Health Secretary Andrew Lansley began to prepare the new bill, just as the NHS public satisfaction with the NHS was at its highest ever in a polling series that ran back to 1983.
Now, ask yourselves, what fool would interfere with any organisation that had such ‘consumer confidence’? Never has the phrase, ‘if it ain’t broke, don’t fix it’ been more apt, particularly for an organisation that employs over a million staff and whose work is critical, and is respected around the world. But Lansley, ignoring international experts like Dr Don Berwick, pushed his own theory (which is all it was) into practice and created the conditions for Jeremy Hunt and his Oxford chum, Simon Stevens, to run the organisation down.
Needless to say, the act worked out badly for the poor NHS. By 2018 public satisfaction had dropped to its lowest in 11 years as Hunt and Stevens tried to cobble together the ‘new’ NHS. Just how did this happen?
Underfunding public services
The perfect opportunity for the neoliberal politicians had been presented by the 2007 banking crash, where, four years later, exploiting the crisis, George Osborne set UK on the path of austerity. This gave the Treasury unbridled power and the excuse to underfund the UK public services, including the NHS. It was a decision of arrogant immaturity.
The NHS CEO at the time, David Nicholson thought he should burnish his reputation, and launched his Nicholson Challenge in 2011, i.e., to take £15–£20bn out of the budget by 2015 through efficiency savings. This amounted to 15% to 20% of the current NHS budget!
In over 30 years of researching organisations, I have never come across any executive in any company in the West that did that. It is the clearest sign of a weak or hubristic executive when they take the simplistic option of cost-cutting to increase efficiency. In the case of the NHS, focusing on reducing the costs while demand was growing was an act of madness.
The immediate result was 7,000 plus redundancies across the board, over half of which were compulsory. And this was happening while there was a three-year freeze on NHS pay. The real terms value of a qualified nurse’s pay was being cut 16% by 2016. By then the NHS was 25,000 nurses short as well as a 1,000 GPs and over 6,000 doctors. The UK was 22nd out of 25 European countries in doctors per 1,000 people. Germany had 2.5 times as many hospital beds and only Ireland has fewer doctors per person.
Utter failure of leadership
All of this was under Jeremy Hunt’s watch who today is playing the elder statesman and wringing his hands over the parlous state of the NHS when he should be on his knees apologising. The biggest misstep was when Stevens forced his infamous NHS England’s Five Year Forward View (2014) on to an understaffed, underfunded and exhausted NHS.
This is why the NHS is in such trouble today: an utter failure of leadership. Just what were they doing to deal with the challenge of increasing demand? The answer – nothing, as we have seen.
Patient wellbeing should have been the priority
What should have happened? Hunt, son of an admiral, should have steadied the ship. This is what real leaders do. He should have stopped every activity that did not directly relate to patient wellbeing. He should have kicked out the expensive consultancies that were being foisted on the NHS, especially McKinsey, who had proposed the Nicholson Challenge in the first place.
At that time many middle managers and doctors were already applying the well-known Toyota approach to management, which starts with recognising that the people who know best what to do for the organisation are the workforce, not outsiders; and certainly not outsiders who wanted to apply USA healthcare models. Of course, this would have meant Stevens losing his job.
Hunt should have studied successful large companies, even those with the typical capitalist practices, e.g., Walmart; but even more so, Toyota. He would have noticed one thing immediately: neither company has had a major reorganisation in over 50 years! Toyota, in particular, is demand-led. So should the NHS be, but at both ends. The leadership should study the nature of demand, AND it should try to reduce the demand. This means starting with social care.
The answer to the question in the heading of whether the NHS decline was due to wilful blindness or deliberate neglect, is ‘Yes’ and ‘Yes’. Nicholson, Langley and Hunt are guilty of wilful blindness and Simon Stevens is guilty of deliberate neglect in the most cynical way. His 2014 Five Year Forward View had two major elements. The first was to nurse the NHS back to strength by extra funding (that failed) and by focus on prevention, i.e., “The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain now all depend on a radical upgrade in prevention and public health.”, which echoed the recommendations of Wanless Review (2002).
The second element was to reorganise – again, just two years after the 2012 Act! Stevens focused on reorganisation at the expense of prevention, while the Treasury was cutting spending on Public Health. In Yorkshire and Humberside alone, this was reduced by £8mn and spending on children’s services was cut by almost £1bn after 2012. Hunt connived in this.
The biggest source of demand for acute care beds comes through GPs and Social Care. The best prevention strategy is to reduce that demand by resourcing public health and primary care and by improving the system. Stevens did the opposite, ignoring both and tampering with the system. Deliberate negligence!
The next article will lay out what they could have and should have done.