Dr Berwick is a world authority on patient safety and was president and chief executive officer of the USA not-for-profit Institute for Healthcare Improvement. He was an adviser on the NHS to Tony Blair and later to Barak Obama. In 2008 gave his famous ‘60th birthday message to the NHS’. In it he gave ten principles for maintaining a successful NHS. His second principle was, “Stop Restructuring”, warning that it is destructive of time and confidence and leads to risk averse healthcare.
David Davis, who has probably never even heard of Don Berwick, would have been well advised to have read it before he wrote his recent Telegraph article.
Davis suggests further structural reform of the NHS
After stating that bold, courageous action is needed to save the NHS and providing flimsy data as to why the NHS is on the brink of disaster his solution is … structural reform, the second choice of any mediocre company executive.
The first choice is of course cost-cutting, which was what an earlier NHS CEO, David Nicholson, did in 2011 to universal applause from politicians. He launched his Nicholson Challenge in 2011, aiming to take £15–£20bn out of the budget by 2015 through efficiency savings. The net result of this 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 fell 16% by 2016. By then the NHS was short of 25,000 nurses, 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 had fewer doctors per person. If you want to know where the increase in discharge delays began, look no further.
Continuous change and chaos in the NHS
So at least, Davis avoided the Nicholson trap. However, as he proposes reform of the NHS, he should consider this: the NHS has been subject to ten major reorganisations since 1982. That is one every four years. Unlike equivalently sized successful organisations such Walmart and the Indian Railways, which have yet to have major reorganisations, the NHS has never been allowed to stabilise. The most successful manufacturer in the world, Toyota, has never been reorganised. It relies on continuous improvement.
Consultants like McKinsey et al have had a field day causing havoc, especially with IT, and were paid billions for it. As a result the NHS has been akin to a laboratory rat tortured by one experimenter after another for over 30 years. No organisation can flourish under these conditions.
So, no, Mr Davis, the last thing the NHS needs is restructuring. That is why you can justifiably call its structure ramshackle, and that is the only reason why it is not the best health service in world at everything.
Blame the NHS managers
But it did not stop there. Davis trotted out yet another shibboleth – too much management. Oh? When just 3.7% of the staff are management compared with the UK national average of 15%. In fact, the number of NHS managers fell by 18.8 percent from 2010 to 2017.
Which right-wing think tank fed him and Liz Truss this drivel?
Yet the article nearly touches on a valid point about the nature of management, which is unfortunately referred to as inept. However, it is not the managers who are inept. It is what government health policy requires them to do, which is mainly compliance and regulatory demands, very little of which addresses real patient care.
That is why we continue to hear about failures in care and nursing homes. And, by the way, the Community Care Act in 1990 removed long-term care of the elderly from the NHS – where it was free at point of use – and switched it to social services, where it would be subject to means-tested charges. This contributed to the rise of the likes of the private Reigate Grange Care Home, which is now facing possible criminal charges following the abuse of Anne King.
NHS and private care
This brings us to private care, which Davis wisely did not propose. But it is a now a policy; an indefensible one. Involving private firms in the provision of health is not simply a question of outsourcing to an appropriate provider. Outsourcing originated when a supplier or contractor had significantly better expertise in a care activity. Shell, for example, outsources the maintenance of the compressors on drilling platforms to the supplier, as they have expert knowledge of their product.
This should be the only reason why another provider is commissioned. Unfortunately, it became a ‘me too’ activity, usually justified as a way of cutting costs, and has become a very expensive fad among under-educated politicians. In the NHS, where it is a neo-liberal imposition, it has become a burden whereby the NHS has to pick up the pieces when the venture fails, as has happened in nearly every sector. This is major contributor to increased costs, generating a high level of failure demand.
Privatisation has not always been the fault of the private sector in terms of care. Some contracts were simply not fit for purpose from the start. I have spent decades working with supply chains, and far too often contractors and commissioners have agreed contracts that could never deliver the return their stakeholders required. Like Brexit, where Davis was the lead negotiator, these contracts are win-lose, inevitably becoming lose-lose, and patients are the first to suffer.
Private Finance Initiatives (PFI) are a good example. For the NHS in England, according to John Appleby from Nuffield Trust, there were 127 PFI contract schemes between the NHS, social care and the private sector in 2016 with a combined value of nearly £13bn. The contracts for hospitals in England cost 18% to 60% more than their construction costs. In other words, if the contract had been a standard design and build, it would have cost 18% to 60% less, saving a minimum £2.34bn. And then there are the failures like Carillion.
With these kind of examples in front of him, you would think that Davis might propose doing away with PFI and other privatised activity.
Private health insurance
Nevertheless, having dodged that bullet, the article suggests the provision of health insurance by the private sector. This goes against all the evidence, economic, social and care itself. It would be unfair to spend time comparing the UK with that OECD outlier, the USA, as the latter is so broken, but the diagram below does wave a huge red flag.
Change in the Consumer Price Index (CPI) for the USA and UK since 1990, showing spending categories for all items and for medical care/health prices alone.
It makes one wonder why Simon Stevens has pushed so hard for the USA system when he was CEO of the NHA – and why Jeremy Hunt supported him: a political and not a health decision?
The single payer model is superior to private health insurance on cost, fairness and outcomes, and not only compared with the USA. There are two key components of cost in health economics: administration and waste. An OECD report in 2014 showed that the UK spent less on administration as a percentage of total health expenditure than the OECD average (2.4% in the UK, and 3.2% average for all OECD countries). This is largely due to the effectiveness of the National Insurance model.
Public health and prevention
Finally, what Mr Davis has not raised is the issue of prevention. The NHS does not need 40 new hospitals. It does need healthy communities and it is not just about employment. The key here is public health, the neglected Cinderella of healthcare. Put the money into the upstream, reduce demand, cut waste and let the NHS and social care staff do what they are best at – caring for patients, residents, their neighbours, and themselves.
The NHS is a community of over a million highly skilled and knowledgeable people dedicated to the health of the people in the UK. It is not about hospitals, care homes, equipment, computers, IT, or money. It is, though, a huge asset in every way because it does more than just care: it is a second-tier employer of millions of people, an economic multiplier, a city on a hill. What it needs is not restructuring, cost-cutting, targets, or a burden of pointless compliance. It needs love and care. Its staff need to be trusted, not threatened as Jeremy Hunt did, to his eternal shame. All the government has to do is to remove the barriers to performance, get out of the way, and let the NHS help our people take the best care of themselves.