Looking back at 60 years of the National Health Service: which R-word?
There are many myths in healthcare. The first is that the Labour government of 1948 invented the NHS. It didn’t. The basic principles were put together by the Socialist Medical Association some 10 years previously, and the first official stab at an NHS was laid down in a British Medical Association report of 1942. Bevan’s difficulty in getting it through (exemplified by his oft-quoted statement that he had had to stuff consultants’ mouths with gold) was not really a problem of principle, but of detail.
An analysis of healthcare in the era between 1930 and 1945 reveals a split hospital service that was largely bankrupt. Large teaching hospitals were cushioned by their endowments. The local authority hospitals were run on a shoestring, while the voluntary hospitals were under severe financial pressure and, if they had not been subsumed by the NHS, many would have had to close. Bevan fondly believed that the NHS would so improve public health that the cost of provision would fall, failing to see that the eradication of some diseases such as TB and diphtheria would prolong lives. New conditions would then rise up (heart disease, cancer, diabetes); treatment of these would negate any saving, and so it proved – and proves today. It is perhaps strange to reflect that in 2012 teaching centres remain cushioned by their endowments but many of the general hospitals are once again near to financial ruin.
I have little doubt that despite all of the inefficiencies of a state monopoly the NHS is a fundamentally sound idea. Indeed it is, in many respects, a communist system, where all parts of the country have by virtue of provision (and salaries) been rendered similar. However successive governments, in seeing the problems and costs, have chosen to think that they can be swept away by reform. I have lived through too many, going back to Kenneth Robinson in the 1960s (I remember several meetings of north London GPs at my parents’ flat, which he attended (not a likely scenario today), through the abolition of health boards, the establishment of district and area health authorities, the purchaser-provider split, fundholding, the development of Trusts and then Foundation Trusts, the introduction of the Private Finance Initiative and most recently the idea that GP consortia should and could run the NHS. Furthermore, just as in the great communist societies of the 20th Century, the NHS has been plagued by bureaucracy that has eventually stifled it, not least because it has become preoccupied with saving itself, and money, and the jobs and reputations of its managers, many of whom have risen beyond their competence level and job-hopped when the going got tough, often to a post with a higher salary and with some gigantic payoff. It remains a way of disposing of the incompetent. Overlying this is a Stalinist doctrine of Five Year Plans, Maoist principles of Great Leaps Forward, Stasi-like suppression of dissent, the punishment of whistleblowers by exile and a North Korean publicity machine fuelled by Directors of Information who begin to believe their own propaganda.
Undoubtedly there have been changes in what we can do for people (much of it good), and the cost of it, but none of the reorganisations or reforms has solved the underlying problems. I do not believe they ever will. Is this an implementation failure, or is it an indication that it’s the wrong thing to do?
One thing that I have learned from experience is that the NHS is not good at reflection. The plans for reform came up at fairly regular intervals, and were introduced with great fanfare. Some were carefully thought through; others (notably the Thatcher reforms of the 1980s) were sketched on the back of an envelope (literally) and then worked up on the hoof. However, analysis of the benefits of each reform is superficial – except that it is deep enough to force realisation that the last one did not work. So another is dreamed up. It seems odd to me that, as each reform fails in its turn, we spend all our time on yet more reform, as if we seek ceaselessly for the Holy Grail. There is an old saying that a surgeon is a blind man looking for something, a physician is a blind man in a dark room looking for something, and a metaphysician is a blind man in a dark room looking for something that isn’t there.
We must remain physicians and surgeons. Medicine is science, not metaphysics. There are various reasons for reform failure. Sometimes it is because the change is impractical. On occasion it is too expensive, and distracts effort, and money, from the real business of patient care (the PFI initiative is a good example – see below). Sometimes it is because science moves on and the world has evolved; the classic example is Bevan’s firm belief, in 1948, that providing a national service would reduce costs as the people’s health improved, not understanding that the costs of medical advances would more than wipe out such savings.
Reform, from experience, merely shuffles the pieces on the board. It is rare for any to be added or removed unless cost dictates it. Reform is destabilising and demoralising. If it doesn’t work, we should understand that the only way to save costs is to ration care, and plan sensibly how we do this. It is a pity that politicians fail to understand that much of the resistance to reform by the medical profession is not stick-in-the-mud stuff, but based on experience. We are here today and tomorrow; they are gone tomorrow.
It is also a pity that modern politicians, managers and to some extent the public have developed their ideas for the NHS from the wrong starting point. If you look carefully at the proposals of the last ten years you will find that they have a common theme – that care in the NHS consists of discrete packages. People become patients; they consult their GP; they may be referred to a specialist; they have an operation; they are discharged. Alternatively they get suddenly sick and are admitted to hospital through the emergency department; they get better; they are discharged. Some, of course, die, but if you predicate the whole of healthcare on such a simplistic pathway you omit great swathes of the medical spectrum that do not fit into it. It is bad enough doing rheumatology, where a proportion of patients do not “get better” in the way those outside medicine perceive “getting better” (in other words, they revert to normal); it is worse being a rehabilitation specialist, where a large proportion of patients inevitably and inexorably get worse.
There is a nice set of posters reproduced from the Second World War by the London Transport Museum. These show a series of reconstructive processes required after damage from enemy action. The strapline reads “Rehabilitation Takes Time” and so does good clinical care. Time and again my clinics overran because I talked to my (chronic) patients. Time and again they told me that they did not get such time with their general practitioner – that is, if they can actually see their own GP and are not given whoever is free that day. I have had patients who told me that if they try to introduce a second problem they are told to go away and book another appointment. So much for holistic care, not least if each system problem (and with rheumatoid arthritis patients develop all sorts of other problems ranging from heart disease to skin ulcers) then gets managed by a different doctor. But such stories stem both from growing pressures on time and from a spreading trait in doctors – that they must do as politicians and managers ask. Do these folk really know what is best for patients? If so, how? What qualifications have they got to make decisions on medical management? It is a sad day when medicine is planned by focus groups of the middle-class well who do not understand some of the consequences of their aspirations. It is sadder when clinicians order clinicians of other disciplines to do as they are told when they have no concept of inter-specialty differences.
I fear that many doctors have lost the skill (or will, perhaps) to ask “Why?” I asked why I had to discharge follow-up patients to meet a ratio target (see below), among many other things, and I was not popular for doing so.
The concept of institutional memory is also important to understand, and respect. It derives from those who have been around a long time. It is useful (like that mythical medical instrument, the retrospectoscope) and should rarely be ignored. Often the guardians of institutional memory can point out that the “reform” has been tried before. Beethoven tried, in one famous example, to reform a sonata by pasting pieces of paper over lines he didn’t like. When musicologists unstuck the amendments they found the first draft was identical to the last. A “modern” colour scheme for Paddington Station turned out, after dozens of layers of old paint had been burnt off, to be almost identical to the original. So it would be helpful to stop talking about reform as if it will improve things.
That said we doctors must be honest in setting our relative priorities, and accept that the common good may downgrade us. Richard Smith expressed this beautifully in the introduction to an editorial in the British Medical Journal:
“The BMJ never publishes anything useful to leechologists. You haven’t got a single leechologist on your editorial board. Once in a blue moon you publish a leechology paper, and it’s always bloody awful. I don’t know who you get to review them. What you don’t seem to understand is that leechology is one of the most important specialties in medicine. There aren’t enough of us, we’re overworked, and general practitioners don’t seem to know even the basics. Everyday we’re dealing with dreadful cock ups. It’s time your journal taught ordinary doctors the rudiments of leechology.”
He reminded me of this when I asked for space for a special plea for rheumatology nearly 10 years later. Fair comment.
Management-speak is a joke in the NHS. New phrases assail us every month as the change-drivers hear what we say. Doctors have a number of defence mechanisms, ranging from passive acceptance to cynical subversion – into which latter category fall the players of “Bullshit Bingo” (take your grid of management words and phrases, tick them off as they are used and shout “Bullshit!” when you complete a line in any direction. There is also a perverse reverse variant, in which participants have to use words in the grid appropriately.)
“Reform” is on the grid. “Modernisation” is another. In the NHS context they set the background for politically driven change and, if ministers are correct, the NHS cannot move forward (and that’s on the grid) until it has reformed and modernised.
Modernisation likewise is a synonym for doings things differently, but with an outcome that may be better, the same or worse. A modern hospital may perform better in some functions because it has smooth surfaces and piped oxygen, for instance, but if it starts to fall down after twenty years, or the flat roof develops a terminal leak, then it may, overall, be no better than a soundly built Edwardian voluntary hospital. If I am tied to paperless records, a server failure, generator test or power cut makes them inaccessible. My analogy is of a clock. Why should I “modernise” my timekeeping by replacing a serviceable and decorative 17th Century grandfather clock with a digital version that automatically updates itself via a satellite link to an atomic clock? Assuming I remember to wind it up it tells the same time to an acceptable precision, and a satellite clock won’t run without a battery.
So “modernisation” is a smokescreen. Keep people modernising and it distracts them from their real jobs. That’s not to say we must set things in aspic; lateral thinking may achieve huge benefits. Our managers call that “thinking outside the box”, or “blue-sky thinking” and, of course, moves to take down local Chinese walls between health and social services will promote joined-up thinking and we can move forward. (My God, I’ve got a line! Bullshit!)
We have all become preoccupied with getting what is best. We cannot afford perfection and so must look at planning what is least bad. I believe we should consider changing the R-word from Reform (including Reconfiguration) to Rationing.
Experience is one of the benefits of getting older. Then you learn from experience that once you have learned from experience, no-one listens to you.