Callous indifference and lack of compassion: they may just reflect a Prime Minister's inability to make an effort

The Devil, they say, makes work for idle hands.

With an idle mind, however, it’s far worse: the Devil makes its owner his tool.

Underneath the surface, and despite the crass indifference of the entitled, David Cameron may well be a not entirely unpleasant human being. He’d probably be most upset, say, by the sight of a woman starving with her children. He’d almost certainly want to help.

The problem is that he has no imagination. He can’t see that woman when she’s out of sight. He can’t connect the effect of his actions as UK Prime Minister with the damage they do to women such as that one. That’s not because he lacks the capacity for compassion, or even the intellectual ability to picture someone else’s suffering, it’s because he simply doesn’t make the effort to exercise them on a scale above the individual.

It was fascinating to read a piece by Fraser Nelson in the Daily Telegraph, in other words by one of the most outspokenly Conservative commentators in one of the most loyally Conservative of newspapers, which warned us that “it’s David Cameron’s laziness that should worry us.” 

Cameron: no effort is too small

Nelson points out, among other incidents from Cameron’s time in office, that when he lost the parliamentary vote on military intervention in Syria, “it was the first time in two centuries that a Prime Minister lost a vote on war and peace – through a basic failure to prepare.”

A failure to prepare. Yes. He simply can’t find it in himself to do the work that’s needed to understand what he’s doing and the effect it will have. Fraser Nelson claims that Cameron didn’t read the NHS Reform Bill, which led to one of the most disastrous reorganisations of the NHS we have seen – and there have been many others that have been dire – until the draft legislation was published.

Nelson’s account is wholly plausible. After all, recently Cameron ruled out any kind of tax on high-sugar foods and drinks to fight obesity. He then admitted that he hadn’t read the report which recommended such a tax. That didn’t stop him rejecting its recommendations.

Nelson also describes him as “utterly loyal to his inner circle” which is perhaps why he stood by the hapless Health Secretary, Andrew Lansley, who introduced the NHS measures. It took years before he was shifted away from Health, and even then it was a while before he was dropped from government entirely.

Returning to our fictional woman, Cameron presumably simply can’t imagine the suffering he’s causing by actions over the NHS which will deprive her, or her family, of the kind of care which her own mother’s generation had come to regard as a right.

Now, though, there’s worse news for her. She’s struggling to get by on a minimum wage job while bringing up her children alone – yes, I’m assuming she’s a lone mother – and Cameron’s government intends to reduce her benefits, in the form of cuts to tax credits. She is likely to lose £1000 a year or more, which is painful since she only earns £15,000.

The move to cut her benefits has suffered a setback, with the House of Lords voting for transitional arrangements to be put in place to lessen the impact on people like this woman. That was effective opposition from the non-Conservative parties. The leader of the biggest of them, Jeremy Corbyn of Labour, followed up that powerful move by demanding of Cameron that he guarantee to the House of Commons that there would now be no negative impact on tax credit recipients.

Corbyn dedicated the whole of his ration of six questions at Prime Minister’s Question Time to this theme. Six times he asked. And six times Cameron failed to answer.

At one point Corbyn claimed that “he must know the answer.”

Actually, Jeremy, I think you may be wrong. It does sound like standard politician’s deviousness, ducking and evading a question he’s uncomfortable with. But Cameron’s not a clever politician. It’s far more likely that, actually, he doesn’t know the answer.

To know it, he’d have to read some of the background briefing material. Which is quite boring. He simply can’t find it in himself to make the time for it.

And so, with his idle mind, he ends up doing the devil’s work.

A worried NHS fan, as young as his heart but older than his lungs

It’s not the cough what carries you off, runs the Cockney saying, it’s the coffin they carry you off in.

My cough, with accompanying wheezing, has lasted on and off for the whole summer. I use the word ‘summer’ here in the calendar sense. A cough that lasts two weeks is neither here nor there, really, and that’s the summer we’ve had by the weather. But I’ve had this recurring irritation pretty well since June.

So today I decided it was time to follow my wife’s advice and visit my GP. Or rather not the GP, but the nurse practitioner, a wonderful institution: people with great wisdom rather than learning who can deal with the minor conditions effectively, efficiently and with great affability.

I got tests galore. From my height and weight to my lung capacity. Over a couple of visits it must have taken two to three hours. And apart from the kindness and professionalism I met, one of the striking features of the whole experience was that it was all free. No-one asked me to produce an insurance document. No-one asked me to provide evidence that anything had been pre-approved by some bureaucrat somewhere. Above all, no-one asked me for a credit card.

It always amazes me when friends or colleagues look at the States, where healthcare costs twice as much, and tell me how much better things are over there. Yeah, right.

Not that things over here are all that safe. The poor old NHS has been put through the wringer over the last couple of years by Andrew Lansley, one of the most inept Health Secretaries it’s been my misfortune to come across. He’d had five years as Opposition spokesman beforehand, which suggested he might know what he was talking about, but it was obvious as soon as he got into office that he didn’t have the faintest idea.

We’ve just had a cabinet reshuffle, the opportunity for a competent prime minister to replace dead wood by fine new brains. Unfortunately, instead of a competent prime minister we have David Cameron. I couldn’t think of anyone who might make a worse Health Secretary than Lansley, but Cameron is unbeatable: he’s found just the man.

I’d forgotten about Jeremy Hunt, Culture Secretary, who gave a lamentable performance before the Leveson enquiry into press standards (for which read lack of standards). He’d revealed himself to be entirely a pawn of the Murdoch family interests, with no control of either his department or his advisers. Basically a walking disaster area. I’d written him off as a man whose career was over and who would be returned to the back benches at the first opportunity.

That was to reckon without Cameron. Step forward our new Health Secretary: Jeremy Hunt. If you want an accurate assessment of the man, just remember that Cockneys like to use rhyming slang.

However, if things don’t look too good for the NHS, so far the results of my own tests have been encouraging, to the point that I’m beginning to be concerned that the condition will turn out to be mostly psychosomatic, a kind of man-wheeze, if that’s the pulmonary equivalent of man-flu.

The best finding was that produced by some little testing machine (so it must be true) that I have the lungs of a 55-year old. If you’re not impressed by that, well it’s because you’re too young. From where I’m sitting, that’s satisfactory news.

Except that I’m worried about the 55-year old. Whose lungs has he got?

Great if they're in good shape. But whose are they?

And it must be time my mother came clean with me. She never mentioned the double-lung transplant I had at four. I think I should be told.

Healthcare reform and its victims

From the moment the present British government was formed in May 2010, the Health Secretary Andrew Lansley has been dead set on reforming the National Health Service.

Lansley: minister for caring

In particular, the organisations that control around 80% of the Service’s budgets, Primary Care Trusts (PCTs) are due to go by April 2013. That means that bodies employing some 200,000 people are into a process of closure that will, by the time it’s over, have lasted practically three years.

Many are jumping ship as quickly as opportunities open, conscious that it may be dangerous to cling on to the end: most will probably be reassigned to positions in the new hierarchy, but some will certainly be made redundant. As people leave, few are being replaced, so the remaining staff are facing increasing stress dealing with an undiminished workload. 

And that’s going to go on for another fifteen months: the certainty of growing pressure coupled with nagging uncertainty over the future.

The process is likely to cost around £1.2 billion at a time of pressure to reduce expenditure. 

I’ve been working with the health service for over quarter of a century and I’ve seen repeated reforms of its organisational structure; I have yet to see any that were clearly better than any other. 

I’ve only seen one that was significantly and radically different: the Thatcherite initiative to introduce ‘GP fundholding’. This meant that General Practitioners held the budget to pay for hospital care directly themselves. Many of the reform initiatives, including Lansley’s, have had the proclaimed goal of involving GPs in decisions about hospital care, but fundholding was the only one which got them actively engaged with the process, because it gave them real clout. 

It was, however, fundamentally flawed: as well as ‘commissioning’ (i.e. paying for) care, GPs were also providers of care, meaning that they could buy services from themselves. That made the system open to abuse that came close, on occasions, to outright corruption.

In fact, the only time that I’ve seen real improvement in the service was under the last government, and not because of any of its tinkering with management structures, but because it invested more money. Spend a bit more and the NHS gets a bit better.

Will Lansley’s brave new system be an improvement? The clue is perhaps provided by the recent revelation that it will involve five levels of management in most areas, and more in some. It will pay lip service to the principle of GP involvement but in reality it will be administered, as usual, by professional managers — the ‘bureaucrats’ the media love to hate but which cost only 3% of the NHS budget and mean that clinicians spend as little time as possible on administration.

So the reform will be painfully disruptive and expensive while leading to little or no gain. Since everyone is against it — the vast majority of health service professionals themselves as well as their organisations — there is some optimism around that it may be possible to block the changes. That’s not an optimism I share: a British government with a majority in the House of Commons can ultimately force any measure through that it has set its heart on. This will go through. The government will do it simply because it can.

So spare a thought for the people working in the PCTs. Most of them take pride in jobs they believe make a real difference. In general, they work hard and do their best to deliver a good service to others.

And they will in the end have spent three years watching their organisations slowly dying, colleagues leaving, their workload piling up and their futures being increasingly clouded with uncertainty. 

British Prime Minister David Cameron used to like to claim that he was building a Big Society in which we would all find our place. Imagine what it would be like if he set out to build a small one.

Fiddling while healthcare burns

It has been a fascinating experience to spend 25 years – what am I saying? knocking on 30 years – working in healthcare information.

Throughout that whole time, the field has been marked by two powerful and constant trends. The first of these is a growing capacity to deal with more and more diseases. Whether it’s breakthroughs in pharmaceuticals, in surgical techniques, in equipment and consumables, or simply in approaches to care, the number of conditions that can be diagnosed, treated and cured has steadily increased.

And the second trend has been a reflection of the first: a steadily ageing in population, at least in the developed world. People are living longer and that is a tribute to the success of healthcare progress.

Unfortunately, the two trends come together to reinforce a third and much more worrying development: uninterrupted grown in health expenditure. When I started work in this area, healthcare expenditure in Britain represented around 6% of GDP, and in the United States, around 9%. The figures today are over 9% and, staggeringly, over 16% respectively.

Now nobody has ever worked out the maximum an economy can spend on healthcare. We know that on current trends, the US is heading towards 100% of GDP going on healthcare by the end of the century, which is obviously crasy. But what if costs were halted at 50%? That does seem a bit high.  What about 25%? Could a society stand that? Could it still spend enough on education? On roads? Or, given the tendency of both Britain and the US to intervene in other countries’ affairs, on the military?

What is clear is that somewhere there must be a limit. And it’s equally clear that the two great forces that have marked the whole of my career both push that limit: as populations age, they tend to require more healthcare, and they require it for longer; as technology improves, it allows more to be done, but generally at higher cost, at least when innovations first appear. So we have a conundrum.

However, it’s not all bad news. Because one of the effects of improving technology is that in the long run it makes it possible to reduce, rather than increasing, costs. By doing things more effectively, we can avoid certain forms of expenditure. And there tends to be a tipping point in all technology developments: there comes a point where things become cheaper because they become more efficient – we’ve seen it in cars, that have improved massively in efficiency and therefore in cost. And we’re seeing it in healthcare, where for example keyhole surgery techniques have reduced the cost of care substantially because patient recovery is so much quicker, without any great increase in the cost of the operation as surgeons have become more proficient and comfortable as the techniques become routine.

That’s why so many procedures that used to involve several days in hospital can now be performed on a day case basis. A striking example is cataract extractions. Even more serious surgery, such as open heart operations, have so evolved that an otherwise healthy individual may be ready for discharge within four days, where in the past it might have taken twelve.

These examples are a clear signpost of the way forward: use evolving technology to improve care delivery. In particular, use it to limit the time patients spend in hospital: hospitals are nasty, dangerous places, full of sick people and the longer you stay in one, the greater the chances of picking up a nasty infection and leaving in a worse state than you came in. They’re also about the most expensive places in which to receive treatment – anything we can do to get treatment carried out in a GP’s surgery, or even in a hospital on an outpatient basis rather than as an inpatient, is likely to be a benefit to the patient and a saving of money for society.

Vital when needed, but best avoided if you can. And very expensive...

Now all this has been known for decades. The trick is to start doing it. Start cutting out the unnecessary treatment, or at any rate the unnecessarily expensive treatment.

But that means taking clinical decisions, deciding what is the most intelligent and appropriate approach to delivering care.

So why instead of tackling those issues does government after government instead try to find economies in the area of healthcare management? The British National Health Service spends around 3% of its money on management. Just how much can you save from that?

And are the savings real anyway? If you take out the administrative support staff, the administrative work still has to be done. So who does it? Why, the front line staff themselves. The nurses and doctors. That diverts resource from healthcare, and is also far more expensive: most nurses and certainly most doctors cost a great deal more than most administrators.

But governments do worse than that. In my time, in Britain alone, I’ve watched the Griffiths reforms bringing in General Management. I’ve watched the idea of ‘Hospital Trusts’ being introduced, and later ‘Foundation Trusts’. I’ve seen the creation and abolition of Area Health Authorities, the setting up of Primary Care Groups and then their replacement by Primary Care Trusts, now just over a year from abolition themselves, if the latest legislation goes through.

In other words, I’ve watched government tinkering with the organisation, fiddling with the structure. Andrew Lansley’s proposed NHS reforms are probably going to cost about £1.2 billion – all in the name of seeking out economies. And all the time the real savings, which at the same time can generate real improvements in patient care, need clinical reform, not managerial change.

No wonder the controversy about the latest proposals is so intense. It deserves to be. The new initiative represents a huge expenditure to address completely the wrong issue. Not because trying to control healthcare expenditure is wrong, but precisely because it’s so badly needed: Lansley's legislation would waste money and fails to address the real problem.

When it comes to hare-brained government initiatives, it has to be right up there with the very best of them...