Do you believe the NHS is safe with the Tories? How Thatcher's behaviour exposed that lie

“The NHS is safe with us,” Thatcher told the nation – well, the Tory Party Conference, but we were all listening – in 1982.

It can take some time – in this case, over three decades – but eventually the truth will out, and the lie is exposed. At least, if you have a newspaper as effective as the Guardian to do the exposing.

It was three years ago that we discovered from papers published under the thirty-year rule, that back then Thatcher’s government had considered a proposal to end free Higher Education and to introduce vouchers to pay for school education, freeze benefits and, most toxic of all, to overthrow the founding principle of the NHS that healthcare should be free at the point of care, replacing the service by one based on insurance. As the paper containing the proposal pointed out, “This would of course mean the end of the National Health Service.”

As quoted in the Guardian: the killer phrase in the 1982 proposals

In her memoirs, Thatcher said, “I was horrified when I saw this paper. I pointed out that it would almost certainly be leaked and give a totally false impression … It was all a total nonsense.”

The government dropped the proposals after what her then Energy Secretary, Nigel Lawson, described as “the nearest thing to a cabinet riot in the history of the Thatcher administration.”

What has now emerged, from newly-published Treasury papers of her then Chancellor of the Exchequer, Geoffrey Howe, is that Thatcher didn’t give up on the proposals herself but kept working on them with him. As he noted, “the prime minister has arranged a series of meetings with the main spending ministers to discuss the follow-up to the discussion in cabinet” on the proposals. Among other things, the discussions were to look into replacing some public services by “more efficient alternatives from the private sector.”

If Thatcher was horrified, it was clearly about the fact that the ideas “would almost certainly be leaked” rather than about the ideas themselves.

Now roll on thirty or more years.

There has been constantly extending privatisation of health services in England with little evidence that they provide better quality. In fact, they don’t even seem to be able to generate levels of profit that would persuade the private companies to keep delivering them – several major contracts have already had to be cancelled.

Meanwhile the NHS is facing an unprecedented level of financial crisis. The 2015/16 year was the second in a row which saw the service in England in deficit – and with three times the level as the year before. The much respected health think tank, the King’s Fund, comments:

The scale of the aggregate deficit makes it clear that overspending is largely not attributable to mismanagement in individual organisations – instead it signifies a health system buckling under the strain of huge financial and operational pressures. The recent strategy of driving efficiencies by cutting the tariff has placed disproportionate strain on providers and is no longer sustainable.

That reference to a “recent strategy” reveals that the problem has been caused by deliberate policy. The government is putting the NHS “under the strain of huge financial and operational pressures”. Unbearable strain, you might say. .

Is this an unfortunate consequence of a misguided policy? Or is it merely the continuation by other means of an approach already launched scouted over three decades ago by Thatcher? An approach that would necessarily lead to “the end of the National Health Service”?

It hardly matters how we answer those questions. What’s clear is that the notion that the “NHS is safe” with the Tories is just sand in the eyes of those too tired or too greedy to resist their propaganda.

Why, you might as reasonably believe that Tories will keep the poor safe.

Ageing: a crisis for healthcare. Or an opportunity for integrated care?

It’s obvious, isn’t it? The wealthy nations face a crisis due to their ageing populations. The problem’s particularly acute for healthcare.

It’s so obvious that even I have said it in the past. But it isn’t entirely true. The error needs correcting, if only because ageing isn’t a curse but a measure of unprecedented success. At the beginning of the last century, life expectancy in the US was just over 48 years. Today, it is nearly 79. In Britain over the same period, it has grown from 45 to 81. How’s that a disaster?

After all, it’s not as though the picture is the same everywhere. In Syria, life expectancy is 64.5 years. In Sierra Leone it's just 50 years, little better than the US over a century ago.

Where there have been gains, the extra years include an increasing proportion in good health. That’s according to a study by the British healthcare think tank, the King’s Fund. It suggests the trend is likely to continue, with our ageing population adding further years of healthy life.

More years of healthy life? Why’s that a problem?

Not so much a healthcare crisis as a cause for celebration, surely. 

That being said, the trend does raise new challenges for healthcare. They need to be addressed. That means a change in approach.

As the King’s Fund points out, what we are seeing is an increase in the specific kind of health problem characteristic of old age. There are more long-term conditions such as diabetes, some lasting for life, and more patients suffering from several disease conditions at the same time.

Why is that such a challenge to the health services? Because historically healthcare has been built around specialisation. Hospitals are organised into departments dealing with neurology or rheumatology or cardiology. But today they’re having to deal with patients who may have suffered a stroke exacerbated by a chronic heart problem, who are also struggling with the pain of rheumatoid arthritis.

How does a specialist of just one of these conditions approach such a patient?

These issues also raise the question I’ve been addressing throughout this series: in what setting should a patient be treated?

The King’s Fund tells us:

…we must strive wherever possible to ‘shift the curve’ from high-cost, reactive and bed-based care to care that is preventive, proactive and based closer to people’s homes, focusing as much on wellness as on responding to illness. When asked what they value in terms of wellbeing and quality of life, older people report that health and care services when they become ill or dependent are only part of the story. Many other things matter: the ability to remain at home in clean, warm, affordable accommodation; to remain socially engaged; to continue with activities that give their life meaning; to contribute to their family or community; to feel safe and to maintain independence, choice, control, personal appearance and dignity; to be free from discrimination; and to feel they are not a ‘burden’ to their own families and that they can continue their own role as caregivers.

Admission to hospital may be vital in certain circumstances but, as well as being the most expensive way to deliver care, it corresponds to only a tiny part of the aspirations older people expressed to the King’s Fund team. They propose reform based on nine points:

1. helping people maintain their independence, to live at home in good health, for as long as possible;
2. helping people to live as well as possible with simple or stable long-term conditions if they develop them
3. helping people deal with complex or multiple health problems, including dementia and frailty
4. in cases of real crisis, delivering rapid help close to home
5. when it becomes necessary to provide hospital care, making sure it’s good and delivered humanely
6. planning discharge from hospital on admission or before, ensuring patients leave with sufficient support and avoid the risk of readmission
7. providing good rehabilitation and re-ablement services so patients quickly return to the best possible level of health and independence
8. providing high-quality long-term nursing and residential care for those who need them
9. ensuring that services supporting patient choice and control, with all the care and support required, are available towards the end of life

The tenth point is that all the others require integrated healthcare, bringing together medical, nursing and social care, in hospitals, family practices and community settings. An integrated approach sees a patient as a whole, not as the vehicle of a single medical condition, or even several. It accentuates quality of life and does everything to maximise choice and independence. Such care would certainly be the best imaginable.  What may seem paradoxical, but isn’t, is that is also likely to be the least expensive. That’s because it minimises healthcare demand and shifts as much as it can to less costly settings, in particular away from the acute hospital.

This approach will have benefits far beyond care for elderly patients. As the King’s Fund argues:

The balance of evidence is clear that integration can improve people’s experience and outcomes of care, and deliver greater efficiencies… It is important to recognise that achieving improvements for older people will also positively affect care for the rest of the population. More effective urgent care and post-acute rehabilitation and re-ablement services are important for people of all ages, while reducing inappropriate care and shortening acute lengths of stay for older people could release resources to meet other needs.

Avoiding the avoidable and coordinating care more effectively will deliver better care. Far from costing more, that may free up resources. So the ageing of the population may not be so much a crisis, as an opportunity.

Austerity? Not good for your health

In 2008, the Healthcare Commission, the body then charged with monitoring and improving care quality in England, published a report into lamentable failures in Stafford hospital, run at the time by the Mid Staffordshire NHS Foundation Trust. Mid Staffs, as it’s familiarly if not affectionately known.

The scandal that ensued revealed shocking levels of poor care which certainly caused great suffering to many patients, and a certain number of deaths. Just how many deaths is difficult to determine. Headlines at the time of “400 to 1200” excess deaths were deeply misleading, as was the report that established that number, by Dr Foster Intelligence, a healthcare analysis company.

Insofar as the number means anything, it is that there were that many more deaths than would have been expected given the levels of illness recorded among the patients treated. That figure does, therefore, depend on the records kept by the hospital, which weren’t necessarily as comprehensive or accurate as they might have been. Besides, no one has ever established that the “excess” deaths were actually avoidable, which would have been a truly devastating finding.

Indeed, Robert Francis who wrote the report into failings at the Trust, would comment, “…it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care.”

Nevertheless, in November 2015 Mid Staffs pleaded guilty to four charges of causing the death of patients, so it’s clear that there were deaths as a result of the poor performance of the Trust, whether or not we can set a reliable figure on the number.

Incidentally, by the time of the guilty plea, Mid Staffs Trust had been dissolved more than a year and the Stafford Hospital, now the County Hospital, was being administered by the University Hospitals of North Midlands NHS Trust.

In his report, Francis identified a number of causes for the failings. Prominent among them was one that had been broadly acknowledged in the general debate: poor levels of staffing, especially among nurses. In its sometimes desperate quests to be granted the status of NHS Foundation Trust that gives hospitals greater autonomy in managing their affairs, Mid Staffs had gone too far in slashing staff numbers to meet financial targets. The Francis report recommended an action on the National Institute for Healthcare Excellence (NICE):

The procedures and metrics produced by NICE should include evidence-based tools for establishing the staffing needs of each service. These measures need to be readily understood and accepted by the public and healthcare professionals.

After the report was published, the government commissioned another, from US Healthcare analyst Don Berwick. It echoed Francis’s views on staffing:

NICE should interrogate the available evidence for establishing what all types of NHS services require in terms of staff numbers and skill mix to assure safe, high quality care for patients.

Admirable idea. What should determine staff numbers is quality and safety of care. Certainly not financial considerations. Nothing could matter more for us: if we’re seriously ill, and admitted to hospital, it would be nice to know that the level of service provided is based on what we need, not on what the hospital can afford.

Or, put another way, if the choice is between an increase in public spending, or the kind of dangerous care that gave Mid Staffs such a bad name, few would choose the dangerous care.

Except, sadly, that too many of us nonetheless vote for people who will make precisely the opposite choice. Those people won’t, themselves, suffer from that choice. The Camerons and Osbornes of this world don’t have to depend on the NHS for healthcare: they can pay for what most of us have to hope will be provided free. So they choose to prioritise money over care.

It was obvious from the beginning, from when Berwick make his recommendations in August 2013. Health Minister Jeremy Hunt rejected the notion that there should nationally backed standards for staffing:

If you start mandating things from the centre you create an artificial target and hospitals and trusts say: well if we meet that national minimum we’ve done our job as far as staffing’s concerned when actually they haven’t – because you’ll find there are places that need a lot more help and a lot more care.

This is a neat argument: it says we’re not accepting a recommendation because we don’t think it goes far enough – but then you don’t do anything at all.

Two and a half years on, few recall the Berwick report. Even the Francis report and Mid Staffs has become a bit of a vague memory: wasn’t that the hospital that did so badly when Labour was in power?”

NHS Nurses: much applauded at the Olympics 2012 opening
But have we now decided we have too many?

So now’s a great time to put the squeeze on, when people aren’t watching that closely any more. And that’s just what’s happening. Faced with a £2.2bn deficit, NHS hospitals are being told to cut staff to get their finances under control. The Guardian quoted Richard Murray, director of policy at the King’s Fund healthcare consultancy, saying:

If trusts do begin to reduce headcount the impact on patients would be swift, through either rising waiting times or reduced quality of care or both. Three years on from Robert Francis’s report into Mid Staffs which emphasises that safe staffing was the key to maintaining quality of care, the financial meltdown in the NHS now means that the policy is being abandoned for hospitals that have run out of money.

The government has long since decided that its overriding aim was reducing the deficit, and ultimately cutting public debt. It’s achieved some reduction in deficit but debt has grown like topsy, making George Osborne Britain’s first ever trillion-pound Chancellor. So austerity has failed.

I don’t know how anyone dependent on the NHS might feel about healthcare being sacrificed for the sake of a failed economic policy. I don’t know how anyone dependent on the NHS might feel about generalising the standards that fuelled the Mid Staffs scandal. I don’t know how anyone dependent on the NHS would want to risk giving that lot another chance in power.