Hardback: £16.99 / $27.95
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2006, 234mm x 156mm / 9.25in x 6in, 320pp
ISBN: 978-1-84310-482-7, BIC 2: LNTM
Introduction: the Death Throes of a Health Service
This book was written against the backdrop of fundamental changes being made to the National Health Service (NHS) in England during 2005 and 2006. They were being achieved by a number of linked policies driven by the New Labour government.
These policies included significant financial investment in the NHS, giving patients more choice, keeping health services local, involving local communities in reconfiguration to local health services, transferring NHS provision to the private sector, creating a competitive marketplace for improved NHS services, and introducing a new system called payment by results.
In addition, other policies were put in place specifically to ensure that potentially vulnerable groups were not sidelined. These groups included older people, people with learning disabilities, and people with mental health problems. Even better, it seemed, central government was committed to something called 'joint working'. This envisaged closer cooperation and sometimes a degree of integration between 'health care' services provided by the NHS, and 'social care' services provided by local councils. This was to iron out the gaps and misunderstandings that sometimes occurred between the NHS and councils.
Overall, the government stated itself still to be committed fully to the fundamental principles of the NHS dating back to 1948. These were universality, comprehensiveness and, by and large, health services free of charge to the patient. If the government was to be believed, everything in the health garden was rosy and set to become even more so.
The acid test of policy is how it actually affects individual local people and communities. Chiefly, this book sets out this range of national policies and then considers empirically, step by step, the direct effect they had on local communities during 2005 and 2006. Examples are taken from all over the country. However, in order to show close-up the effects on the ground, the county of Suffolk, and in particular West Suffolk, are the focus. This in no way renders the book merely local in scope or relevance. The same issues were being played out across the country. West Suffolk was not a little local difficulty; in many ways it epitomised a widespread pattern. The local detail spelt out from Suffolk and many other places is by way of evidence that it really was all happening and was affecting real people in real localities.
Therefore, as well as setting out the national picture, the book contains local detail. Much of this is described through local voices, including patients, relatives, voluntary organisations, clinicians, councillors and MPs. This is to emphasise the effects on real people and local communities. It is also to hear from these people inherent common sense and wisdom about health care. Unfortunately, despite all the lip service paid to 'patient choice', and to the empowerment of frontline clinicians, central government and local NHS senior managers seem to pass by on the other side.
As central government policy played out in West Suffolk and other locations, the implications became apparent. Instead of health service improvements and expansion, it was severe cutbacks that came to the fore. Ward closures, bed and job losses and community hospital closures were being reported, it seemed, from every quarter. Rehabilitation services for older people seemed to be in the process of being strangled in some areas. Both wards and day services for people with mental health problems were likewise being targeted. And the NHS strove still harder to reduce its provision for people with learning disabilities. More generally, and affecting the population at large of all ages and health status, were cuts to maternity services, accident and emergency departments, minor injuries units and a range of other services. Local health services generally, both rural and urban, were under assault. Increasing numbers of NHS Trusts and PCTs were reported to be in significant deficit.
The government's reaction to this apparent bonfire of health services was inadequate and lacked transparency. First, it would generally ignore and play it down. Then it would focus on those local NHS bodies with the more spectacular deficits and attempt to portray the problem as affecting just a very few areas. It ignored the fact that a large number had financial problems. It also seemed that measuring the 'crisis' in terms of financial deficits was only half the picture. This was because it appeared that significant numbers of NHS Trusts and PCTs were in financial balance only through having already made substantial cuts to services. In effect, the government seemed to be concerned less with patients losing services, and more about those NHS Trusts and PCTs that had failed to make sufficiently drastic cuts.
Second, the government's response, namely that each local NHS Trust and PCT in deficit had to 'live within its means', was incoherent. This was because it meant that, through no fault of their own, local communities would be forced to pay – with their own health – for the mistakes, mismanagement or miscalculations of senior NHS decision-makers at both local and national level. Given that we are all tax payers, who contribute to a national health service, such an approach is self-evidently unfair. The Secretary of State's office opined that the NHS must 'experience pain locally'. This was, no doubt unintentionally, a sadistic-sounding statement. But it was not, in substance, far off the mark; only it would be patients who would be punished and suffer that pain (literally), not NHS chief executives, chairmen and their Boards.
Third, the government would ritually respond that waiting times had improved, with, for example, cancer and cardiology services particularly benefiting. But this seemed to miss the point. The achievement of targets is not meant to bring the rest of the organisation to its knees. Yet this is what seemed to be happening. It was as if the Secretary of State fiddled to the tune of her targets, while other parts of the NHS burned. There seems to be little doubt that in various ways, both directly and indirectly, patients have suffered as a consequence of the obsession with targets, both clinical and financial.
The cost to patients has sometimes been high and very direct. None more so than when, at one major hospital (Stoke Mandeville), nearly forty patients died during two major outbreaks of Clostridium difficile – and hundreds of others were infected. The Healthcare Commission investigated and published its findings in July 2006. It concluded that, despite having been well advised by its infection control team, the NHS Trust Board had other priorities, on which it would not compromise. Infection control advice was disregarded, even after the first outbreak of infection. Even with the advent of the second outbreak, the Trust only changed its priorities when the story was leaked to the national media.
The priorities, to which the Board so doggedly stuck, comprised waiting list targets, financial control and reconfiguration of services. Right across the NHS, such pressures arising from these priorities daily lead to all manner of shortcut being taken with people's care – particularly that of older people. And so it happened in Buckinghamshire. It just came to national attention because of the extreme and lethal consequences. It might be tempting to hope or assume that the behaviour of the NHS Trust was an aberration, a statistical outlier. But we should make no such assumption. Nor did the Healthcare Commission. It concluded that the pressures, which led to the Trust running off the rails, exist for all acute NHS trusts in England. These pressures stem from the uncompromising demands of central government, levelled at local NHS Trusts, via strategic health authorities.
On a different tack altogether, 'joint working' between the NHS and local authorities was all the rage – but would frequently seem to be a cover for moving people away inappropriately from NHS health care to local council social care. Health services could then be re-labelled or not provided at all. A lack of appropriate health-care rehabilitation will leave people more disabled and requiring social care services they might not otherwise have needed. Social care can be charged for, whereas NHS services mostly cannot. This creates an added incentive to shunt people and services over to local councils. People may have to use their savings to pay for services and even sell their home. That is, if local councils have the resources to provide social care services for them at all. Increasingly they do not and, year by year, they are rationing provision according to ever-stricter criteria. Fewer and fewer people are eligible for their services.
This means that even in those circumstances where this shift from health care to social care is appropriate (which it sometimes is) – local councils are in any case hamstrung in terms of finance and resources. It is not then a case of an orderly and beneficial transfer of responsibility and of an enlightened approach to meeting people's needs. Instead it can degenerate into an unseemly and detrimental pushing of people from pillar to post – from a shoulder shrugging NHS to the overburdened but increasingly flinty, and financially rapacious, arms of local councils.
Once within the orbit of social care, people are also deluged with the politically correct language of 'choice', 'control' and 'independence'. All highly laudable and important principles. Central government's favoured method of achieving of these is to pressurise local councils into not providing services directly, but instead contracting them out to the private sector. If possible, the government wants people to purchase, or at least direct the purchase of, services through things called 'direct payments' or 'individual budgets'. The money can then be spent on the private sector.
While these payments or budgets do have the potential genuinely to give people more control and independence, the signs are that, once they are given in larger numbers, this may not happen. They are likely instead to be used by councils to cap expenditure and force vulnerable people to fend more for themselves – even when this is inappropriate and the required services are either not available or not affordable. Direct payments and individual budgets may be the flavour of the month among policy makers and beneficial for some users of services; but potentially they also constitute a Trojan Horse by which council social care services will be finally dismantled – whether or not this is in the interests of all users of services.
Overall, these government policies were having harmful effects. People with complex, longstanding health-care needs were being victimised and excluded from NHS provision in order to save money. Patients were being increasingly treated like financial and business units, as NHS trusts sought at all costs – both financial and human – to meet targets and save money. It became increasingly evident that New Labour was attempting to dismantle the NHS by privatising the provision of its services and throwing it open to market forces.
Universality and comprehensiveness were being eroded. Change, it seemed, was being achieved particularly at the expense of vulnerable groups, including older people with more complex needs, younger adults with disabilities, people with learning disabilities and people with mental health problems. In other words, perversely, those with the greatest needs were losing out. Allied to this was the loss, or further erosion, of what for want of a better term we might refer to as 'good, basic care'. That is, treating people as people and not as business units, outstaying their allotted welcome by blocking beds or 'frequently flying' in and out of hospital. Real care, for instance, involves making sure that older people are treated with dignity and respect, treated in a non-discriminatory fashion, assisted to eat their daily nourishment, assisted to avoid pressure sores, are not unnecessarily written off as incontinent, are not discharged from hospital prematurely, and so on.
At Stoke Mandeville Hospital, for instance, the Healthcare Commission uncovered just such shortcuts in care, stemming from concentration on targets and not people. These shortcuts – which are entirely unacceptable even had they not resulted in a lethal outbreak of infection – included the following. Side rooms were not used for isolation of infected patients but for non-emergency surgery cases (to meet targets) thus putting other patients at serious risk of infection. People were frequently moved from ward to ward for reasons of capacity rather than clinical reasons. They would end up on the 'wrong' type of ward, where staff would be less knowledgeable about their condition. Doctors would then be unable to find their patients. Low levels of staffing and an effective recruitment freeze meant that staff might have no time to assist patients to the toilet in time (or to change the sheets when patients didn't make it in time), write up care plans, wash hands, wear appropriate aprons and gloves, ensure that faeces were not coating bed rails, give patients their food supplements, give therapists the information they needed, and so on.
All such basic, humane care might be unglamorous in the supposedly bright new world of the NHS, but it is fundamental to us all. The pressure on acute hospitals is increasing, although it could be relieved cost effectively in part by community hospital beds. Yet nearly 30 per cent of community hospitals in England are faced with cutbacks (particularly of beds) or closure altogether. This is despite the fact that community hospitals across the country are viewed by many as an invaluable bastion of care in its real sense.
Furthermore, the ill effects were not confined to the more vulnerable among us. Accident and emergency services, maternity services, children's services – in fact a whole range of local beds, clinics and services affecting people of all ages – were being removed all over the country.
As the picture became clearer, the worse it looked. This was not just because of the apparent harm being done. A chasm was opening up between government policy and local practice. Change was occurring with a lack of transparency. Decision-making at all levels seemed increasingly to be characterised by the deployment of emotive language, mantras, euphemism, doublethink, and the use of red herrings to achieve concealed aims. Casualties along the wayside typically included evidence, logic and genuinely participative and democratic decision-making.
Instead of working with the local community, local NHS bodies would try to impose change by diktat and confrontation. They would break assurances and promises without notice, often without convincing explanation or apology. Transparency was notable – but only for its general absence. Breathtaking statements were made about how the severe cuts taking place would have no detrimental effects on patients. The more severe the cuts, the more NHS chief executives and chairmen protested that it was all for the best. It was, we were told, about 'changing for the better', modernisation and improvement, or a service fit for the future. 'Less' truly had become 'more'. In some instances, the statements and explanation emanating from the NHS were so absurd that in any other context they would have been taken for outright parody.
In the same vein, the more trumpeted a government policy – such as keeping health services local and involving local communities – the greater the departure from it in practice. Local services were melting away. The ensuing reasoned objections and protests of local communities were mostly disregarded. The engagement between communities and their PCTs was not of the cooperative and enlightened type portrayed in government policy. Instead, all too often, it involved fierce and bitter conflict, driven by fear and anger.
The crucial point is not that there should be no change. But importantly, there needs to be a sensible transition between the old and the new. People are likely to be supportive of change if an effective, well evidenced, fair and comparable alternative is in place. However, instead, throughout 2005 and 2006, the country was treated to closures and cutbacks bearing all the hallmarks of panic, chaos and mismanagement. In many cases, it would prove impossible to detect a decision-making process that could in any sense be described as well evidenced, planned, communicated, organised or implemented. As for adequate – let alone improved – replacement services, they appeared in many instances to be so many figments of the imagination.
The policy of having specialist regional services (to which people would have to travel further) might have made sense – if the basic range of services were made more local, just as the government said would happen. Thus, it announced a new generation of community hospitals and that it would be keeping the NHS local and providing 'care closer to home'. But in reality, local services were being scythed down indiscriminately in both town and countryside. Both basic and more specialist services were set to become more distant than they had been. Existing community hospitals (old or new build) – beacons of local NHS care (in the true sense of the word) and treatment – were threatened by the score. District general hospitals were starting to be closed – or downgraded and rebadged as community hospitals. And care closer to, or in, people's own homes? This seemed – through lack of resources, staff and proper planning – to be more about leaving people to fend themselves or forcing family members to look after them, than about providing reliable NHS care and treatment. In sum, the policy about local services smacked of a confidence trick. Services were in fact moving further away from, not closer to, people – if they were not disappearing altogether.
In addition, it seemed that NHS trusts and primary care trusts were prepared to proceed by ignoring – or referring highly selectively to – relevant evidence. Logic and facts would sometimes be apparently abandoned in equal measure, wholesale if necessary. Policies, reasonable on the surface, would be hijacked and used for quite different purposes. In such a way, the world could be turned upside down with impunity. A 'model of care', all the rage one day, could without rhyme or reason be abandoned the next. Anybody querying this would run the risk of being labelled sentimental, emotional or just plain reactionary.
For instance, one of the central battlegrounds was over something called 'intermediate care', a policy aimed mainly, but not only, at older people. It was designed mainly to avoid unnecessary stays in acute hospitals. On its face it was a sensible policy. But like so many central government policies, it lent itself to distortion and misuse. Local NHS bodies, seemingly unable to help themselves in the face of severe pressure from central government, would hijack the policy. Sometimes this could lead to justification of proposals to implement severe and seemingly unevidenced cuts to health services for vulnerable people. Intermediate care was in principle designed originally to complement and add to all-important rehabilitation and recuperation services. Now it was in more danger of being perversely misused as a cover for the NHS to do quite the opposite – actually to run down rehabilitation services.
Above all, local NHS bodies were perceived to be riding roughshod over the unprecedented objections of local communities. Across Suffolk (and in many other parts of the country) public meetings, marches and petitions would abound but bear no real fruit. People would take to the roads, the waterways, the buses, bicycles, chartered trains, boats, vintage cars, Harley Davidson motor bikes, tractors – and to Whitehall. Skeletons and grim reapers would stalk the streets. Physical protests would routinely run into thousands. Local people expressing opposition to local closures would regularly number tens of thousands. It all seemed to make little or no difference.
Desperate local campaigns would be run by local committees, drawing together expertise and support from all corners of the community. Patients and their relatives, the people who really knew first hand about the importance of rehabilitation and recuperation, would express their views. In Suffolk alone, they protested in their tens of thousands, but would be all but ignored. Military metaphor is used to describe one of these campaigns towards the end of the book, for the good reason that it was a conflict and it ran deep. Local communities soon discovered the nature of the beast they were up against. They had to try to work with PCTs and NHS Trusts, but at the same time many had swiftly to learn not to take these NHS bodies, or their ritual reassurances and deceptive promises, at face value. They also had to grasp that the NHS does not speak the language used by the rest of us. Skilled interpretation is often required.
Dire warnings from their own clinicians would be downplayed by NHS primary care trusts, the clinicians sometimes dismissed as suffering from a lack of understanding. From the small parish council to the county council, and through every council in between, local government would let its concerns be known. The protests of the churches and the NHS Patient and Public Involvement Forums (to whom NHS bodies are meant to listen) fell on stony ground. Regional medical associations would present letters in vain, and the unions would appear powerless.
The consequences in Suffolk and many other areas would be disastrous. Fear, anger and distress took hold across the country. In turn, local NHS trusts and primary care trusts, professing bemusement at the hostility they had excited, retreated into their bunker. This was to protect themselves from criticism and also to maintain the integrity of the make-believe world they increasingly inhabited. Abstract models of care would be dreamt up, as well as imaginary armies of health-care workers who would be delivering the new scattered 'care in the community'. To local communities looking on aghast, these NHS bodies adopted what seemed to be an ever more obdurate, uncompromising and detached approach. Even so, as the NHS trusts and primary care trusts scurried underground, so it became clear that they too were in part hapless victims – caught in the crossfire of contradictory demands being made by central government.
Under competing pressure to deliver on all manner of target and policy, local NHS trusts and primary care trusts had come under intense pressure to make financial savings very quickly. In some parts of the country (including Suffolk), huge deficits had to be reined in. The perversity of such sudden, uncompromising demands was highlighted by the fact that many of the deficits were not new. They had been in existence for some years, not only tolerated but also even encouraged by central government, so that vote-winning NHS performance targets would be met. The explanation for a sudden change in approach appeared to be wholly political. It occurred immediately after New Labour's general election victory in May 2005.
Worse still was the lack of accountability. This led to frustration and exasperation in local communities seeking explanation and dialogue. None was to be had. They searched in vain for a true decision-maker but simply could not find one. Local NHS trusts and primary care trusts would quietly concede that their hand was being forced by their political masters. Yet central government would flatly deny responsibility for local decisions. And the intermediaries, the strategic health authorities, lying between local NHS bodies and central government? They had simply donned cloaks of invisibility.
Even so, behind the smokescreen, the hand of central government seemed to loom ever greater. Perhaps the most damaging cue provided, and taken up by local NHS bodies, was the hasty imposition by diktat of ill-thought-out policies, themselves based on unclear aims and ambiguous motives. In this respect, the arrogance and contempt with which local communities felt they were being treated would arguably amount to an abuse of power. All this would be exacerbated by the various concealed agendas apparently being perpetrated by central government, including the exclusion of vulnerable people from, and the dismantling and privatisation of, the NHS.
The scale and nature of local opposition up and down the country was astonishing. Such radical change (and its serious consequences) had not been spelt out plainly by New Labour in its election manifesto. In short, the government clearly had no political mandate for what it was doing. It went ahead all the same.
Local NHS trusts and primary care trusts were being pressurised and told what to do by central government. Schooled in a form of doublethink, which ultimately boiled down to 'less is more', they clearly had convinced themselves that they were acting for the best. But pressurised and rushed decision-making led inevitably to shortcuts being taken.
Pressurised they may have been, but this is not to say that local NHS bodies were victims in the same sense as patients, families and other informal carers. For these, the consequences were very different. They stood to lose in terms of lack of care, respite, rehabilitation, recuperation – leading to greater disability, suffering, pain, distress, stress (physical and mental) on carers and in some cases even avoidable, premature death. For instance, premature death may occur not just through any immediate neglect or omission. It can also flow, quicker or slower, from the all-too-familiar spiral of physical and mental decline attendant on a lack of suitable and timely rehabilitation and recuperation. Local communities were threatened more generally also, as key local services (some involving life and death) for people of all ages and health status – from accident and emergency services to maternity units – were increasingly under threat of closure.
Local NHS primary care trusts would at times be taken aback at the breadth and depth of opposition they faced. They seemed not to realise just how confrontational, aggressive and harmful their actions appeared to be. To local communities, the actions of these 'trusts' spoke far louder than any soothing words offered up by way of unconvincing explanation. Central government's 2006 White Paper had spoken of local communities being fully involved in, and feeling ownership of, decisions about local health services. It was a distant aspiration only. In its place came a fundamental breakdown of communication and trust.
This loss of trust was accompanied by fear. The harm being done (or proposed to be done) to vulnerable people – as well as to people more generally – was perceived to be very real and akin to a policy (whether or not thought through) of the weakest to the wall. It was all made worse because the changes were being implemented so quickly, together with a lack of transparency and of accountability. To take services away from vulnerable people – that is, all of us when we are in need – is bad enough. To do so covertly prevents debate as to whether such a policy is acceptable and, if not, how to ameliorate it. This is unforgivable. But then to add in lack of accountability takes it all beyond the pale. In short, if central government and local NHS bodies wish to remove our local health services generally, abandon certain groups of vulnerable people, undermine the fundamental principles of the NHS, and throw open the doors to privatisation of our health care, they should at least have the courage, political and moral, to say so. Of course it is easy to criticise. But one thing is clear. Answers and solutions may be elusive, but lack of transparency and of accountability will in any event not deliver them.
Perhaps it is summed up by the level-headed, intelligent and well-informed resident of Sudbury in Suffolk who stopped the author in the street. He spoke of the picture he had of NHS decision-makers in Whitehall. This was of people in a darkened room, working out how to cut NHS costs by shuffling older people out of the NHS equation, into social care for which they could be charged and might have to sell their house – and then, if possible, discreetly into a cost-effective early grave. From such a resident this was shocking. Was it all paranoid imagining? The author would like to think so but is not certain any more. As one placard read, during a protest about Suffolk health services: 'The 11th commandment: thou shall not grow old'.
Dave Gooderham, 'Health workers step up cuts protest.' East Anglian Daily Times, 3 November 2005.
