If you have half a morning to spare put "NHS at breaking point" into your web browser. It will take you from elevenses through to a late lunchtime just to finish scrolling through the list of articles, never mind reading any of them. This is not just the current reflection of a service stretched "to the limit" by the Covid pandemic, but is a hardy perennial of front line reporting about it. That the nation's health service is always in such a state of crisis would, in a normal world, reflect poorly on those charged with the stewardship of it. Yet far from attracting criticism, it is a condition that is always adroitly used to the NHS's advantage. Indeed, the institution is invested with a sacred status such that it is rarely called to account even when egregious failings and even criminality are found on its watch.
The obeisance given to the NHS takes many forms: Danny Boyle's baffling homage to it during the opening ceremony of the 2012 London Olympic Games or the more recent national "clap for carers" during the first outbreak of Covid spring most easily to mind. Elsewhere, the reverence is more insidious. The BBC (as another "public service" monopoly provider) has become a mouth piece for its fellow institution, whether in its news, drama or current affairs divisions. From the fictionalised "Holby City", the risible "Doctors" and "Casualty" to the documentaries "Hospital", "Surgeons: Life at the Edge" and "Ambulance", the weekly schedules are incomplete without one medical documentary or soap for prime-time viewing. There is also C4's "One born every minute" and ITV's "24 Hours in A&E". The health service is, as Nigel Lawson once observed, the closest thing the British now have to a religion.
The veneration has prevented some long-overdue scrutiny of an organisation, which in its institutional culture is little changed from that which was set up in radically different circumstances in 1946. But when politicians come to discuss it or to deal with it, their moral courage and critical faculties desert them. Every election, the Labour Party comes up with some new variant of its famously mis-leading "24 Hours to save the NHS" strap-line of 1997, and the public has been conditioned to assume that any attempt at rationalisation, efficiency or even improvement is a prelude to privatisation.
The Covid crisis has exposed the shortcomings of the NHS like never before and it would be fair to say that the entire government strategy has been predicated on a determination that it not be "overwhelmed" by the pandemic. After nearly nine months of increasingly futile restrictions and counter-measures, a ludicrously expensive and poorly designed "Test and Trace" system, hundreds of billions spent on economic support for national inactivity, the opening of numerous and unused Nightingale facilities, the explosion of non-Covid hospital waiting lists and the scarcely believable sum of £15bn spent on PPE, it feels like the UK is back to square one. After various iterations throughout the spring and summer, the strategy is once again "Stay Home, Protect the NHS, Save lives".
Sir Simon Stevens, CEO of NHS England and his compadres in the devolved regions have been almost invisible as the crisis has evolved. Indeed the FT reported one NHS official describing Sir Simon's part in the pandemic thus: "I think it was evident from the outset that this was going to be a shambolic response and I think he's done quite well to emerge unscathed and focus on the NHS's priorities (sic). NHS England is a commissioning organisation - it wasn't his job to deliver some of this stuff in the way that it was for Public Health England or the health department, and I think he's quite rightly stayed out of it". Yes indeed.
Although the NHS has operational independence (at least in its English variant) and has nearly 1.4m personnel on the pay-roll, it has managed (with the aid of the BBC) to shift the whole blame for the mismanagement of the crisis onto the government, whose only fig leaf has been the perception that other countries in western Europe have similarly struggled, although none have yet to surpass the UK's mortality rate. Yet the shambolic procurement and distribution of PPE, the lethal decision to discharge Covid infected patients into care homes, the risible Test and Trace procedures that leave many health staff needlessly self-isolating, and the ballooning lists of untreated ailments other than Covid are all outcomes in which the NHS leadership has had a hand. It would be fair to say that the UK has erased a decade of growth and taken on its biggest level of public debt since WWII in order to prevent 170,568 bed spaces being filled too quickly, an outcome premised on inaccurate modelling, incompetent planning and institutional panic.
Naturally, the working assumption of those like the Health Secretary, Sir Simon and their cohort of advisers and on-message statisticians is that the proles are neither able nor can be arsed to work out where things are going wrong. The latest attempt to bamboozle citizens is the fatuous determination to "Save Christmas", as if the jingle of sleigh bells and a 72 hour "window" in which we may hug members of our extended families wipes the slate clean. Are we really so stupid?
Despite the increasing tone of exasperation in the printed media and the steady loss of public confidence in the strategy to deal with Covid, it seems pretty clear that the pandemic will subside and will either be ameliorated by a vaccine or reduced to a recurrent ailment (such as influenza) which could be dealt with calmly and without destroying the economy and other people's livelihoods in the process. The bigger issue is whether or not the UK is able to afford a return of the NHS to "business as usual" or if that was desirable even if it could.
Being married to a former state-registered nurse, medicine-on-TV is a staple of our cultural life. So here are a few observations about what the last 12 month's worth of documentaries have (sympathetically) portrayed about "our" NHS:
- A viewer could be forgiven for thinking that the Health Service is entirely about hospitals, an impression massively reinforced by the top priority given to them by Covid. GPs, health care workers in the community, care and respite homes, mental health specialists, health charities? Forget it : too dull.
- Hospitals are a conglomeration of cottage industries gathered under one roof. The advances made in medicine and the growing range of treatable ailments have spawned a hive of specialisations with their own ever increasing demands for resources. Yet while some units (like the Alder Hey children's hospital in Liverpool) are centres of excellence, others manifestly are not. Or to put it in bureaucratic-speak, "Outcomes vary across the UK".
- Medical outcomes are as much about what the NHS wants as what the patient needs. Specialisation brings its own status and consultants and the hospitals which they serve are not averse to being regarded as stars if they are both literally and metaphorically at the cutting edge. So Alder Hey will do expensive ground breaking "cranial reversal" surgery on one poor mal-formed mite, but has binned the performance of a simple procedure to reverse a "pigeon chest", a more prevalent and uncomfortable syndrome suffered by many adolescents as well as older adults.
- If you are ill and require hospitalisation, to have a better than even chance in the lottery of likely outcomes, you generally have to live in the right area. More importantly, you need access to a bed.
- There is not a single documentary (either pre or cum Covid) that does not contain extended "drama" about the hunt for bed space. At heart is the daily but not insoluble problem of allocating resources between elective procedures (planned) and emergencies (unplanned, but not difficult to anticipate). There is always a sequence with consultants pleading/ admin staff pencil sucking/ ward managers negotiating/ practitioners warning / trust boards whingeing and bean counters complaining. And at the end of it all, there is the inevitable sight of a highly paid specialist medical team being idled and of a patient, often in great discomfort, being sent home or being telephoned to say that, yet again, their op is being postponed or cancelled. Or being brought into hospital, there to wait (quite literally in one episode about London's Royal Free), for weeks on end. When it comes to the planning of bed usage, hospitals are like zoos where every animal is let out at feeding time at exactly the same moment.
- Naturally, if a child was in charge of the NHS it would see with great clarity what was needed - more beds. But you don't get to run your bit of the (pre-Covid) £145bn annual budget without being able to complicate things such as you can justify your huge salary and your army of expensive management consultants, non medical "executives" and administrators. Every documentary has a sequence with a Chief Executive Officer (Trust, Hospital, Department - take your pick), a Director of Operations, a Clinical Operations Manager, a Service Manager and/or some other health authority panjandrum furrowing their brows. And they all have their own expensive staffs and agendas that seem to bear little relevance to clinical outcomes except in the sense of arbitrarily set targets. In today's NHS, non medical admin staff make up 37% of the workforce. In 1946, the proportion was 7%.
- A child would also perceive that although there is a profusion of important sounding titles in a hospital, no-one really seems to be in charge. In today's culture, being seen to take a grip of things is perceived as a sign of bullying or of showing a "micro-aggression" or some other form of "disrespect". So in hospital, things get done by a laborious process of back-scratching, favour calling, muddling along and low level politicking - all of which takes time and money and where the patient seems almost incidental to the process. But this being 2020 Britain, inefficiency is taken as a mark of compassion.
- The term "nursing" should perhaps be -re-defined. Nearly every sequence involving a nurse sees him or her either administering a procedure or sitting frowningly at a "workstation" in front of a computer. There is only very rarely a scene where they are doing something mundane yet vital, like making a patient comfortable in bed, helping them to feed or wash, stroking a hand or offering some cheering words beyond those which other ears may find patronising. Nursing is now a degree-strength discipline, with all the demand for additional reward, advancement and status that that implies. The care of patients seems increasingly to be part of a route map to further credentials, rather than a vocation in its own right.
- What is "free at the point of use" is open to abuse. Folk turning up at A&E because their child is a bit "under the weather" or people asking for condoms because they've run out. The time wasters and those who self-diagnose. The callers of ambulances because they've split up with a partner and feel "suicidal". Persistent trouble makers at hospital who turn up demanding attention and threatening staff. Happily, they are outnumbered by those folk patiently waiting for attention and who seem amazingly stoical (mostly the elderly) when they get bad news and almost pathetically grateful when it is good.
- Covid is taking a heavy toll on hospital services, but not necessarily in ways you might expect. Even though the Nightingale Hospitals were erected at great expense, there seems to be an extraordinary reluctance to use them, not least to isolate the treatment of the most seriously infected Covid victims. Instead, hospitals are still trying to run themselves as before, except for a massive reduction in service as they follow laborious safety protocols to accommodate the actual or likely incidence of Covid. Unbelievably, testing of NHS staff is still not routine and until very recently, hospitals were allocated a preposterously low number of "rapid" tests which can only be used "in an emergency". As a result, many practitioners are having to needlessly self-isolate and the pandemic has spawned a whole new layer of administrative intervention as managers try to work out who has been in contact with whom among medical staff. There is a growing incidence of patients going into hospital, only to get Covid whilst there.
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