God Bless the NHS - The Truth Behind the Current Crisis, Roger Taylor, Guardian / Faber Books
According to the front cover God Bless the NHS reveals ‘the truth behind the current crisis’. This is something of an exaggeration, but Roger Taylor has written an interesting, wide-ranging and thought-provoking book. Its arguments are relevant to anyone who cares about the NHS and the debate about its future. A former journalist and co-founder of Dr Foster, Taylor is a lucid writer, with an ear for illuminating patient stories and reportage and an excellent grasp of what is involved in providing safe and high quality care.
The book was written in the context of three significant events. The first is the 2008 banking crisis. According to Taylor this not only put an end to any further increases in government spending on the NHS but has resulted in an effective 4% p.a. reduction in funding.
A second significant event is the passage of the Health and Social Care Act in 2012 which followed on the heels of four major restructurings by New Labour, and two under the preceeding government.:. Taylor is in favour of NHS reforms but no fan of the Act
“The political shenanigans over the Heath and Social Care Act have, in the main, been unhelpful. A largely unnecessary piece of legislation encompassing a largely unnecessary reorganisation of NHS structures, the act has been more of a distraction than a help in finding ways to make the NHS more sustainable”.
Taylor is not however a supporter of the Act’s opponents, as is evident from his discussion of a ‘Reclaiming our NHS’ conference which he attended in 2012.Critical though he is, Taylor’s analysis differs significantly from that of academics like Allyson Pollock who (in NHS Plc) emphasises the growing marketisation and privatisation of the NHS, the stripping out of public accountability and the reduction of the patient to the role of consumer in the marketplace.
God Bless the NHS is a different kind of book with a strong focus on culture, what happens in hospitals and how patients experience their care.
Each of these perspectives can learn something from the other. Accounts which focus on privatisation tend to pay insufficient attention to cultural questions, quality and safety issues and the experience of patients. God Bless the NHS, on the other hand, would be strengthened by a greater awareness of how government policies impact upon the culture of the NHS and what happens to patient care.
The most important influence on Taylor’s thinking is the Francis Report into the catastrophic failure of care at Mid-Staffordshire NHS Foundation Trust (Mid-Staffs). God Bless the NHS opens with an account of the press conference at which Robert Francis QC presented his report on Mid-Staffs. Several of the themes identified by Francis are also key themes of Taylor’s book. How can a health service allow standards of care to fall so badly without anyone taking this seriously or doing anything about it? Were the failings due to the action (or inaction) of individuals or did they stem from ‘the culture of the NHS’? Was Mid-Staffs an exceptional case or does it lie at the extreme end of a continuum ranging from excellent to awful care?
Politicians v the public
Taylor believes that despite some differences of emphasis between the last Labour government and the coalition, there is a general consensus among politicians about what needs to change in the NHS. The significant divergence is not between politicians of different parties but between the views of the political elite and policy advisors on the one hand and the public and the majority of people who work in the NHS on the other.
He examines three areas where the architects of NHS reform want to see change - getting doctors to decide how NHS budgets are spent, the drive to close hospital services and relocate them in the community or specialist centres, and the desire to involve more private sector organisations in delivering services. Taylor is aware that these proposals are contentious:
“To those engaged in designing the future of the NHS, these all seem like good ways to improve things. To much of the rest of the population, they appear self-evidently daft ideas that will only make things worse”.
Taylor’s solution? Politicians and NHS leaders need to convince the public of the advantages of reorganisation. In order to do this, they first need to know whether or not existing services are good and whether reorganisations will lead to improvements in care.
There is a real problem here. It is clearly important to know how good existing services are and about the likely benefits of proposed reorganisations for patients and local communities. But the question of what ‘good’ looks like and what criteria are used to make judgements about it are complex.
The divergence of views between politicians and advisors on the one hand and the public and NHS staff on the other is also problematic. The idea that metropolitan politicians are out of touch with public sentiments – that we have a democractic deficit – is commonplace in discussions of contemporary politics. But who will arbitrate on whether the politicians and advisors are right or whether patients and the public have equally legitimate, or even better prorities? And how can patient and public voices be properly heard?
Quality, safety and culture
Like Francis, Taylor places considerable emphasis on the culture of the NHS. He agrees with critics who argue that the NHS is an upward-looking organisation rather that an outward-looking one, that is has a ‘culture of blame’ and ‘public humiliation’ and that constant reforms are one of the biggest obstacles to improving care. Taylor also believes that the NHS subscribes to a ‘big lie’, that the quality of care is uniform across the country. This, he suggests, is one of the reasons why staff, patients and relatives often find it hard to speak out about poor care.
Many people understandably want to know whether a particular hospital is safe and which hospitals provide good care. These are not, however, questions which have definitive answers, according to Taylor. Hospital trusts, commissioners and regulators, as well as organisations like Dr Foster, collect vast amounts of information. But the people who run them do not always know how to interpret the data or what to do with it. Mid-Staffs, for example, was apparently aware of the high hospital standardised mortality ratio statistics, but instead of acting on this information the Board kept asking for more information.
Taylor has some interesting things to say about NHS statistics - the danger of box-ticking, the ease with which statistics can be manipulated, and the problems which arise when statistical evidence becomes a substitute for real world experience. He sees the Department of Health’s shift of emphasis from targets to outcomes as positive because the latter are more effective and harder to ‘manage by diktat’. Statistics can alert trusts and regulators to the possibility that something is amiss, Taylor argues, but they need to exercise good judgement, consider a wide range of information and means of interpretation, and seek opinions from diverse sources rather than work with a single unequivocal measure of success.
Recently, Furness General Hospital (part of University Hospitals of Morcambe Bay NHS Foundation Trust) has hit the headlines due to a high number of unexpected deaths of mothers and babies in its maternity services unit. Interviewed on the Today programme, Robert Francis found echoes of what happened at Mid-Staffs in accounts of Furness General. These include a lack of candour to patients, openness with the public, and transparency about what went wrong and why. In both cases there were regulatory failures. Francis described the Care Quality Commission as a closed and defensive culture in which people from top to bottom of the organisation felt unable to speak out.
Taylor’s analysis of NHS culture tends to lack context; the broader picture that Robert Francis painted. In his report on Mid-Staffs Francis points out that the Board’s preoccupation with financial issues and attaining foundation trust status led to cuts among nursing staff and a lack of awareness of the potential impact of proposed savings on the quality and safety of care. In discussing Furness General Francis also emphasised a lack of leadership; the adoption by management of a business model which has lost sight of the NHS’s main aim of helping patients; and insufficient involvement of clinicians, patients and the public in management. If Taylor had paid more attention to such contextual issues his cultural analysis would be stronger.
Taylor has little to say about the role of governors in foundation trusts. This is odd, given his belief that NHS organisations need to become more outward-looking and his emphasis on the importance of seeking diverse opinions when evaluating performance. A strong and independent-minded governing body can have a significant impact by giving voice to the views of patients and the wider public and helping to change the culture of a trust. Governors can also make a substantial contribution to improving quality, safety and patient experience, as I know from my experience as a governor at UCLH NHS Foundation Trust.
God Bless the NHS contains some powerful vignettes of patients and carers and Taylor is sympathetic to patients, relatives and others who encounter poor care in the NHS and want to do something about it. Julie Bailey, whose mother died at Mid Staffs and who founded the Cure the NHS campaign, is a striking example of this, her cafe providing a refuge for people who wanted to talk about what happened to them or their relatives at the hospital.
What kind of relationship between patients and healthcare professionals should we strive for? Whilst think tanks such as the King’s Fund emphasise the importance of partnerships between doctors and patients and believe that the patient should be seen as a member of the care team, Taylor goes further. In his view ‘the patient is – or rather should be – the captain of the team’. He also suggests that a doctor who is unclear about how to talk to a patient who has to make a decision should ‘try to imagine that the patient is your new chief executive’.
I find such claims bizarre and obfuscatory: a linguistic transformation of the patient who may well feel powerless due to illness, depression or isolation into an all-powerful ‘master of the universe’. As someone with complex medical conditions I greatly value having a partnership with my doctors and find the idea of being ‘the boss’ absurd.
Despite the failure of the national NHS IT programme Taylor believes that new technology is the way to develop a scientific approach to 21st Century health and social care and that having the information to do this is a first requirement. It is also crucial to his conception of the patient with power.
Tim Kelsey, another co-founder of Dr Foster who is now Director of patients and information at the NHS Commissioning Board, emphasises the importance of increasing transparency by sharing three types of data: making clinical quality measures and survival rates in 10 surgical specialties available; collecting Trip Advisor-style feedback; and giving patients online access to their GP records.
Taylor has ambitions beyond this. He is keen that electronic patient records should combine GP records with those of other health and social care agencies and be supplemented by patients’ own reports on their health. He is also enthusiastic about the quantified self movement which he believes represents a paradigm shift in the collection of personal data.
In a recent interview for a Radio 4 Analysis programme Taylor described the possibilities opened up when people are able to input data about different aspects of their lives, e.g. jobs, diet and health. He believes this will make it possible for them to analyse interactions between these areas, understand risks and modify their behavior. Such self monitoring will, in his view, enable people to improve their individual health while also contributing to ‘real-world’ evidence which will be available to health researchers and pharmaceutical companies.
I find this one of the most troubling aspects of Taylor’s thinking. Aside from the issue of getting the technology up and running, these developments obviously pose huge challenges. Increasing openness and transparency are essential, but there are big issues of privacy, confidentiality and ethics to be considered.
There are also issues of access. Hackney, where I live, has an older people’s reference group with 800+ members who use health and social care services. However only 1-2% of these have access to the internet or show any interest in being online. This illustrates the importance of finding ways to empower patients and service users who do not have, or want, access to online facilties as well as those who do.
Taylor’s concept of the individual is problematic. His vignettes of patients and carers are sensitive and evocative, but when he discusses patient empowerment he tends to become reductionist. It is important to remember that most patients are rooted in relationships, families and communities and that the majority of those that use the NHS are older people who often have several things wrong with them and younger people with complex conditions and disabilities. People’s social circumstances and the complexity of their health conditions can have implications for how they are treated and on the outcomes of treatment. They can also affect what they think about proposed service reconfigurations.
The quantified self movement also involves a reductionist concept of the individual and I find it scary as a basis for public policy. The idea that you can track, measure and analyse every aspect of yourself and share it with others to look for generalities and causal connections is both simplifying and dehumanising. It also has no regard for the expertise of professionals. A number of contributors to the Analysis programme discussed above expressed great aspirations for the movement. These were mostly geeky, enthusiastic and male. Others were sceptical, pointing out that self-trackers are giving up any narrative authority over their lives by sub-contracting this to technological devices; and that such endeavors have nothing to do with self-knowledge as they treat the self as a big data system.
If I had to choose between the quantified self and the examined life, which the psychoanalyst Stephen Grosz discusses in his bestselling book of the same name, I would opt for the latter. Talking, listening and understanding are, in my view, far more important aspects of the human condition than inputing data into smartphones, tablets and laptops. They are also, I suspect, better for our health and wellbeing.