House of Commons: Queen's Speech debate on Health
WH Auden said that, "propaganda is a monologue which seeks not a response but an echo".
It is propaganda that is the main currency of the Secretary of State and his ministers. Rather than a rational analysis and honest appraisal of the current state of our health care we have the statistics which seem to patients and medical staff to describe a parallel universe rather than Britain's NHS in 2002 in Labour's sixth year of office.
Increasingly policy seems to be a series of knee jerk reactions from a Government increasingly panicking about its clear lack of delivery.
So before we drug ourselves on more Government promises, let's take a more rational view.
We can see the clarity of thought, the intellectual cutting edge with which Labour approached the task in 1997.
"New Labour is a party of ideas and ideals but not of outdated ideology. What counts is what works. The objectives are radical. The means will be modern."
"We will not return to the top-down management of the 1970s. So we will keep the planning and provision of healthcare separate, but put planning on a longer-term, decentralised and more co-operative basis. The key is to root out unnecessary administrative cost, and to spend money on the right things - frontline care."
"Under the Tories, the administrative costs of purchasing care have undermined provision and the market system has distorted clinical priorities. Labour will cut costs by removing the bureaucratic processes of the internal market."
So, have Labour returned to top down management?
Have they cut administration costs?
Have they distorted clinical priorities?
The problem for Labour is that they believed their own propaganda. There was nothing basically wrong with the NHS if only the wicked Tories would spend more money on it. And so, for five-and-a-half years they have thrown money at the NHS - billions and billions more.
And what have we got in return?
· Despite a 10.8% funding increase between 1998-9 and 2001-2, hospital admissions have only risen 0.9%, and finished consultant episodes by 2.3%. The average waiting time for a coronary artery by-pass graft is now two weeks longer.
· Still over 1 million on the waiting lists.
· 80,000 fewer receiving domiciliary care (Laing & Buisson).
· Emergency readmissions increasing - up 23,000 in two years (NHS Performance Indicators).
· An Audit Commission report states that in 1996, 73% of hospital patients in A&E were seen by a doctor within an hour; this has now fallen to 53%. Similarly, the proportion of patients admitted within four hours was 90% - and that figure has now fallen to 76%.
· 60,000 fewer care home places since Labour came to power in 1997.
· 77,818 operations cancelled last year - a 54% increase on 1997/8.
And our hospitals are so dirty in Labour's sixth year that 5,000 patients die every year from infections they contract while in hospital.
But in New Labour's parallel universe, everything must be rosy, so the response to bad news is to distort it, deny it, or fiddle the figures.
· One in eight hospital managers admits to distorting figures to fit government NHS targets. One manager stated: "All chief executives in the region contrived to make the same 100% return to the Department of Health on absence of waits in A&E. This was done with the encouragement of the regional director because we all agreed the requirement was meaningless" (BBC Online, 7 October 2002).
· Another example - knowing the their target of 2,000 extra GPs by 2004 was not going to be met, the Government have merged two targets into '15,000 new GPs and consultants by 2008' in their Delivering the NHS National Plan (BMA News, 18 May 2002).
· And another distortion - delays for cancer treatment as opposed to diagnosis continue to remain lengthy, despite Government bragging. The number of patients starting radiotherapy treatment within the Government's 4-week target fell from 68% to just 32% in 2000 (The Observer, 3 March 2002).
· And broken promises - £50 million for palliative care was promised, but only £4 million reached hospices (National Council for Hospice and Specialist Palliative Care Services).
What's more, the Minister of State had the sheer nerve to launch the announcement in a hospice in his own constituency, which has yet to see any money.
The result of all this centralisation, distortion and deception can all be seen in the plummeting morale of those who work heroically to keep the NHS running. And the deprofessionalisation they suffer can be seen in the workforce crisis now happening.
· 24% of nurses on the UKCC register are now over 50 and so eligible to retire soon. One third of all new entrants onto the UKCC register in 2001 were from outside the UK.
· NHS Professionals, set up to end the reliance on commercial nursing agencies, is in financial crisis with between £5-£10 million in unpaid bills, and relying on the very agencies it was meant to replace. It simply doesn't pay enough to build up a bank of nurses, since the private agencies still offer better rates (Nursing Times, 3 September 2002.)
· The RCN claims there are around 20,000 nursing vacancies still - roughly the same as the number of agency nurses working in the NHS on a normal day (BMJ, 7 September 2002).
· A third of new graduate nurses are not registering to practice (BMJ, 7 September 2002.)
· What about nurses leaving the UK? 6,021 in total left the UK in 2002, the highest for ten years, most heading for Australia or New Zealand. (Nursing Times, 2 April 2002.)
· Despite a Government pledge to recruit 2,000 extra midwives by 2004, the BBC reports that the number has actually fallen since the target was set. Citing the Royal College of Midwives, they said that there are now 45 fewer midwives than when the target was set (BBC Online, 27 September 2002).
And, if you think the nurses are unhappy, try the consultants.
Consultants have become increasingly disillusioned by the restrictions on their clinical freedom, the manipulation of waiting lists and the burden of red tape.
According to Professor Irving Taylor, Professor of Surgery at University College London, various bodies are assessing, appraising and validating his performance and activity:
· General Medical Council revalidating procedures
· UK Council for Regulation of Healthcare Professionals
· National Clinical Assessment Authority
· National Care Standards Commission
· Commission for Health Improvement
· National Patient Safety Agency
· Cancer Accreditation Teams
· Clinical Governance Committee
· Continuing Professional Development Committee
· Professional Advisory Panel
· Clinical Audit Committee
· Annual Consultant Appraisal
· Junior Doctors Hours Action Teams
· Pre-Registration House officer and Senior House Reviews for Postgraduate Dean
· Specialist Registrar Review for Postgraduate Dean and Royal College of Surgeons
· Internal Quality Assurance Committee
· Staff Review and Development Committee
· Annual University Appraisal
· Quality Assurance Agency
· Research Assessment Exercise
· Peer Review of Teaching
· Research Governance Committee
They have also been pressured to remove the longest waiters from the lists irrespective of clinical urgency. This has been done by failing to treat an increasing number waiting under six months and has resulted in the 'bunching up' described in the recent King's Fund report.
"Overall, this 'bunching up' of the waiting list distribution is to be expected: as long waits are squeezed, the numbers waiting shorter periods of time (between 6 and 12 months) will grow. The question is whether the squeeze can push waiting times back to the target maximum of six months by 2005. As more and more patients crowd into progressively shorter (but longer than six month) waits, it will become increasingly difficult to cut the longest waits. A concern will be the ability of the NHS to increase its level of activity in order to get patients through the system fast enough to make headway into the waiting list. Recent increases in inpatient and day case activity have been surprisingly small - averaging around 2% a year since 1997/8, but in 2000/01 only increasing by 0.8%. This is certainly too low to do much more than stand still given demand pressures, let alone reduce the number of people waiting over six months." (King's Fund Five Year Health Check, April 2002)
Consultants were also outraged by the clumsiness of the handling of the proposed new contract. In particular, they were upset by the Department of Health presentation which made clear that management would use the new contract to instruct doctors what work to do and which patients to see. It was made an issue by the infamous Slide 9 of the DoH presentation. Yet the Secretary of State, after all the fuss and the rejection of the contract said he had never heard of Slide 9 - which was either completely clueless or totally disingenuous.
But if you think there are problems with consultants wait till you get a look at general practice.
To meet their National Plan targets, the Government needed to recruit an extra 2,000 GPs between 2000 and 2004.
The net increase across the country in 2000 was 18.
The net increase across the country in 2001 was 18.
GPs increasingly look to early retirement to escape the burden of red tape and paperwork imposed by this Government. Fewer GP trainees are deciding on a full time GP career and the crisis of South Asian retirement will soon hit us. Most members will be unaware of this particular timebomb.
· Currently, one in six general practitioners practising full time in the NHS qualified medically in a South Asian medical school; two thirds are likely to retire by 2007.
· It is unlikely that doctors who qualify in South Asia will be a source of general practice recruitment in the future.
· The posts from which South Asian qualifiers are retiring may be more difficult to fill because they are often in practices in areas of higher need.
So the biggest problem will be in the areas of greatest need - no problem to the PM who thinks it's only hospitals that matter.
And no problem either in the Secretary of State's parallel universe.
And management is not immune from demoralisation.
The Government's bungling approach to the NHS has resulted in the paradox of a system which is under managed but over bureaucratised. In other words, those at the sharp end are not allowed to manage because of endless interference from the centre.
And is any of this the fault of the Secretary of State - why of course not.
He said on Newsnight:
"We have national standards in place, if we have poor performance that is because of poor management."
All this adds up to a picture of a Government that doesn't understand that in a free society you cannot force people into the professions - thy have to be encouraged yet they are singularly failing to do so.
Perhaps the most worrying recent figures was the fall in the number of those applying to study medicine.
Applications fell from over 13,000 in 1996 to under 10,500 last year. We had only 1.6 applicants for each medical school place.
So called modernisers - friends of No. 10. talk about greater economic freedom and more private sector involvement.
The dead hand of the Chancellor however seems set to kill any such ideas at birth. This was the background to the grubby and ultimately unworkable compromise reached recently by the Secretary of State and the Chancellor.