The challenges of a changing NHS

Mark Ferguson

In the wake of the Francis Report into the shocking failures at Stafford hospital, it’s not an easy time to talk about Labour’s vision for the NHS. Of course we love the NHS – that is as true as the slogan is simplistic – but to truly be “the party of the NHS”, Labour needs to focus on the failures of the service to the same extent that we laud its successes.

Being the NHS party means being as aware of the problems with the system as we are of its successes. That’s not an easy thing for us to do. For Labour the NHS is our religion (with Nye Bevan as prophet in chief), and quite possibly the greatest thing that our party has ever achieved in office. But as the NHS has expanded, the size (and scope) of the health service has presented new challenges for governments of all stripes. With almost one fifteenth of the UK workforce working in the NHS (the world’s fifth largest employer) the NHS can’t run in exactly the way it was conceived by the saintly Bevan.

And of course it hasn’t.

As David Cameron told the Royal College of Nursing before the last election:

“We went from the NHSE to the DH. Then we had 28 SHA and then 10 SHAs. Then PCGs went to PCTs…the recent history of the NHS reads like a wretched bowl of alphabetti spaghetti and it has got to stop.”

Of course it didn’t stop at all. If you’re reading a Fabian pamphlet you don’t need to be told the story of the bungled ‘top-down’ restructure that followed – and the fact that it completely contradicted Cameron’s earlier assertion that such reorganisations of our largest national employers were a problem.

The question is – have Labour already unwittingly fallen into the same trap that Cameron did?

The party’s current position is that post-2015 we would repeal the NHS bill, but wouldn’t go through a “costly reorganisation” of the health service. On the face of it that sounds sensible – but there are immediate questions. What does repealing the NHS bill achieve if the restructure (which was the source of so much discontent within the NHS) is left untouched? And moreover – how does Labour change the NHS to meet the challenges of the future – in particular the huge challenges around adult social care – without a further restructure?

Since Labour party conference Andy Burnham has begun to sketch out the ways in which Labour’s approach to the NHS might be different should the party return to power. The idea of ‘whole-person care’ – essentially bringing social care under the NHS umbrella to create what we might one day call the National HealthCare Service – is now Labour policy. It should be applauded for being a necessarily radical approach to a problem whose seriousness cannot be overstated. But achieving this laudable aim is no small task. Provision of adult social care is fragmented, with funding and delivery spread across local government and with a large variety of suppliers. And that’s before we even begin to discuss the cost implications of ‘solving’ the social care crisis, which – as George Osborne will surely tell people in the wake of his inheritance tax u-turn – is not as easy thing to do.

So how does Labour face the challenges of the future without a major top-down restructure of the NHS? And is avoiding a restructure even the most preferable way of doing things?

In government our take on the NHS seemed so simple. It could even be summed up with just one word – more. More money, more choice, more doctors and nurses, more investment – and of course more targets. The exception to the rule of more was waiting lists – which would be fewer and shorter (an achievement which is often understated, and shouldn’t be. This was a target that worked).

But we were also responsible for a few other “mores” as well.

More unpopular NHS managers. More closures of popular local services (all fought against vehemently – even (perhaps especially) by Labour MPs). Both of which fed more disenchantment with the system.  And, of course, more centrally imposed targets that in some cases had an unexpected and harmful impact on the provision of care

Whilst people felt that the NHS was theirs – a right – they didn’t feel like they had any say in how it was run, and when decisions were made they felt like they were made by cold, calculating and remote bodies that few had heard of and even fewer understood. Not so much decision taken by head over heart so much as decision taken by spreadsheet alone. Such feelings were often most acutely felt when local A&E units faced closure.

Much time has been spent of late discussing the plans for such a closure at Lewisham Hospital under a Tory government, but the last Labour government wasn’t opposed to such closures either. I was one of thousands who marched against plans to close the Whittington A&E in north London in 2010 – which thankfully resulted in the preservation of the service (until 2013, where the whole depressing cycle has started again). As the secretary of state for health in 2010, Andy Burnham knows better than most how strongly such feelings are felt.

So if reorganisation of some sort will be necessary under Labour – and I think it’s impossible to make the kind of huge changes necessary to deliver whole-person care without them – how do we make sure that the changes address the problems that those on the ground see in the system?

The watchword for Labour’s reorganisation must be democracy, rather than the much vaguer notion of ‘consultation’. Targets have their place, but they should be part of a decision-making structure that empowers people to have a genuine say over how those most loved of local institutions – hospitals – are run. It was Andy Burnham who perhaps put the conundrum best, when he said that Labour had “a tendency to focus on numbers, not people”.  Labour’s next stewardship of the NHS must not make that mistake – and must learn the lessons from the campaigns that have sprung up to save and defend local hospitals – empower the community, appreciate the emotional power and resonance of the local hospital and most importantly – don’t ever think that targets are a problem free panacea. Because Mid Staffs is only the most obvious example of how that kind of limited focus can end up with a system that is blind to the kind of glaring failures that can reduce the quality of care received – and worse – cost lives.

The challenges that lie ahead for the NHS and social care are enormous – perhaps the greatest since the formation of the service. Think how much easier it will be to face down those problems alongside local communities, rather than being unfairly characterised as working against them. That must be Labour’s aim.

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The Fabian Society’s 2013 New Year Conference saw a wide- ranging conversation, which opened up new areas of debate across the contested territory of how Labour should govern. This essay features in Remaking the State – a collection of essays from some of the conference’s key speakers seeks to develop this discussion, exploring how we view the state. If Labour can be radical enough to build a different state that works hand-in-hand with the people of Britain, it could bring a seachange in the way that we define politics and policy.