25 February 2016
Focus on Healthcare
A perspective on the hospital crisis
The author works in a junior management position in the NHS
The new contract set to be imposed on doctors across the NHS represents the tip of the iceberg in a much deeper crisis in Britain’s healthcare. The proposals set out by health secretary Jeremy Hunt are justified to the public as being about fixing a currently-existing healthcare crisis – that is that those going to hospital outside standard hours, especially at the weekend, are at greater risk. In reality, he has manufactured the idea of a crisis in order to obfuscate the real motivations for the current raft of health-care reforms.
Hunt’s arguments just don’t add up. First, the entire (public) justification for the new contract reforms are undermined by the very evidence Hunt calls on to support it. Far from identifying a drop in care quality on weekends, the academic research Hunt cites finds that patients are less likely to die on a Sunday than on a Wednesday. Hunt’s ‘weekend effect’ claim is really based on the fact that patients who enter hospitals at a weekend are slightly more likely to die within 30 days. There is no evidence that this has anything to do with staffing levels. Instead the only indication provided by the data is that patients who enter hospitals at weekends are more likely to be more unwell from the outset.
The second problem is that the proposed new contract actually threatens the weekend outcomes it is purporting to improve. By massively decreasing the number of hours considered ‘anti-social’, the new contract significantly reduces the incentives for doctors to work weekends and late evenings. It punishes the very doctors it is trying to encourage – the emergency services doctors who, more likely than any other, will be working antisocial hours. Lower pay for weekends means lower morale and lower incentives for new doctors to specialise in emergency care. This threatens to worsen an already developing staffing crisis, rather than mitigate it. By jeopardising staff levels on weekends, far from ‘saving lives’, the new contracts risk creating the issue they claim they are solving.
The backwards nature of the Government’s reasoning not only demonstrates harmful incompetence, but also suggests that there may be more to the issue than the ppoints which have so far been discussed. Once the facade of the debate about healthcare outcomes has been peeled back, it reveals a complex conflict between an overstretched health service and an ideology of austerity, all thrown around in the mixing pot of public opinion.
The Government’s approach to austerity has been to suggest that they can, to a large degree, get away with their cuts because the public sector is a bloated inefficient organisation. If they just stop feeding it so much, it will start to shed the unnecessary parts and become more efficient out of necessity. This was driven by an assumption that most ‘back-room’ and ‘managerial’ positions were just bureaucratic and unnecessary. To an extent this has proved true; across the public sector simple and often major efficiencies continue to be made. However, it turns out that many of these nuisance backroom staff actually do things like negotiating contracts, paying invoices, maintaining records, identifying efficiencies, and other such useful tasks that allow the smooth and effective running of hospitals or other public bodies, and allow the idolised front line staff to actually do their jobs.
All the while, the NHS remains remarkably underfunded, with the lowest percentage of GDP being spent on health-care of any country in the G7. There is also a recruitment crisis with under-enrolled medical courses and a massive number of qualified doctors deferring or abandoning completely their entry into full time public practice. On top of this there are obesity and mental health crises costing billions a year just to deal with fallout, with no possibility of actually fighting back. At the same time, public opinion is all for the NHS – any apparent cost-saving or reforming measure on it is met with vitriol from across the political spectrum.
The illusion that more or the same could be had for less and less and less has been shattered by the cold-face realities of modern healthcare. Doctors are already giving their all, and for the hours junior doctors work, their salary works out at being in the same ballpark as till-workers. This bloated public sector is already looking pretty emaciated, leaving Jeremy Hunt looking like a vulture, picking at any last morsels of savings he can get his hands on. From this position it makes perfect sense from a PR perspective for Hunt and his team to flip it and implicate the doctors in causing thousands of deaths for not working hard enough, while Hunt swoops in and saves the day with a new reformist contract.
The argument, which Hunt has historically been a strong and open proponent of, that the private sector should take much of the burden of healthcare is predicated on the assumption that the private sector manages better than the public sector. But there should be nothing inherent about working for the state or for private industry that determines managerial ability. What does have an impact is managerial ideology. The ‘profit motive’ of private industry is a positive ideology that is driven by some kind of growth and improvement. This means they are willing to invest in efficiencies, and cut back inefficiencies, because this leads to better ideological outcomes – more profit. The problem currently is that the Department of Health and the Government as a whole is driven by a negative ideology – austerity. Spending less for the sake of spending less, without any intentions to actually reform and improve beyond this, is only one way to deal with financial hardship.
If the Government remembered that they should be driven first and foremost by excellent public service, then this positive ideology could quickly lead to more positive outcomes. With it comes recognising the value of investment in health; this means not just investing in reforming the system to make it a more streamlined and effective service provider (the idea that investing can actually be a cost-saving tool), but investment in improved healthcare outcomes that don’t necessarily have a direct financial benefit. Every pound spent in healthcare keeps more people safe and well than the pounds spent on wars and weaponry – far more people die in hospitals every day than in terror attacks or on battlefields. When the Government is motivated by health-care outcomes rather than economic austerity, they will also find themselves on the same page as health-care professionals. This will not only raise morale, but the Government will also find that the standoffish attitude that has led to unprecedented strikes and animosity vanishes in favour of productive discussions with NHS workers who are committed to running the system more efficiently and economically. They are just waiting to be asked by people who share their intentions.
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