The NHS – a cherished institution?

The NHS is said to be one of our most cherished institutions.  At the same time, it has become one of our most popular punch bags.  Newspaper campaigns and populist headlines shout repeated criticism.  Politicians cite ‘declining standards’ to accuse their opponents of failed stewardship.  Selective quotes from regulatory bodies and international reports (such as the recent OECD publications) are used to support misleading assertions of poor quality.

From time to time individual institutions are found to be failing those in their care.  Over five years ago serious failings were uncovered at Maidstone and Mid Staffordshire hospitals.  The experiences of patients and families in those situations were appalling and unacceptable.  The Public Inquiry into the Mid Staffs situation, chaired by Robert Francis QC, described the situation there as ‘… the worst crisis that any district general hospital  in the NHS can ever have known’.

This failing has become a cloud under which it is difficult to defend or champion the qualities of the NHS.  It continues to colour all public debate.   But such failings should be seen as isolated events which can afflict all health systems, rather than as a distinguishing characteristic of the NHS as a whole.

Under this cloud, it is perhaps not surprising that politicians have adopted a critical tone in relation to the NHS and have sought to position themselves as being ‘on the side of patients’ in demanding better care for their constituents (of course, the very great majority of those who work in the NHS would see themselves also as ‘on the side of patients’).

This recurring tone has been applied to general practitioners and their ‘failure’ to provide urgent care services,  to A&E departments and their management of elderly patients, to the management of hospitals, and to the bureaucracy of appointments and admissions to hospital.

It is more surprising, and unfortunate, that a similar tone has been adopted by some leaders of the system on issues ranging from management of waiting times to consultant medical cover at weekends.  This tone appears to ignore the fact that operational performance reflects the longer term strategies and policies set by the central political and executive leadership.

The reality of the NHS’ performance is rather different from that so often described.  Some press reports have referred to the recent OECD 2013 indicators of health and healthcare to show the relative failings of the NHS.  Yet even a cursory reading of the OECD publication ‘Health at a Glance 2013’ shows a more complex (and in many instances more favourable) picture.

Examples (also selective) include the UK being one of the three countries with the lowest rate of admissions to hospital for diabetes –  indicating high quality overall management of the condition; being among the best three countries for managing the use of second line antibiotics in the community; being above average (and well ahead of, for example, Germany and Japan) in the acute management of stroke; doing better than a number of equivalent countries in rates of mortality from cancers of breast, cervix, and colorectum.

At the same time, the UK is consistently in the top rank of countries on issues such as equity of access, comprehensive coverage, responsiveness to need, patients’ involvement in their care, lengths of waiting times, efficient use of resources, and value for money.  Over the past decade the NHS has made significant achievements in bringing down waiting times, reducing MRSA and other hospital infection rates, and providing information on its standards to the public, such that it would stand up to any international comparison on these issues.

For any organisation to flourish and succeed, it must retain the confidence and trust of those who use it, and the pride and commitment of those who work in it.  All of these are under strain in the current climate.  It is the responsibility of those who lead the system, both politicians and executives, to maintain them.  This will not be achieved by assuming a position outside the system, pointing out its flaws and accusing others of failing to resolve them.

The high calibre of people working in the NHS is the basis of its success.  Many of them take professional pride in, and the satisfaction of, caring for the needs of others.  If those people feel that their commitment is not reciprocated, that their efforts are not appreciated, that their work is criticised and denigrated by those inside as well as outside of the system, then not only will the quality of their contribution decline, but so will the prospect of maintaining levels of recruitment to the service.

People should be able to talk to their friends with a sense of pride about what they do and the organisation they work for.  That pride should be fostered and supported by leaders across the system, politicians and executives alike.

The NHS employs over a million staff and costs over £100bn pounds a year.  It is a large and complex system. Its day to day operational management is governed by national policy and standards.  In such a system there will always be room for improvement.  There will be examples of inefficiency and waste to find.  There will be individual examples of failure.  But these require a coherent and collaborative approach from all parts of the system working in support of each other to resolve them.

One consequence of the current climate of debate and the positioning of politicians and leaders as champions of the patients whom the system is failing, is the temptation to introduce simple solutions to complex problems, to be seen to be doing something.  Such initiatives, which require a response from across the system, can cause a disproportionate amount of time and effort to achieve.  They can disrupt existing systems and processes with inevitable consequences of inefficiency and loss of focus on local priorities.  Recent examples of these include prescriptive statements on ‘comfort rounds’ on hospital wards, the introduction of the ‘family and friends test’, and the requirement for a single name of nurse and doctor above each bed.  These single initiatives in response to general concerns about lack of compassion or lack of accountability fail to recognise that there is no one simple intervention that will address such complex concepts.  In many circumstances, each of these examples may indeed be of benefit – but only when taken as part of a coherent approach combining longer term strategies with local operational circumstances, not as a universally applied sticking plaster.

The reputation of an organisation is critical to its success.  A good reputation is too easily lost and hard to recover.  The reputation of the NHS within the UK has been scarred by the Mid Staffordshire disaster.  Politicians, national leaders, and the system as a whole should work together to repair that damage and restore full confidence in what is internationally recognised as one of the UK’s strongest assets.   This does not mean attempting to cover over problems or difficulties.  The current drive across the NHS for greater openness, transparency, and the provision of information to help patients choose their care provider and be involved in decisions about their care is an example of the continuous improvement and international leadership that the NHS provides.

National bodies should refrain from setting operational tasks in apparent despair at the system’s inadequacies.

Politicians should champion the continued development of patients’ rights and system responsiveness by building on existing success not denigrating current performance.

The system’s leaders should recognise that local service performance reflects the quality of national strategy as much as local operational management.

High standards should be expected of all parts of the NHS.  Leaders and staff at every level should support each other in achieving them.