Patricia HewittHealth Secretary Patricia Hewitt has found herself embroiled in a bitter dispute over job cuts in the National Health Service in the last week. Everyone is crying foul – patients, the Unions, the nurses (all BBC links) – but what is actually going on and who is to blame for all of this?

Firstly, the NHS has enjoyed a major funding boost over the last 5 or 6 years. Services have improved across the board – I think this is generally appreciated. If patients are asked what they think of the NHS and its services, they will tell you better things now than they did in 1997. There is some sort of a perception gap – those that have used the NHS think it is better than those that have not (see this column from Polly Toynbee for more). Hence I wonder whether part of the predicament has been NHS trusts just assuming that the investment is going to keep on coming, and hence their choice to recruit too many staff.

Secondly, the government has handled its response very badly. Patricia Hewitt, whose awful patronising manner is akin to a 1950s headmistress, blithely stated that the NHS was having its best year ever. Not really a sensible approach! She did however also say that the government was not going to write the NHS a blank cheque – quite right. But I am not sure that the communication betweent the Department of Health and the NHS trusts has really worked effectively.

Related to this is the third issue: communication and trust. In Britain everyone loves doctors and nurses – the darlings of UK public service – and dislikes managers and politicians. So when the nurses have a whinge about job losses, the public always assumes that they are right and that everyone else is wrong. Add Patricia Hewitt’s abrasive approach into the mix and matters become highly complex.

Last but not least is the thorny issue of reform. Part of the problem is that Britain still has too many people in hospital for too long, and the government has realised that this needs to be addressed. This BBC comparison of healthcare in Sweden and the UK is illustrative. Further, the push is for larger, more effective hospitals, rather than smaller hospitals that do everything. This leads to howls of indignation from inhabitants of small towns that might no longer have a hospital, or an A&E department. The government continues to talk blandly about how reform of the NHS is necessary, but they never seem to make it clear why the reforms are needed. The word reform seems to slip out of Blair’s mouth without a second thought.

So please, please let’s draw a line under all of this. The NHS needs to take responsibility for mis-management, the government needs to take responsibility for lousy communication, the health workers need to realise that their jobs need to change, and everyone needs to reach a decent consensus on the way forward. All the parties complaining at each other, as has happened this week, serves no-one’s interests.


  1. Just quickly:

    Agree about the impossibility of having a sensible discussion about the NHS in British politics. Any public discussion about any change at all is seen as likely to mean the end of the NHS and political suicide for anyone who does it. This just means all the changes happen without any public discussion – which is bonkers!

    Agree let’s not get too far into how local taxation should be reformed! Warning: party political point coming up: Everyone agrees the CT system is wrong, but only one party has said how it thinks it actually ought to work instead. The Government is all over the place about it – it’s currently undertaking a review of it, whose actual remit honestly is to review the outcomes of the last review they did about it, a couple of years ago! And none of this even starts to get into including funding local health services in it!

    On Postcode Lottery – the point is that that it’s the ‘Lottery’ half that’s wrong – ie that it is completely by chance (or rather by decision of an unaccountable bureaucrat) that you might be able get a particular treatment if you live one side of a border, and not if you live the other. But if local people make an actual decision through the ballot box that they want a particular service to be available, whereas the people in the next county don’t, they’re surely perfectly entitled to do that. Postcode Lottery Bad; Postcode Democracy Fine. A very ‘federal’ approach, in fact!

  2. Thanks for the super-comprehensive response! 🙂

    I think the points about patient focus are very valid, but it is a nightmare to manage to make this case in the UK media as (1) people tend to love nurses and hate politicians, and (2) I think people don’t distinguish between the needs of the profession and the needs of the patients in their own minds!

    I’m intrigued by your sentence:

    If local health services are supposed to be serving local people (and paid for by them as taxpayers) then they ought to be accountable to them.

    Healthcare does need to server the needs of local people, and indeed the taxation to pay for it might be raised locally. That would need a complete revision of the Council Tax system – a completely different topic alltogether, although I would tend to agree it needs to happen.

    But on the other hand, everyone bemoans the postcode lottery in the health service, and local people always have a moan about their local accident and emergency closing down. Good quality local healthcare, and what the population thinks it needs for good quality healthcare are often very different things.

    This comment does not reply to all of the points raised, but let’s hope for more comments here!

  3. A couple of points on this.

    First, it was the dynamic of the week and of the Government generally at the moment that determined that Hewitt’s address to the RCN was reported the way it was this week. This government has (rightly, in my view) ploughed vast amounts of money into nursing over the last few years. There are far far more nurses than there were a few years ago, and they are all much better paid than they were. The fact that some of these are now losing their jobs needs to be seen very very firmly in this context. And I am not an expert on NHS staffing, but as I understand it, there are plenty of new nurses being taken on in new areas – even if not in precisely the same jobs. So some nurses will lose their jobs and get other ones elsewhere – not a big deal. It all comes doen to the old question of whether public services like the NHS should be producer-driven or patient-driven. Should no NHS nurse ever be allowed to lose their job? Or should the service be focussed around providing services to the public, even if that means some moving jobs?

    The other point about what is really wrong with NHS management (this is the serious political point, sorry). The problem with the NHS is that it is far far too centralised. The NHS employs more people than any other organisation in the world, with the exceptions only of the Chinese Army and Indian Railways (interesting comment on relative priorities of the three nations, incidentally). And it is all accountable to one person – the (as Jon says) heavily nanny-ish Patricia Hewitt. Every single person who sits on an NHS Trust (the boards responsible for running hospitals and other local health services) – thousands of people – is appointed by her (now generally following the advice of a centralised NHS Appointments Commission). This is not only an incredibly inefficient way of running a huge organisation, it is a complete negation of democracy. Where on earth is the accountability? And anyone who has ever had anything to do with local NHS managers can attest to their complete bemusement and incomprehension at ever being asked to explain or account for any of their actions. (They retreat instantly into claiming it is about ‘professional judgement’ in how to handle patients: this is totally bogus: clearly it should be clinicians rather than managers making individual clinical decisions about individual patients, but policy decisions about which services should be provided, how much public money they should be given, should absolutely be a matter for public debate and decision).

    If local health services are supposed to be serving local people (and paid for by them as taxpayers) then they ought to be accountable to them. Local education and housing services are run by people directly accountable to local people who you can sack through the ballot box if you don’t like what they are doing (this may be happening to some of them next week). But if you want to look for the line of public accountability of NHS decision-making, the first person in the chain you come to is the Secretary of State. This is ridiculous. We need radical decentralisation of power over local health services to people who are locally elected and accountable.

    Light note to finish off after the heavy stuff: my view of nurses has not, I promise, been in any way influenced by going to Bournemouth last weekend, where the nursing conference happened this week. Obviously there were also some nursing exams happening in Bournemouth happening last weekend. I know this because as I came back on the train last Sunday, I could hear about half a dozen of them loudly re-running all the exams they had had over the weekend and how they had all gone. Annoying as this was, it was not nearly as either scary or alarming as the experience of sharing a carriage with six other nurses on the way down on Friday, who were clearly preparing for their exams by running through in very intricate detail multiple choice questions about various obstetrical and gynaecological matters!

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