Our first Vice Chair, Sir Ian Kennedy gave the first Bob Sang Memorial Lecture in Camden during November 2010. In it he was invited to reflect on progressing person-centred care in the NHS. He also looked more widely at attempts to make the organisation work better in the past and why continual restructuring misses the point.
Sir Ian said that he wanted not to get into the bowels of systems for engaging patients but rather to take a bird’s eye view of the overriding aims and purposes. ‘I want to consider the place of patients in healthcare and how best to ensure that they get the care and respect they are entitled to.’
He asked what the advantages of patients having a voice in healthcare – does it improve the care, or is this a pseudoscientific assumption? But he said it certainly improved the level of kindness in the system.
The idea of the rights of patients has grown. It alarmed some people when it first appeared: the language of duty offered control – rights are much more challenging. At the political and policy level there has been an embracing of rights — and also the rights of patients to be in charge. Labour advocated the patient led NHS, while Conservatives have promoted the ‘nothing about me, without me’ motto.
This can be useful in some, but not all situations. Patients will not have the expertise in some contexts to decide the right sort of operation or the best course of action. But we must be careful that this isn’t used as an excuse to throw out ‘patient power’.
The Reality of the NHS
Lord Darzi describes the NHS as ‘islands of excellence in a sea of mediocrity’. There are surgeries and even hospitals where patients are empowered. We should share good examples – where something works we should send people to go and see them.
Mediocrity and scandals are also a recurring part of the culture, and we have just had another about the care of the elderly. Somewhere there will be a hospital providing terrible care as we speak. Where we are at is a very mixed picture: rhetoric good, reality either really good, lagging or really bad.
Many complain that altering the culture of the NHS is like ‘turning a tank around in the channel’ but that has been the case for sixty years and there have been repeated attempts at culture change.
Why haven’t things got better?
Would the NHS improve if patients had more power? There is some truth in this, although it is less so in services for children and young people. When we push people to the margins of society and call them ‘vulnerable’ we make them so, make it more likely they will be treated differently and poorly.
There’s no one key thing that will transform the NHS, but by analysing the situation, but this lecture proposes several suggestions.
A whistlestop history of the NHS
The first 25 years were quiet enough with doctors and matrons running the service and grateful patients tugging their forelock. Since then the service has been in a continual state of change, with each change flagged as the change. But nothing changed on the ground for patients.
Three factors were driving this:
Healthcare is expensive and consumes a huge part of the resources of rich nations – the ‘rationing’ word is banned, so people speak of ‘resource allocation.’ Who does the rationing and who gets the service in this situation?
There are powerful ideologies about and within the NHS. The NHS has become more and more politicised and all political parties want to be seen as its guardian. Consequently it is torn by disputes.
The Griffiths report consisted on 24 pages on the concept of management, replacing the idea that doctors and matron are in charge. The clash of managers and professionals continues to this day. Managers are there to give a cost effective service. For doctors that can easily translate into stopping them caring for patients and interfering with their care. This continues despite a doubling of NHS resources.
Changes, never change
The NHS is treated to changes, but never to change as a consequence of the other two factors. It is in the hands of politicians who want to make their mark. So they do things. Then in a few years more politicians arrive wanting to make more change. These tend to be always about structures and always done piecemeal.
How do we respond to this?
The NHS has to be out of the reach of political fashion. It needs a new constitutional settlement. With this arrangement the government would merely vote money to the NHS and leave it to it. This was Alan Milburn’s ambition, but he got drawn into micromanagement. In this scenario the Department of Health ‘grows up’ to become a Department of State, leaving the NHS separate. But to date, no politician has had the courage or wisdom to step back.
Service seems to have got lost as a central principle a long time ago. How far would John Lewis be a good comparator for NHS services in this area? Its staff are trained to be courteous and helpful. It’s goods are ‘never knowingly undersold’ – it offers value for money and its staff have a financial stake in its success. How can these sorts of ideas be carried over into the NHS?
The central issue is the culture. Care depends on a vocational commitment that is too often lacking – as in the recent case where nurses told patients to defecate in their clothes since they didn’t have time to take them to the toilet.
Leadership should have no tolerance for poor service and make sure that monitoring collects the right information to promote service. In this paradigm the cleaner needs to be as respected as the surgeon – hospital uncleanliness has often been traced back to undervalued cleaning staff with insufficient time and equipment to do their job properly. The classic ‘story of the two mops’ where a cleaner used the kitchen mop to also clean surgical areas because they would otherwise have had to pay for a lost mop out of their small wages, is a classic example of how it’s possible to spread infection and kill patients by undervaluing staff.
There is a great fear of the private sector in the NHS, because of perceptions that it might lead to its eventual dismantling. The three priceless things about the NHS are that it is mainly free at the point of need, funded by tax and offering an integrated service. However the private sector already plays a vast role: the key may be to define the areas where it can provide a better service, and where its pursuit of profit leads to a worse service.
In finding a way to a better NHS we may need to embark not on another reorganisation, but a more radical journey than we have bargained for.