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The NHS in the age of anxiety: rhetoric and reality—an

essay by Rudolf Klein

A dangerous gap is opening up between rhetoric and reality as the NHS faces a grim fiscal future,

Rudolf Klein argues. High flying ambitions for transforming the NHS are not matched by

achievement, and austerity will compel a new agenda of minimising harms rather than maximising

benefits

Rudolf Klein emeritus professor of social policy



Statistically there does not seem to be much wrong with the

National Health Service. At the turn of the year, the Department

of Health could report that “key performance standards” had

been maintained even as fiscal austerity began to bite.1 Some,

such as hospital infection rates, had even continued to improve.

Further, the department expected the NHS to have passed the

halfway mark towards achieving its £20bn (€23bn; $31bn)

savingstarget by the end of the 2011-12 financial year.2 A more

recent sample survey also suggests that there has been no

deterioration in performance, bar a marginal increase in the

number of patients waiting for more than four hours in

emergency departments.3

Organisationally, too, the NHS seems to be a success story. It

has successfully implemented the disruptive and distracting

Lansley programme of change. Thisinvolved closing down 170

organisations, creating 240 new ones, making 10 000 staff

redundant, andthenre-employing2200of them.4 NHS England,

as the NHS Commissioning Board has chosen to style itself, is

now in charge of the service, churning out instructions,

consultations, and exhortations at a manic rate. Yet it would be

surprising if the public and patients noticed any difference in

the way the NHS operates, so smoothly managed has been the

transition; it is those working in the service who have absorbed

the shocks and pain of change.

Bad news stories

But, of course, there is another story to be told: that of the NHS

stumbling into crisis. The three volumes, 1781 pages, and 290

recommendations of the Francis report into failings at Mid

Staffordshire trust5

fell heavily on the public consciousness. If

so many changes were needed in order to ensure patient safety,

what had gone wrong with the NHS? If a cultural revolution

was called for, what did this say about the staff of the NHS and

the system within whichthey worked? Subsequentlythe Keogh

review confirmed anxieties about standards, even while being

careful to avoid making dramatic recommendations on the basis

of a small sample of trusts.6 And the launch of a campaign by

the chief nursing officer to promote “compassionate care”

provided little reassurance.7

If a campaign was needed to

promote such core values, what had happened to the NHS?

Then there is the drip of bad news. NHS Direct withdrew from

its contract as a major provider for the NHS’s newly revamped

telephone advisory service for the public, raising doubts about

the viability of a project designed (among other things) to

prevent panic visits to emergency departments. Barts Health,

the country’s biggest NHS trust, brought in management

consultants to help it deal with mounting financial losses; staff

cuts are expected. The House of Commons Health Committee

reinforced anxiety about emergency servicesin a highly critical

report.8 And so on. Above all, it became clear that the fiscal

squeeze on the NHS was getting ever tighter and set to continue

into the indefinite future, as the target of achieving £20bn

savings by 2015 to fund demographic and technological

pressures out of a standstill budget was raised to £24.25bn to

be achieved by 2016.9

Ministers, of course, find justification for their policies in the

fact that the NHS seems so far to have survived both

organisational turmoil and fiscal austerity without any

conspicuous deterioration in performance. Conversely, their

critics pick on the signs of a system under stress as the

indictment of unnecessary organisational change, compounded

by an excessive emphasis on competition. Given the

impossibility of separating out the effects of the government’s

organisational policies for the NHS from the impact of fiscal

pressuresonthe service, I willnot attempt toadjudicatebetween

the competing interpretations. In any case, given that variation

within the service is the norm and that different dimensions of



performance do not necessarily march in step, it is possible to

make two contradictory statements about the NHS, both of

which will be true. Instead, I will focus on three areas where a

dangerous gap seems to be opening up between rhetoric and

reality.10

Swimming through treacle

What the NHS needs, everyone agrees, is “transformational

change.” The prescription is clear. Specialist services have to

be centralised; community based services have to expand to

reduce demands on hospitals; there hasto be greater integration;

the mutual interdependence of health and social services has to

be recognised. There is little new about this programme. The

various policy themes can be traced back over the decades. So,

for example, the reorganisation of the NHS in the 1970s was in

part driven by the desire to facilitate cooperation between health

and socialservices, while in the 1990s an ambitious programme

for improving primary care services in London was launched

in the hope of reducing the capital’s over-reliance on hospitals.

The new element is a sense of urgency: without such

“transformational change” how isthe NHS to survive in the age

of austerity?

But reality is lagging behind rhetoric. Successive reports from

the House of Commons health and public accounts committees

have shown that it is the freeze on NHS pay and the reduction

in the prices paid for healthcare that account for most of the

savingssofar achieved. Toooftenthe measurestaken, thehealth

committee argued, “represent short-term fixes rather than

long-term service transformation.”11 “The Department has not

yet convinced the public or politicians of the need for major

service change or demonstrated that alternative services will be

in place,” the public accounts committee concluded,2 while also

pointingout that “The existingpayment mechanismsinthe NHS

were designed to incentivise hospitalsto carry out more activity,

and do not drive service transformation.”

The difficulty of achieving change should come as no surprise.

In many respects the NHS is a constituency for the status quo:

witness the coalitions of professionals and public that mobilise

to resist threatsto localservicesin campaigns which may stretch

over the years. If the NHS’s resilience in coping with

organisational turmoil, noted earlier, is one side of the coin, its

ability to absorb change without greatly changing is the other.

Thus both Margaret Thatcher’s introduction of the internal

market12 and Tony Blair’s resurrection of it13 disappointed the

hopesof their advocates andconfoundedthe fearsof their critics.

The NHS did not become a model of efficiency overnigh nor

did it become a competitive jungle.

If achieving change in the NHS was difficult in the years of

plenty, it becomes doubly so in the age of austerity. In the years

of plenty, new developments—investments in primary care,

say—couldbe fundedoutof the annual incrementsinthe NHS’s

budget. Everyone could gain. Now it has become a zero sum

game. Inevitably there must be losers.

NHS chief executive David Nicholson and his colleagues at

NHS England must surely be more aware than anyone that

exhortation alone will not remove obstacles to change. But the

rhetoric of transformation has yet to be translated into an

analysis of how to overcome the institutional obstacles and

perverse incentives that stand in the way of its achievement, let

alone into the political will to risk the unpopularity that might

be involved in, say, streamlining the process of closing down

services.

Overflowing ambitions
The gap between rhetoric and reality in the case of
“transformational change”becomes ayawningchasm if we turn
to the government’s mandate for the NHS.14 The mandate is the
key document in the new, hands-off relationship between the
secretary of state for health and the NHS. It is, in effect, a
contract defining what the secretary of state for health expects
NHS England to deliver by 2015. It sets out the outcomes that
the NHS is expected to achieve and thus defines the currency
of accountability against which the performance of not only
NHS England but also clinical commissioning groups will be
judged.
In many respects the mandate is a welcome and radical
innovation. It replaces targets with outcomes. It makes the
government’s policy goals explicit: if, in the first place, the
mandate is a tool for ministers to call the NHS to account, it
can in turn be used to call ministers to account for their
stewardship. Moreover, the fivepriorityareas where the mandate
expects “particular progress to be made” offer reassurance to
those who see the coalition government as a set of hard nosed
privatisers, intent only on dismantling the service. The priorities
are improving standards of care, and not just treatment,
especially for older people and at the end of people’s lives; the
diagnosis, treatment, and care of people with dementia;
supporting people with multiple long term physical and mental
conditions;preventingprematuredeathsfrom thebiggestkillers;
and supporting people with health conditions to remain in or
find work.
In addition, the mandate sets a number of more specific
objectives for NHS England, such as ensuring that the NHS
becomes “dramatically better” at involving patients, that the
incidence andimpactofpostnataldepression“isreducedthrough
earlier diagnosis and better support,” and that everyone will
have online access to the health records held by their general
practitioners by 2015. The list could be extended; the point is
simply to illustrate the variety and width of the policy ambitions
setout inthe mandate. Andcruciallyprogresstowards achieving
those ambitions will be measured using the NHS Outcomes
Framework15: a compendium of indicators. NHS England will
be required to “demonstrate progress” against “all of the
outcome indicators in the framework—including, where
possible, by comparing ourservices and outcomes with the best
in the world.”
In a world of plenty, with NHS budgets rising year by year, this
programme would rightly prompt cheers. How realistic is it,
however, to expect the NHS to improve on so many fronts in
the age of austerity, when simply maintaining existing services
and quality will be an achievement? True, the mandate does not
specify how much progress will be expected. There is wriggle
room. But there is no attempt to specify an order of priorities
between competing policy objectives. If choices have to be
made between the many desirable objectives set out in the
mandate—as they surely will—what are the criteria to be used?
Instead of answering this question, the mandate offers only the
rhetoric of all embracing, aspirational ambitions. It contrasts
starkly with the bleak warning that the “challenges of the future
. . . threaten the sustainability of a high quality health service,”
from Nicholson and the chief executives of a gaggle of NHS
agencies when launching a national debate about the future of
health and care provision in England.16 Some “tough decisions”
are required, they argue, if the NHS’s future is to be guaranteed,
even while excluding consideration of what may turn out to be
the toughest decisions of all—such as, whether more incom


shouldbegeneratedbychargesor the whether the scopeof NHS
services should be cut back.
The government has been trawling for public views about
“refreshing” the mandate. But it is not refreshing but shredding
that is needed if the mandate is to close the chasm between
rhetoric and reality. A new document might start by addressing
the question of how “tough decisions” will be taken and by
whom: will ministers take responsibility or are they hoping to
cascade responsibility (and blame) down the line in the name
of devolving power and promoting local autonomy?
Paradox of plenty
Twointertwinedthemeshave shaped muchhealthpolicyrhetoric
and action over the past decade and more. On the one hand there
has been the quality theme. On the other hand, there has been
thepatient empowerment theme. The commonelementhasbeen
an emphasis on transparency, and the outcome has been a
statistical striptease by the NHS, unveiling its activities in ever
greater detail. Not only is more information available than ever
before, but it is also more accessible than ever before.
The logicdrivingthisdevelopment ispersuasive. Transparency
exposes poor quality care, while the threat of exposure helps in
turn to prevent it. Data about hospital performance not only
informs patient choice but also acts as a spur to quality
improvement as patients gravitate towards consultants and
hospitals with the best record. The arguments for greater
transparency in the name of quality and patient empowerment
are mutually reinforcing. Unsurprisingly, the Berwick review17
charged with distilling the lessons to be learnt from events at
Mid Staffordshire, endorses this consensus in its decalogue of
recommendations: “Transparency should be complete, timely
and unequivocal.”
To illustrate the explosion of information, consider the NHS
Choices website and the information it offers about local
hospitals: user ratings, the proportion of staff who would
recommend their organisation, responsiveness to patient safety
alerts, mortality rates, Care Quality Commission ratings, and
“friends andfamily” testscores. The mortalityratesof individual
consultants in a range of surgical specialties can also be
inspected. Or consider the information presented about each
hospital under review in the Keogh report. This included the
number of “never events,” the readings of the “safety
thermometer,” the ombudsman’s ratings, clinical negligence
payments, the incidence of pressure ulcers, the number of harm
incidents reported, consultant appraisal rates, sickness absence
rates. The list could go on.
Exposure of the NHS’s activities on this scale would have been
inconceivable even a decade ago. But it may be that the
rhetorical claims made on behalf of transparency need
qualification. How are would-be consumerstointerpret mortality
rates when the vexed question of their relation with avoidable
deaths remains to be resolved?18 What weight should they give
to the newly introduced friends and family test
score—enthusiastically hailed by the prime minister as ”a single
measure that looks at the quality of care across the
country”—when the results are based on an England-wide
response rate of 13.1%?19 More information may complicate
rather than enhance the ability of consumers to make choices
because they have to cope with an ever growing menu of
indicators,varyinginqualityandsometimespointingindifferent
directions.
Notonlyhastherebeenanexplosionof informationover recent
decades. But a succession of agencies, regulators, and
inspectorates have been set up to ensure patient safety and to