James Gubb: Patients benefit from broadening boundaries of NHS care

ANDREW Lansley opened his account as Health Secretary with a statement of intent: "We need a cultural shift in the NHS. From a culture responsive mainly to orders from the top-down, to one responsive to patients, in which patient safety is put first." The problem is the same words could have been taken from the lips of pretty much every health minister since Aneurin Bevan.

Much is written about "culture" when it comes to the NHS. Where it is criticised, focus – as with Andrew Lansley's statement – more often than not turns to the damaging and de-professional-ising effects of central "command and control".

There is, of course, weight in this. Three reports commissioned by the Department of Health during the eminent surgeon Lord Darzi's time as a Labour government health minister showed the pernicious effects all too clearly: disengaged clinicians, closed leadership circles and a culture ultimately driven by compliance not innovation. And yet there is perhaps an even deeper cultural issue that is barely touched on: the aura surrounding "the NHS" itself as something approaching the untouchable.

There is, of course, a level on which this is entirely justified. Many of the values the NHS embodies should always be part of the framework of a civilised society. Universal, comprehensive, health care is something that should always be defended. It is as the architect of the welfare state, William Beveridge, intended: in return for everyone accepting a responsibility to contribute in their working lives, "medical treatment covering all requirements will be provided

for all".

But, in embracing the additional post-war ideal of nationalised provision, the NHS has also taken on a mantra of being a part of a "greater good". In one sense, this provides some much-needed civic glue. It has also been used in too many quarters as an excuse for inertia, complacency and false attachment to the status quo. As one interviewee in a study published today by the think tank Civitas put it: "Many people in the UK were brought up to behold the NHS as something almost infallible... these concepts stay with people and come out in unexpected ways, even when logically they know otherwise".

Three examples present themselves. One, there is an uproar almost every time a commissioning organisation proposes pulling a service out of a hospital or awarding a contract to a voluntary, private or even other NHS provider. Going outside the "NHS family" of providers is seen as a particular sin. Yet, if another organisation can offer a better service, at lower cost, all we are doing is denying patients and the public better health care and better value for money. There is no reason, for example, why care for many chronic conditions should be taking place in expensive hospital settings.

Two, the aura around the NHS inculcates a broader, and damaging, "us versus them" attitude between the NHS and private and voluntary sectors, that at times puts patient care in real jeopardy. One private provider said, after his company was contracted to provide care for the state, that "NHS doctors ignored the clinic staff at meetings, barred them from training courses and made it extremely difficult to integrate into the medical community". Yet, as King's College Hospital NHS Foundation Trust have proved with their recent joint venture with Serco in pathology services, patients could gain much from a partnership of talents.

Three, in stifling the competition that Labour attempted to inject into the health service, NHS providers have collectively enabled services offering a poor deal for patients to keep running, and isolated surgeons, in particular, from pressure to up their game.

One medical director said to us: "In the health service there just isn't the will to work too hard, because you can't get fired and you've got your pension. We need to embrace the idea that more work equals more security". Another described a shocking story of how surgeons take two-and-a-half hours to perform an operation in the NHS that they do safely in 45 minutes in a private hospital.

In his 1942 report, Beveridge was at pains to emphasise that "in organising security the state should not stifle incentive, opportunity and responsibility". The NHS as currently thought of is doing just this.

It is time for the coalition Government to focus less on endless structural change as a solution to the NHS's woes and focus instead on introducing a new public consciousness: not of the NHS as a culturally revered system of provision, but as a service that supports civil society through enabling all to access the highest quality health care. Who provides it should not matter: instead providers should compete on the quality of their service offering. Above all else, we need new entrants with new ideas to support us through tight financial times.

James Gubb is co-author of Refusing Treatment: the NHS and market-based reform, published today by think tank Civitas


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