Book review: Hunt’s dreary, well-informed, well-meaning book about the NHS will make not one jot of difference

24 Jun

ZERO: Eliminating unnecessary deaths in a post-pandemic NHS by Jeremy Hunt

“He who would do good to another must do it in Minute Particulars,” William Blake wrote. “General good is the plea of the scoundrel, hypocrite and flatterer.”

Yet politicians find themselves obliged to talk about the general good. They have to make speeches and issue manifestos about what they will do to make things better for the whole country, or even the whole world.

Although they often have no real idea about how to solve or ameliorate some problem, they have to pretend that they do. How easy, in these circumstances, to degenerate into a scoundrel, hypocrite and flatterer.

Once a politician aspires to, say, the presidency or the prime ministership, speeches and manifestos are no longer enough. A book is required.

Words like “future” and “hope” often appear in the title of this volume, which is unreadable.

Jeremy Hunt is aware of these pitfalls, and has sought with immense conscientiousness to avoid them. He knows that particular cases are more interesting than general moralising.

At the start of the book, he relates a thought which occurred to him a year into his six years as Health Secretary, at Margaret Thatcher’s funeral in 2013, as he listened to the eulogy delivered by Richard Chartres, the Bishop of London:

“He read out a letter she had received from a nine-year-old boy called David, to which she had replied personally. I sat there, and thought: In my seven months as Health Secretary I haven’t read a single letter from an NHS patient. If Margaret Thatcher had found the time to do personal replies as Prime Minister, couldn’t I?”

The Department of Health received more letters than any other government department. It employed 50 officials in the correspondence unit to draft replies, and to protect ministers “from the highly personal and emotional missives received from people who had experienced problems with their care”.

Hunt asked to see one letter a day to which he would write a personal reply:

“I didn’t know it at the time, but this request sent the department into a spin. Sir Humphrey-like meetings were held behind my back to work out if they could dissuade me from such a thoroughly dangerous idea. They saw their job as shielding me from such letters, not exposing me to them.”

He at length received a letter which said: “I am just writing to thank you for the fantastic NHS care I received…”

This, of course, was not the point, and at length he started getting some proper letters of complaint, which were “eye-opening and sometimes horrifying”.

Hunt reckons the problem is that when error is admitted, a search begins for someone to blame. This means mistakes are covered up, nothing is learned from them, and often the same mistake is repeated over and over again before anyone does anything about it.

Hence the horror of the Mid Staffs hospital scandal, which continued unchecked for four years. The whole system is designed to pretend things are better than they actually are.

All this can be stated quite briefly, and is already generally accepted. Atul Gawande, mentioned by Hunt, and others have written about the need, as in the airline industry, for mistakes to be reported, not hushed up.

Once Hunt manages to get a letter a day of complaint presented to him by the department, he drafts a personal reply to it. And he uses some of these letters to introduce each of the 15 chapters in his book: his method is to recount some monstrous case of neglect, before drawing some general conclusions about the need for a culture change within the NHS.

No normal reader is likely to have the stamina to read through all these cases. One soon feels one has supped too full of horrors, and has also had enough of clunky, inconclusive passages like this one:

“I put in place an ambition to halve neonatal deaths, stillbirths, maternal deaths and severe injuries which was very ably led by leading obstetrician Matthew Jolly and chief midwife Jacqueline Dunkley-Bent, which contributed to neonatal deaths dropping by over a third and stillbirths by a quarter over the last decade. I also set up a maternity scheme modelled on what happens in Sweden, to allow instant access to a settlement in maternity cases where the NHS knows a mistake has been made. It was designed to bring faster closure for families and prevent the frustration of long court processes. To my frustration, it was not up and running before I left my role and ended up being cancelled, presumably on cost grounds.”

When I was a child in the 1960s, I knew who my NHS doctor was, and he would visit me at home when I was ill. Dr Price was a comfort both to me and to my parents.

He behaved, so far as I can tell at this distance and through a cloud of the usual childhood ailments, as he would have done before 1948, when the NHS was founded. That was the tradition in which he had been trained.

Does anyone now know the name of their doctor? Hunt works round to this question, and on page 173 states:

“we need a decisive change in the model of care offered by the NHS, so that patients always have one doctor or nurse clearly responsible for their care. In normal circumstances that should be a patient’s GP, although for frail elderly patients it might be a district nurse.”

How right he is, but can such an outcome be attained by Hunt, or some other well-intentioned Health Secretary, declaring that it ought to be attained?

In the absence of a single doctor or nurse who takes responsibility for a patient’s care, the family try to act as champions, desperately trying to see that relevant notes from the past are presented to doctors new to the case, and to provide whatever the harassed nurses are unable to provide in the way of care.

But what a supplicant one feels as one goes about this task of asking the nurses whether they could possibly provide this or that, or simply tell one, on the telephone, what sort of a night the patient has had.

The melancholy paradox must be stated that to survive a stay in hospital, one needs to be feeling more than usually fit, even though one has been taken in because one is more than usually weak.

Hunt is full of good intentions. If he appeared at one’s bedside, he would be marvellously sympathetic. It would do one good to see his furrowed brow. One would be sure he really cares. One might even think that if he was in charge, the world would be a better place.

But as Health Secretary, he too was reduced to the role of supplicant. And his dreary, well-informed, well-meaning book will make not one jot of difference to anything.

The post Book review: Hunt’s dreary, well-informed, well-meaning book about the NHS will make not one jot of difference first appeared on Conservative Home.

The two variables that will predict the extent of the NHS winter crisis. And what we can do about them.

16 Dec

Over the last few weeks, and in the months preceding, there’s been a huge amount of media coverage about the NHS’s “looming winter crisis”. “The NHS staffing crisis is killing people – and this winter it will be even worse”, reads one paper, and you can expect fears to increase as we head towards January, when demand for health services normally peaks.

Clearly there are reasons to be worried about what lies ahead, due to multiple pressures on the NHS, which has been put on its level of emergency preparedness due to the Omicron variant. There’s the strain caused by the “twindemic” of flu and Coronavirus, both of which flourish in winter; the fact that millions of non-Covid procedures, including operations, have been scrapped to ensure that GPs and otherwise can focus on urgent needs and vaccinations; and there are staff shortages too. It’s estimated that the NHS has a shortfall of up to 100,000 employees in total, with vacancies for medical practitioners rising 15 per cent in the last year and seven per cent for nurses. 

Are we about to head into one of the worst crises on record? When I ask Dr Raghib Ali, Senior Clinical Research Associate at the University of Cambridge and a consultant at Oxford University Hospitals, where we are on a timeline of events, he replies “If you mean [by a crisis] ‘will the NHS not be able to deliver all services, as was the case in both the first and second waves, then that is likely – in fact, it’s already happening to an extent because some elective services are being cancelled in some places.” He explains that “the NHS is under a lot of pressure now because of non-Covid… we’re much, much busier than we were certainly in the first wave and, to an extent, even the second wave.”

Ali believes that there are a number of variables that will influence what January looks like. One is how big the backlog is of a) the people who avoid coming into hospital around Christmas and b) those currently staying away, in their own “voluntary lockdown”.

The crucial factor, though, is how effective vaccines are against hospitalisations for the Omicron variant. In short, the less effective, the more hospital beds will start to fill up. Ali says that we should have the hospitalisation data in around one to two weeks, which will mean SAGE – and the Government – is far more able to predict what kind of winter the NHS is in for, and whether it should take preventative measures.

Should the worst outcome prove true (that hospitalisations increase rapidly as a result of Omicron), expect Keir Starmer to use this to argue that the Government did “too little, too late”, even though he knows Boris Johnson would have an extremely challenging time trying to get any more restrictions through (judging by Tuesday’s vote). Were the Labour leader to be granted a vote on the measures, which he’d probably vote through, he could still take the view that they were introduced too late or not enough, as a means to knock the PM.

When I ask Liam Fox, also a doctor, about where we are in the “crisis” timeline, he says we have a chronic problem of under capacity. “I think the question we have to ask is why is it that the NHS seems at almost all times of the year now to be in what we used to call a winter crisis, and what does this tell us about the capacity of the system and the way it’s being run?” 

Fox cites two major factors that are destabilising the system. One is that “the NHS runs at a bed occupancy rate that is too high” which “leaves it lacking resilience” if demand changes suddenly (e.g. Covid patients increasing).

The other is medical practitioners’ “lack of ability to discharge patients who don’t need to be in hospitals” partly due to the closures of community hospitals and respite care – particularly in the 90s. He says that “we’ve been obsessed with increasing high-tech medicine, without considering convalescence as a concept”, which is – in turn – leading to imbalances in healthcare.

Similarly, Ali believes that part of dealing with NHS pressures means working out how to physically discharge patients (who have been medically discharged), who don’t have support afterwards. He believes that key to solving this is better funding for social care; and that this would be economically wise, too, as the cost of hospital beds being taken up by medically discharged people is probably more than the cost of paying social care workers more (who can look after them).

The Government has made a start on tackling this area. Hotels have been transformed into temporary care facilities, for one, and workers from Spain and Greece have been flown in to take care of patients. It seems ministers are well aware of some of the main ways to relieve the strain on the NHS, but they will come under pressure to create reforms for the long-term.

In conclusion, it’s impossible to predict whether the NHS was justified to move into its highest level of emergency preparedness, mainly due to the unknowns about the Omicron variant, which – in the best case scenario – could be highly transmissible, but less severe than others. There’s also the booster jab programme, whose success could radically change the situation. But the Government does know what structural remedies can help it avoid, as one paper put it, “the worst winter.”

A big question for libertarians: what would they do about obesity?

17 Jul

In the last few days, there’s been a lot of discussion about the latest instalment of the The National Food Strategy. Commissioned in 2019 by the Government, and put together by Henry Dimbleby, the co-founder of Leon, it contains radical proposals as to how to tackle the nation’s obesity rates.

Some of its most controversial suggestions are that we need salt and sugar taxes, that the NHS should prescribe vegetables and everyone should eat less meat. Hardly anyone likes the last idea, but libertarians have been vexed by the whole strategy – viewing it as the latest example of the nanny state gone mad.

Having combed through Dimbleby’s report (the second of a two-part strategy – intended to shape legislation in England, but also recommended for Wales, Scotland and Northern Ireland), it seems to me that much of the criticism has been unfair.

For starters, the document is 289 pages in length, so it’s a little ungenerous to write it off in one day. The reactions reminded me of when members of the Left immediately dismissed the Commission on Race and Ethnic Disparities report, which is 258 pages, on the basis of a few passages.

Some of the stereotypes about Dimbleby, too – that he’s a rich bloke, like Jamie Oliver, telling us plebs what to do – don’t add up, especially in the context of the report. Far from being bossy, large parts of it are about nature and ecosystems. And where it makes recommendations about food, it acknowledges the challenges for those on low incomes, whom it advises the Government to support more.

On a more serious note, the report has not come about because rich blokes have run out of hobbies. It’s an attempt to tackle a complex but devastating issue: the UK’s rising obesity rates. It points out that one in three people over 45 in England are now deemed clinically obese. You have to wonder sometimes if we have desensitised to these facts and our situation, despite all the warning signs (as the report points out, “[o]ur obesity problem has been a major factor in the UK’s tragically high death rate” from Covid-19).

There are many other things you could say about this report, but for the sake of one article, I have one question: what is the libertarian answer to obesity rates? Because at the moment it appears to be “do nothing” or sneer at the baddies who want to take away our Kellogg’s Cornflakes. Dimbleby and Oliver may not have the perfect answers, but what is our solution exactly?

I count myself as fairly libertarian, incidentally, but obesity is an area that challenges this philosophy. That’s because scientists have increasingly found that weight has a heritable component, meaning people have differing levels of willpower with diets. As the report spells out: “not all appetites are the same… in an environment where calories are easy to come by, some of us need to work much harder than others to maintain a healthy weight. You have to swim against the powerful current of your appetite.”

This corroborates with findings from Robert Plomin, one of the world’s leading experts in behavioural genetics, and author of the book Blueprint: How DNA makes us who we are. He points out that: “Twin studies estimate heritability of weight as 80 per cent, even though all the genetic data together estimate heritability as 70 per cent.”

In short, people are on different starting points when it comes to how easily they can control their weight (and I say that as someone who has to swim hard against the current), hence why telling someone to use willpower doesn’t always work.

Genes are uncharted territory for libertarians because all of our arguments centre around personal responsibility, free will and individual choice. Of course, these are all important things and many of us reject how much lockdown has taken them away. But there’s a big difference between politicians telling people to wear masks, and how people cope in an environment that encourages overeating, which our society does, especially should they have a predisposition to gain weight. We have to make those distinctions.

Even if we ignore research on genes – some people will say that my argument is fatalistic, wrong and that choice is paramount – it’s here and has already been embedded into public policy. Since 2019, the NHS has sold people genetic tests to spot risk for cancers and dementia. People underestimate how easily these tests can be extended into completely new areas (a test to estimate your risk for obesity), which could then be used to justify preventative measures.

While Dimbleby mentions genes creating differences in eating habits, it’s interesting that the report doesn’t delve much into medicine’s role in addressing obesity rates. Yes, the NHS could prescribe vegetables. But we have also seen drugs developed to help prevent obesity, and even a contraption that stops people’s mouths opening properly.

While I find the latter a rather horrible prospect, I think drugs and other medical solutions (gastric bands, for instance) will become more common and less controversial in years to come – the more we test the “willpower argument”, sugar tax, and move very little on obesity rates.

Ultimately, I don’t think The National Food Plan will make any substantial difference, as – shock, horror – it’s not radical enough. It’s also overly romantic in places, suggesting that school cooking lessons are part of the answer (as someone who did Home Economics for two years, I can’t remember any of the recipes. Boys messing around, however…).

But the report gets it right about environmental triggers and how these correspond with genes. And it has, at least, drawn attention to the urgent situation we are in. A situation to which the libertarian response cannot continue to be – as it seems currently – “let them eat cake”.

Stephen Booth: The Northern Ireland Protocol. A crisis is averted. But for how long?

1 Jul

Stephen Booth is Head of the Britain in the World Project at Policy Exchange.

Last week marked five years since the EU referendum. It was a seismic political event, and Leave/Remain political identities look set to continue to drive political changes across the country for years to come.

Most polling suggests that, in hindsight, most voters have not changed their minds about their 2016 decision. Nevertheless, both the Labour Party and the Liberal Democrats appear to see little political mileage in reopening the Brexit debate or mooting the prospect of re-joining. Perhaps this is because, while Remain and Leave identities continue to be strong forces in domestic politics, the question of actually re-entering the EU is a different matter.

A poll conducted last week by Opinium found that, when presented with four options, just 27 per cent think that Britain should re-join the EU. Of the other options, 22 per cent think we should negotiate a closer relationship than we have with the EU now, 20 per cent think the current relationship is about right and 22 per cent think we should form a more distant relationship. This suggests that future political debates about the EU are more likely to be about the type of relationship we have with Brussels and the various member states, rather than reopening the fundamental membership question.

In the here and now, the UK-EU dispute over the implementation of the Northern Ireland Protocol continues to rumble on since it came into force six months ago, and still threatens to sour the broader relationship. A range of issues are being discussed, including chilled meats, pet travel, VAT on used cars, tariff quotas on steel, medicines, and customs processes.

Last week, appearing respectively before the Northern Ireland Affairs and Foreign Affairs Committees, Brandon Lewis and Lord Frost repeated the Government’s position that the current state of play is unsustainable, due largely to the “chilling” effect on Great Britain-Northern Ireland trade, and that all options are being considered to deal with the situation.

Yesterday, the EU formally confirmed its agreement to the UK’s request for an extension of the grace period for trade in chilled meats, which has avoided an imminent potential ban on sausages and the like being imported into Northern Ireland from Great Britain. The agreement on the extension avoids a further escalation, which might have occurred if the UK had unilaterally extended the grace period, as it did with other grace periods in March this year. Meanwhile, the EU appears to have taken the view that a further public bust up isn’t in its interests at this stage.

However, the extension merely buys time over the summer rather than fundamentally resolving the situation regarding checks on food, or the wider Protocol, where the UK and EU positions remain at odds in many areas. The EU suggests the time be used for Northern Irish retailers to adjust their supply chains to source products from the Irish Republic and the rest of the EU – a further diversion of Great Britain-Northern Ireland trade. Meanwhile, the UK insists that the time be used to find permanent solutions that respect Northern Ireland’s position within the UK’s customs territory.

On Monday, Maroš Šefčovič appeared before a Stormont committee, and repeated the EU’s position that the long-term solution to reducing or removing checks on food and animals should come in the form of the UK adopting Swiss-style dynamic alignment to EU agri-food rules. This would, he has suggested, remove the need for 80 per cent of checks. The alternative model – a New Zealand-style mutual recognition of standards – would reduce checks but leave many in place, he added.

Yet, the fact that Switzerland and New Zealand each have their own arrangements would suggest that a bespoke arrangement for Northern Ireland ought to be possible. This is what the UK is proposing. Frost has rejected a Swiss-style approach, describing it as an “abrogation of sovereignty”, since the EU would insist on the “ability to police it through its institutions”, such as the EU Court.

Frost outlined to the Northern Ireland Affairs Committee that the UK’s proposal is based on a bespoke equivalence arrangement, whereby both sides acknowledge each other’s current high food safety standards, and if either side diverges from those standards, then the other side can increase checks and controls accordingly. Ultimately, this is likely to require the EU to change its own border rules, which Brussels has fiercely resisted up to now, insisting that any flexibilities must be agreed within the legal confines of the Protocol and existing EU law.

However, in a significant departure form that stance, Sefcovic told this week’s Stormont Committee session that the EU would be prepared to change its own legislation in the particular case of medicines placed on the NI market, which under the current terms fall within the purview of the EU, rather than UK, regulator. “We want to ensure that citizens in Northern Ireland have full access to all the medicines they need,” he said. “This will not be easy, as this would require a change of our EU rules but I am committed to do this important effort if it requires actual legislative change on our side.”

If EU law can be tailored for medicines, why not in other areas, since it is not only medicines that are a publicly sensitive issue under the Protocol.

poll of voters in Northern Ireland by LucidTalk for academics at Queen’s University Belfast, published yesterday, found that, while 67 per cent said they believe that Northern Ireland does need “particular arrangements” for managing the impact of Brexit, 43 per cent agree that the protocol is, on balance, good for Northern Ireland, whereas 48 per cent think that it is not. And, while 57 per cent think the Protocol provides Northern Ireland with a “unique set of post-Brexit economic opportunities”, by providing it access to both EU and UK markets, more than two thirds see the Protocol impacting negatively on political stability.

The UK’s current approach appears to be to grind away at the EU position, rather than adopt further unilateral measures at this stage. However, with the Protocol continuing to cause major problems on the ground, despite the current stop-gap easements in place, this position may be revisited in the autumn if the stalemate continues.

Luke Evans: While we all hope for a vaccine, we know that we will never return to pre-pandemic normal

22 Jul

Dr Luke Evans is a member of the Health Select Committee, and is MP for Bosworth.

Four months ago, around the start of the Coronavirus lockdown, the Editor of ConservativeHome contacted me to ask whether, as both a GP and a newly-elected backbench Member of Parliament, I would like to write a weekly diary about how Covid-19 would come to affect my constituency.

Of course, as any newly-elected backbench MP would, I jumped at the chance. It would hopefully be a way to give an insight into what goes on at the grassroots of backbench business.

But far more importantly, I saw it as an obvious opportunity to assess Covid-19’s impact on my constituency of Bosworth on a weekly basis.

I would have to step back and think for a couple of hours before picking up my laptop. That’s vital time which helps you to reflect and strategise about what you do next.

A space to breathe in a fast flowing, ever-changing situation.

So as Parliament breaks up for its summer recess, it’s a good time to reflect on the past four months – to ask what went well and, of course, what I could have done better as a new MP.

A chance to gather my office together. After all they have shouldered the load with me, and without their dedication, tenacity and expertise the situation as a new MP would be nearly untenable. Four weeks to simply focus on the constituency; clear the decks, reset, and prepare for the next phase.

Until September an uneasy hiatus, as we’re nowhere near the end of the Coronavirus story I fear.

I recognised right at the very start of these columns that I was fortunate to come from a medical background. I was able to understand the data, the system, the clinical constraints on staff and hopefully ask pertinent questions at the Health and Social Care Select Committee – and in the virtual Chamber of the House – while also raising ideas that were fitting to ministers and their departments, and where possible offering solutions.

That experience as a GP, I hope, meant that I was able to communicate those aspects effectively to my constituents. As we were learning about the virus at a rate of knots I was able to record videos about the differences between social distancing and shielding, and – even now the most effective weapon in our fight against the virus – good hygiene.

But it quickly became apparent that while this period in our history has been driven by a global virus, with far too many lives tragically lost, the medicine has only been one part of a much wider crisis.

Where I was comfortable in discussing the science the role of an MP is seldom that of a specialist. I had to gain knowledge in supporting businesses on the verge of collapse, constituents losing their jobs and – certainly not least – a world-renowned zoo fighting for survival.

Anyone entering politics really does need to know that at base backbench level, to serve your constituents you quickly need to become a problem-solving generalist. It should come a surprise to no one that in the past month I’ve asked as many questions about the economic impact of Covid-19 as I have about the medical one.

But as Parliament breaks for the summer our minds turn to what comes next.

Like everyone else I’m eagerly watching the promising medical breakthroughs that we have heard about in the past two days and hope that they come to fruition. While we all hope for a vaccine, we know that we will never return to pre-pandemic normal – this can be construed as a positive or negative, and we all have an active role in the preponderance to which it is.

Although we all have to be working for the best, we also have to be preparing for the worst. We must be mindful of the economic impact of the virus, how we begin to pay it back and the absolute need to protect younger people who may well bear the brunt through unemployment. All balanced with the plan to deliver on what we promised as Conservatives that lead to a large majority in the House.

I’m proud of how this Government has responded to the greatest threat to us all in living memory. Of course not all has gone to plan, and there will no doubt be lessons to be learned, but to be here with one of the best health services in the world and a growing economy is a huge testament to the work of the Cabinet.

So I leave Parliament for recess with a thought stuck in my head: what do we want our virus legacy to be?

I believe a question the public, businesses, politicians and Government all need to think long and hard about and actively make a choice. As a crisis creates opportunity now is the time to harness it for good.

I hope to return in September, rested, refreshed and ready to articulate a positive future for Bosworth and the country.