Command and Control

As the son of a Royal Naval commander, Jeremy Hunt was never going to be shy about commanding the NHS. In four years, he has become possibly the most controlling health secretary the NHS has endured. He picked and ‘won’ an entirely avoidably battle with junior doctors by persistently threatening to impose a new contract on them and then arguing in court that imposition was never his intention. The new contract is not being imposed, it is merely the only one being offered. In his conference speech, he pleaded with junior doctors ‘let’s not argue about statistics’ – or rather, who needs science when you can force changes through with ideology? Hunt has at least noted that Britain has fewer doctors per head of the population than 23 of its European neighbours, with gaps in rotas a persistent safety concern. Hunt’s antics may have driven some doctors out of the NHS, so now he is commanding his way out of trouble.

Hunt’s conference announcement to increase the number of doctors in training by ‘up to 1500 a year by 2018’ is welcome, but he didn’t say how it will be funded. The first batch won’t graduate until 2023/24, and won’t apparently be able to leave for 4 years unless they pay back their training costs. A bigger issue for workforce planners is that many doctors– both male and female – choose only to work part time in the NHS because the full-time workload is too unsafe and stressful. So a 25% increase in doctors in training may have much less impact than hoped, especially if some of the 25% of NHS doctors currently come from overseas leave, or a forced to leave, post-Brexit.

NHS nursing shortages are even more acute – there were 30,000 advertised nursing vacancies in January to March, compared to 9,000 medical vacancies. The government has removed the cap on nursing places but scrapped nursing bursaries, and Trusts are under such pressure to balance the books, safe staffing guidance has been buried and nurses are still having to care for far more patients than it is safe to do so. Irrespective of how many staff you train, you can only retain them is they feel supported, motivated and safe. No-one goes to work in the NHS expecting it to be easy, but the NHS has the highest levels of work related stress, staff illness, bullying and discrimination of any organisation in the UK. 26.8% of NHS staff have significant anxiety and stress – 50% higher than in the general population. And long-term, unremitting stress causes illness and even premature death.

Chronic staff shortages are driving the centralisation of services to fewer sites, with widespread unit and even hospital closures planned. The public will have little say in it all. Sustainability and Transformation Plans (STPs) have been developed with no public consultation for most NHS regions, along with 2 year planning guidance from NHS England with tough financial restrictions and a host of ‘system control totals, STP-level assurance and performance metrics and a strengthened STP wide risk pool.’ Very few doctors understand the jargon, never mind patients, but in essence NHS England chief executive Simon Stevens and Hunt are doing a strategic dance of death around the NHS debt to see who gets blamed if parts of the service collapse. Expect a lot of mergers, chains, federations and more desperate pleas to the private sector to step in and ‘outsource’ NHS services. Staff are generally not consulted in the process, merely told that their jobs and pensions have been outsourced.

And then there are the regulators. The Care Quality Commission and NHS Improvement expect excellence and efficiency in a service where demand grows by 4-6% each year but funding increases are a mere fraction of this. The burden of inspection is growing, and almost impossible for small practices. Spare a thought for Dr David Zigmond, a single handed GP in Bermondsey with an unblemished 40 year career, cared for and happy staff and patients and no serious complaints. In 2014 he had a very satisfactory CQC inspection but the bureaucratic requirements of his 2016 inspection were so great, he decided to be a conscientious objector and refused to comply with what he saw as a draconian, exhausting, industrialised tick-box process. Having got red crosses in nearly every CQC column, his practice was promptly closed down by NHS England. And yet having spoken to him at length, Dr Zigmond is just the thoughtful, insightful, rebellious and humorous GP MD would want for himself. Too much ‘clinical freedom’ can breed dangerous doctors, but too much command and control kills the spirit of rebellion. We should be grateful for junior doctors and Dr Zigmond.