Constitutional Crisis

Jeremy Hunt doesn’t want to be remembered as the health secretary who presided over the worst NHS performance figures on record. As doctors were gathering evidence of patients dying while waiting for emergency care, Hunt was refusing a reshuffle and grabbing extra responsibility for social care. Theresa May knows that NHS and social care services aren’t going to find the staff and beds they need to recover anytime soon. More than 33,000 nurses gave up working in the English NHS last year, a rise of 20% since 2012-13. Over 10% of the nursing workforce have left the NHS in each of the past three years. There are now more leavers than joiners. Hunt remains a convenient lightning rod for the anger that was supposed to be directed at NHS England CEO Simon Stevens.

In November, Stevens was warned by May that he would be held ‘personally responsible’ if the NHS went tits up over winter, but Stevens’ very public protestations that the NHS urgently needed an extra £4 billion this year gave him a convenient get out when the chancellor only gave £1.6 billion. Hunt has used the word ‘unacceptable’ for NHS failings under his 6-year watch more than any other health secretary, but at least he’s now publically admitted the NHS and social care needs a long-term funding settlement, rather than being bunged a scrap from the treasury at each crisis point.

Hunt’s new job title sounds grand but thanks to the Tory’s own Health and Social Care Act, he is an irrelevance to the running of the NHS, which has been devolved to NHS England. Hunt’s role is to agree a yearly mandate with NHSE which fits in with the ‘rights’ of the NHS Constitution and the ‘outcomes’ laid down in the Act. Each year, the NHS must improve on 1. Preventing People from Dying Prematurely 2. Enhancing quality of life for people with Long Term Conditions 3. Helping people recover from episodes of ill-health or following injury. 4. Ensuring people have a positive experience of care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm. Evidence of improvement is sorely lacking, particularly in premature death. Life expectancy in poor post-industrial towns and isolated rural areas in England has fallen by more than a year since 2011. People are dying from the same causes, but sooner than previously expected.

Hunt and Stevens are also bound by the NHS Constitution which gives English patients the ‘right’ to

1. be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality.
2. be cared for in a clean, safe, secure and suitable environment.
3. receive suitable and nutritious food and hydration to sustain good health and wellbeing.
4. be treated with dignity and respect, in accordance with your human rights.
5. be protected from abuse and neglect, and care and treatment that is degrading.
6. privacy and confidentiality
7. access certain services commissioned by NHS bodies within maximum waiting times

Many English NHS patients have had multiple constitutional ‘rights’ denied recently, and some will doubtless have died in doing so. Whether these rights will stand up in court remains to be seen. The tragedy is that the NHS does deliver truly exceptional care when it has the staff and capacity to do so, as the response to last year’s terror attacks illustrate. In emergency care, there is a golden hour for killers like sepsis, pneumonia, heart attacks, strokes and internal bleeding that relies on rapid diagnosis and a sequence of proven procedures that have to be done every time, quickly and consistently well. The NHS has got much better at doing this when it is safely staffed and patients are properly monitored in high dependency beds. But when critically ill patients are stranded at home, in the back of ambulance queues or down the end of a dimly lit corridor, it becomes impossible.

Hunt keeps repeating that the NHS came top overall of 11 countries in the 2017 Commonwealth Fund ranking of health systems but it came tenth for ‘health outcomes.’ Cutting the public health budget is not helping. The NHS scores highly for cost efficiency and equity because it does less of nearly everything, yet allows access to everyone. The total number of NHS hospital beds in England has more than halved over the past 30 years, from 299,000 to 142,000, while the number of patients treated has increased significantly and many are too sick for community care. The NHS is also facing a Brexit staff haemorrhage. We only need one health and social care secretary, if that, but we need 100,000 more clinical staff and 20,000 beds just to keep the Constitution afloat.