Serialised in the Mail on Sunday on 27 February 2022.
Authoritative new book by LORD ASHCROFT and ISABEL OAKESHOTT says our health service is riven with gross inefficiency and the only way to save it is radical reform – not yet more billions.
Last summer, the NHS was awarded the George Cross by the Queen. In a handwritten personal message, she said: ‘Over more than seven decades, and especially in recent times, you have supported the people of our country with courage, compassion and dedication, demonstrating the highest standards of public service.’
Most people would agree with this sentiment, particularly in light of the heroic response of frontline workers to the coronavirus pandemic.
Curiously, in a development that says much about Britain’s relationship with its favourite institution, the perception that we had a deteriorating health service appeared to be turned on its head during the pandemic itself. The bleaker things got, the greater people’s adulation.
The NHS is often compared to a national religion. Even without a global health crisis, it perennially tops voters’ concerns, which makes the debate over how it is run and funded extremely sensitive.
Sadly, politicians and many of those who run the NHS wilfully deceive the public about the quality of service they receive.
The aim of our new book is to strip away such spin and paint a picture of the NHS as it really is: the good, the bad and the ugly.
It is only by knowing the truth that the country can demand better.
Extensive research among focus groups at the outset of the pandemic in March 2020, and again last November when the crisis eased, showed that people were impressed by the way the service had responded to an unprecedented situation. Nonetheless, most (rightly) believed the NHS is in a worse state than it was before the crisis began.
In our polling and focus groups, the prevailing view was that the pandemic had exacerbated existing problems – chiefly waiting times and differing standards of care between different parts of the country – and that things were unlikely to improve any time soon.
All this is true, as Health Secretary Sajid Javid recently acknowledged when he set out the extraordinary number of people who now face very long waits for hospital care.
The majority of the NHS staff work tirelessly. Undoubtedly, millions of patients receive care that is good, and thousands receive care that is outstanding, every single day.
The trouble is that millions of others do not, and the number of those who are failed is growing at the same time as taxpayers are pouring billions more into the system.
When the NHS was established in 1948, it had an annual budget of today’s equivalent of about £15 billion. Average life expectancy for men was 66 years, while women could expect to live to the age of 70.
Today, NHS England has a budget of £129.7 billion and rising, but male life expectancy is just under 80, while female life expectancy is almost 83 years. In 1948, the UK population was about 50 million. Today, it’s just under 70 million.
Pre-coronavirus, the NHS was dealing with more than a million patients every 36 hours, with more than 17 million hospital admissions and about 96 million outpatient attendances every year.
Much of that demand went unmet during the pandemic. Now the situation is very much worse. This is a whole new ball game. Maintaining the standard of care that everyone who works for the NHS would like to provide is becoming ever more challenging. Sometimes, it is impossible.
The public’s devotion to the service and its principles – that it’s available to everyone and free at the point of use – means ideas for reform are always met with suspicion. Crucially, we do not believe there is any case for diverging from the founding principles.
Even if this were desirable, no political party will do so. But change is necessary, and for the right change to be identified, we first need to define where we are.
To provide some depth, we carried out a special investigation into the state of health services in one particular part of the country. Prompted by disturbing evidence about standards of care, we selected the Isle of Wight.
Until very recently, the island was one of the worst-performing NHS Trusts in England and a dangerous place to be seriously sick.
An assessment by the Care Quality Commission (the independent regulator of health and social care services) in 2017 concluded that the trust was failing on multiple levels and was guilty of an array of safety breaches. Inspectors ruled that there were insufficient staff; medical care was inadequate; end-of-life care was ‘dire’.
Under a new chief executive, much has improved. But that is of cold comfort to relatives of the many patients who meet an untimely end in the island’s St Mary’s Hospital and many more who receive sub-optimal care.
During official investigations into 35 unexpected deaths in 2018/19, several themes cropped up with depressing regularity.
They included overcrowding; breaching A&E waiting-time targets; doctor shortages; use of agency nurses; poor staff communication; poor medical record-keeping; inexperienced doctors; clinical staff shortages; and inadequate IT systems.
These epitomise the sort of low-level bad care that takes place every day in the NHS alongside care that is fair, good or outstanding (often all in the same place).
Taken individually, the lapses are not very dramatic. Combined, they point to an organisation that lacks the basic systems and structures to guarantee a decent standard of care.
More sinister, in May 2019, the trust admitted to ‘failing terribly’ in not disclosing abnormalities over the deaths of patients.
The island’s coroner, Caroline Sumeray, said the trust failed to inform her of 20 serious incident investigations before the bodies were cremated, meaning the truth about how patients died, and the hospital’s role in their demise, could not be uncovered. After a period in special measures, the hospital’s official mortality figures are thankfully now in line with the rest of England.
However, many of the themes that contributed to the terrible failures at St Mary’s – including, shockingly, the reflex to cover up errors and distort the true picture – recur throughout the NHS.
It was while watching a woman having a life-threatening seizure that the then Health Secretary Matt Hancock was prompted to try to sort out Information Technology systems in the NHS. He was shadowing a team of nurses when an alarm went off at a bed, signalling a medical emergency.
The woman needed immediate attention or she would die. Yet critical minutes were lost in a frantic scramble to locate her medical notes. In scenes that would have been farcical had it not been a life-or-death situation, someone eventually arrived with the necessary records in a big box, which was wheeled into the ward on a trolley.
As the patient fought for breath, a female consultant stood on a chair and read out the notes to the assembled medical team, occasionally struggling to decipher the handwriting. Nobody except the Health Secretary seemed fazed.
The incident could have occurred in any NHS hospital. The truth is that hospitals are still working with hopelessly patchy, unreliable and outdated computer systems, leaving doctors and nurses making critical clinical decisions in the dark.
Unfortunately, Hancock’s efforts to digitise the entire NHS were somewhat derailed by coronavirus – though the pandemic showed how fast and effectively the machine can move in an emergency. The NHS app was rapidly improved and (for better or worse) online consultations became mainstream.
Nonetheless, parts of the NHS remain in the digital Dark Age, particularly when it comes to patient records. In the early 2000s, efforts to modernise the system ended notoriously in what a parliamentary committee called ‘one of the worst and most expensive contracting fiascos in the history of the public sector’.
Today, across the NHS, huge sums are squandered procuring software that is unfit for purpose and must then be upgraded, repaired or changed, usually by the same company that failed to provide what was required in the first place.
Mark Gordon, who spent years working as an interim chief operating officer in troubled NHS trusts, says the NHS ‘continually’ makes strategic errors commissioning the wrong systems or failing to train staff in how to use new software.
During his time at St George’s Hospital in Tooting, South-West London, the introduction of a system known as Cerner descended into chaos because people did not understand how it worked.
Gordon claims that as many as two million patient records were lost during the fiasco in 2017. As they pieced everything together, he says the trust identified a high volume of cases in which patients may have been put at risk or harmed as a result of failures to follow up clinical investigations or act on test results.
He says: ‘We started to find 300 patients a week who were potentially harmed, and that was only out of a sample of 650,000 of two million lost records.’
Following a ‘clinical harm review’ of 646 patients potentially affected by the debacle, St George’s admitted that 15 had suffered ‘severe harm’ – meaning ‘permanent or long-term damage’ – and four more had suffered ‘moderate’ harm, but Gordon is certain the real figure is far higher. ‘There were thousands of patients whose prognosis was either worsened or who were dead. It has been hugely covered up,’ he says.
Those in positions of responsibility have a legal ‘duty of candour’. In reality, a deeply disturbing culture of omerta continues to permeate the health service, especially in hospital trusts, meaning errors, abuses and failings are routinely covered up, and staff are fearful of speaking out.
Whether little or large, cover-ups are the norm.
Professor Sir Brian Jarman OBE is an 88-year-old academic who probably knows more about hospital mortality than anyone else in the world.
Now an emeritus professor at the School of Public Health, Faculty of Medicine at Imperial College London, he is best known for developing a way of measuring whether hospitals have higher or lower death rates than expected.
Jarman’s methodology adjusts patient data for factors such as age, gender, deprivation levels and whether patients were admitted to hospital as an emergency. The aim is to create a reasonable measure of the quality of care.
With depressing predictability, managers soon figured out that if they gave more patients a ‘palliative care’ code – meaning those patients were assumed to have come to hospital to die, and thus the hospital could not be criticised for failing to save them – they could dramatically reduce official death rates.
In another fiddle, hospitals found that they could reduce death rates by discharging dying patients to hospices.
Jarman claims that the Department of Health has been lackadaisical about rooting out such ruses. He says: ‘When I first developed the [high mortality rate] alert system with chief executives and medical directors of various trusts, the Department of Health did not want to receive it. The attitude was, “Please don’t tell us what’s wrong!” ’
In hospitals, the most widely used patient safety database is called Datix. It relies on staff inputting information about safety incidents.
It is a big database of guilty secrets, revealing the blunders and oversights, accidents and abuses, communication failures and confusions that take place every day in NHS trusts.
Every month, in almost every hospital, there are errors with anaesthetics; cancer diagnoses that come too late; mistakes with drug dosages and medicines given to the wrong patients; botched gynaecological operations; injuries to mothers during childbirth; blunders with blood transfusions; and lapses in infection control.
Taken together, these paint a worrying picture of management failures and poor standards of care.
A Freedom of Information (FOI) request to all NHS trusts asking for Datix records from 2016 to 2019 received a comprehensive response from about half of those approached.
In all, the trusts that provided figures recorded just under 1.6 million Datix incidents in 2018/19; 173,890 more than in 2016/17, in a 12.2 per cent increase.
Assuming those that replied to the FOI request are broadly representative of all trusts in England, the total number of adverse incidents could potentially be double this figure. The three trusts with the most reported incidents were Barts Health NHS Trust in London (47,532); Nottinghamshire Healthcare NHS Foundation Trust (46,413); and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (40,782).
The mystery statistic is how many adverse incidents are not recorded in the first place.
A veteran nurse who has worked in several NHS trusts and frequently uses the Datix system has witnessed widespread reluctance to flag up problems. ‘Datix is there to highlight risk. It’s for learning from mistakes, not punishment, but people don’t like using it because they’re afraid of kickback,’ she says.
There are about 150 avoidable deaths in the NHS every single week, around nine of which are the result of what the Department of Health calls ‘never events’: blunders so serious they should never happen.
Examples that occurred before the pandemic include amputating the wrong toe; removing the wrong part of a patient’s colon; leaving items including a surgical glove and part of a drill inside patients’ bodies; and mistakenly removing organs.
According to the latest available data, several patients underwent operations that were supposed to be carried out on someone else.
These catastrophic errors come at a heavy cost for the NHS.
In 2018/19, NHS Resolution, the quango that handles medical negligence lawsuits, paid out £2.4 billion in damages and costs for claims. The number of compensation claims is soaring, and settling disputes takes a huge chunk out of the stretched-to-breaking-point NHS budget.
A combination of soaring demand for services, crippling legacy contracts with the private sector, mismanagement and waste means that the NHS is always in financial trouble.
In 2018/19, just under half of all NHS trusts were in deficit. A total of nine trusts were in so-called financial special measures.
Figures for 2019/20 showed a significant improvement, with just over a quarter (27 per cent) of trusts in deficit. The number in special measures fell to seven.
The single biggest financial burden on some trusts is the payments they must make every quarter for buildings constructed and maintained via so-called Private Finance Initiatives (PFIs).
Had it not been for these deals, almost all struck during the New Labour years, there would be far fewer modern hospitals. The buildings are well-kept and look good. However, they have come at a crippling price.
As of 2017, there were 128 active PFI projects, 109 of which were for hospitals and acute health units.
The average length of the contracts is 31 years. Latest estimates suggest the final bill will exceed £80 billion for buildings which would have cost about £13 billion to construct had they been paid for up front.
For patients, the only upside is that these are nice environments in which to be treated, which is a great deal more than can be said for most of the rest of the NHS estate.
Almost a third of that estate was built before 1974, and a further ten per cent dates back to the 1980s. Many trusts operate both old and new buildings but are shelling out so much money on the mortgage for the new-builds that they cannot afford to maintain the older premises. Collapsing ceilings, leaking roofs, burst pipes, broken boilers, malfunctioning air-conditioning systems and numerous other maintenance issues all present a constant challenge to hospital bosses and frequently pose a real danger to patients.
In a damning Government-commissioned report into the condition of the NHS estate, Sir Robert Naylor labelled it ‘unfit for purpose’, warning that the situation is probably far worse than many trusts care to admit.
There is ‘no real incentive’ for them to tell the truth about how dilapidated their buildings have become, he said.
Added to trusts’ crippling PFI debts are the vast financial losses due to inefficiency. Mark Gordon, who has worked in multiple hospitals across the UK, estimates that hundreds of millions of pounds are lost every year due to time-wasting and operating theatres being under-used.
He recounts how surgery routinely started so late in the morning that patients at the bottom of the list were sent home without having their operations, or were delayed until the following day.
He was appalled by how often operations were cancelled just to suit staff.
He says: ‘Vested interests would stop theatre lists for their own reasons – for example because a member of staff did not believe the list [would] “finish on time”, thereby causing them to stay over their scheduled work time… The impact on the patient is dire.’
The reality is that NHS workers have little to no incentive to maximise output. They are paid the same amount however many patients they see, and slow work is rarely reprimanded.
Against this backdrop, it is a testament to the dedication of the depleted workforce that the NHS gets as much done as it does.
A problem which is, thankfully, far less common within the service is fraud.
Nevertheless, every year, both the General Medical Council and the Nursing and Midwifery Council deal with multiple cases involving healthcare professionals who falsify qualifications. Many other such abuses may never come to light.
In recent years, authorities have shut down hundreds of bogus higher education institutions peddling fake degrees, and it is now more difficult to obtain false medical training certificates.
However, our investigations revealed that very convincing fake qualifications can still be obtained on the so-called dark net, part of the internet that is not indexed by search engines and is accessible only via specific software. There are multiple sellers charging between $200 and $700 for documents.
In return for sending $650 to a personal account in China, we were able to obtain a highly realistic fake degree from the University of Southampton, awarding a ‘John Stone’ a bachelor of nursing degree with first-class honours in adult mental health.
What is apparent from the cases that periodically come before professional regulators is that neither recruitment agencies nor NHS trusts have the resources to conduct exhaustive checks on all those who apply for jobs.
The fact is, the need for many additional healthcare professionals is among the thorniest and most urgent now facing the NHS. Yet there are no quick fixes.
Meanwhile, coronavirus and the possibility of more dangerous mutations is not going away. For the foreseeable future, the NHS will be expected to maintain high levels of surveillance, and resources will continually be diverted to ongoing vaccination programmes. Thus more planned procedures will be delayed and cancelled.
The surgeon who decides: life or death
Every day, hospital doctors have to make delicate judgments about when to stop treatment that is more likely to prolong suffering than prolong life.
What is disturbing about one surgeon whose work we investigated is their judgments about the very sick have sometimes been influenced by their personal feelings.
Here’s what happened on this surgeon’s watch: when a very sick patient was admitted, they read their medical history, looked at them and then decided if they were likely to make it. If the surgeon liked what they saw, if they were surrounded by family and – crucially – if the surgeon thought they had a ‘spark’, the medic would go the extra mile. Otherwise…
‘I am a very experienced clinician,’ the surgeon once told bereaved relatives. ‘I know who can survive and who can’t.’
During an investigation into the sudden death of one of the surgeon’s patients, it emerged that the medic had misdiagnosed him, used an insulting phrase to describe him and failed to involve the patient’s wife in a discussion about whether attempts should be made to resuscitate him if his heart stopped. The surgeon did, however, decide to give the patient a chance of life, having initially written him off, because he had a spportive family.
During an inquiry into the case, the NHS Trust involved apologised for a string of failings, while surgeon insisted they had done their best.
Many will sympathise with doctors who are reluctant to perform interventions when a patient clearly cannot be saved. Less can be more in these situations. These are delicate judgment calls, and experienced clinicians who regularly deal with patients at the end of their lives develop an instinct for the point at which further treatment does more harm than good.
Caring for the elderly and frail is extraordinarily challenging. When they are critically ill, judging whether they will pull through is an inexact science.
Doctors must draw on instinct and experience, as well as medical knowledge.
What few would support is one rule for patients whom doctors like, with relatives to advocate for them, another for those who are dispirited and alone.
© Michael Ashcroft and Isabel Oakeshott, 2022
Abridged extract from Life Support: The State Of The NHS In An Age Of Pandemics by Michael Ashcroft and Isabel Oakeshott, published by Biteback on March 8, priced at £20.