Politics is often like chemistry: you can start with two apparently inert substances which are minding their own business, before mixing them and causing an almighty reaction. Two separate policies might, on their own, seem benign – sensible, even – but combine them, and you end up with the equivalent of dropping caesium into water: a big explosive mess.
The NHS is by its nature a highly reactive part of our public services, and is right now at risk of a bad chemical reaction between government pressure to drive down waiting lists and the financial “reset” that is being demanded of it.
This week, NHS Providers, the organisation representing hospital, mental health and ambulance trusts, found that around one in four NHS trusts in England are going to have to close some services, with a further 55 per cent considering doing so as well. Its survey of trust leaders, carried out last month, uncovered “eye-watering” choices that many of them are having to make to cut costs. One trust is looking to shed 1,500 jobs, including doctors and nurses, while other services are being scaled back significantly, including for diabetes services, virtual wards and palliative care.
What a list. What a set of choices for NHS leaders, who are having to deal with a predicted financial shortfall of nearly £7bn this year. NHS Providers pointed out that budgets have been stretched further by the pay awards for healthcare workers, but once again those raises represented an impossible choice between a demoralised workforce that goes on strike, or a better-paid one working in a denuded trust.
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These choices alone would be difficult for those working in the NHS and still worse for patients who will see the care they receive change or disappear. But the chemical reaction comes in the form of pressure on the health service to drive down waiting lists, something the Labour Government is particularly anxious about as a measure of the difference it is making to voters.
Keir Starmer named the fall in waiting lists again last week when he responded to his party’s difficult set of results in the local elections. It’s not just waiting lists, but productivity targets, set at a level the previous NHS management simply did not seem to know how to reach.
As is so often the case in the NHS, we have seen this movie before. When trusts are under financial pressure and shed jobs, while also trying to meet stringent targets, terrible things can happen. The Mid Staffs scandal was one of the most notorious in healthcare, but is often misunderstood as simply the NHS somehow deciding to be cruel to its patients. The truth is much more worrying, because it involved decent healthcare staff having to make thousands of impossible individual choices as they treated too many patients with too little time.
The trust was pursuing foundation status at the time, and trying to meet tough financial targets to do so. One of the ways it met those targets was by shedding 150 jobs to save money, on top of 150 which were already vacant. This was not because those jobs were not needed – they were. There were now not enough staff to treat the patients.
One of the most searing pieces of evidence in the public inquiry into the scandal came from Dr Chris Turner, who worked in the emergency department of Stafford Hospital, and who explained that the impact of trying to care for too many patients was that staff became “immune to the sound of pain”.
Patients were waiting longer and longer to get their pain relief, not because the staff wanted to deny them treatment, but because they simply could not get round everyone in a timely fashion. Slowly, that became the norm, with workers forgetting or at least numbing themselves to what good care looked like.
There were obviously individual choices in that terrible scandal too: the report of the Francis Inquiry into Mid Staffs contains evidence of appalling practices and words from workers which, even if explicable, can never be excused. But the point is that the culture of that trust became toxic at least in part because it had experienced a bad chemical reaction.
Healthcare leaders have been warning for some time about the “moral injury” that workers have been experiencing in a stretched NHS that is unable to give people timely care. With fewer workers and services, and pressure to work as fast as possible, the risk of that moral injury leading to more staff becoming immune to the sound of pain, or making other choices that no decent person wants to make, is growing.
Labour needs to put as much effort into ensuring the quality and safety of care, as well as its speed and financial sustainability. Otherwise it is concocting a powder keg.
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