Clapping the NHS won’t improve health care

Zero: Eliminating unnecessary deaths in a post-pandemic NHS by Jeremy Hunt (Swift Press), £14.19.

“Let’s Get Zero Done!” The man — Jeremy Hunt — who was Heath Secretary for a record six years and may, or may not, one day would be Prime Minister, is on a mission. To reduce the harm done in NHS hospitals to zero. 

Coincidentally published as the Care Quality Commission reveals the terrifying failings of Nottingham’s maternity care services, Hunt will probably resist the temptation to claim prescience. But luck is a prized asset in generals, as Napoleon famously said, and is useful for politicians. 

Hunt and his publishers have been lucky. This essential message of this book for the NHS — first, do no harm — is being reinforced by front-page splashes.

I read Zero, Jeremy Hunt’s attempt to place himself at Boris Johnson’s back, knife firmly in hand, with a growing sense of familiarity. I was Minister of State for Health between 1994 and 1997. Zero is a riveting trip down memory lane.

It’s also a sobering read. Our NHS, so recently clapped and pan-banged on Britain’s locked down streets, is stripped bare. At its worst it kills people; ignores patients; destroys evidence of failure; is not fit for purpose. Hunt should know. He ran it as Secretary of State for six years. Hunt reveals few heroes in Zero. 

But, the catalogue of failure set out in grisly detail in the opening Blame section that will shock most readers to the core is no preparation for a brave revelation, tucked into a vignette, on page 217. 

No longer in the Cabinet, Hunt sets up a meeting with a former foe — he racked up many — Dr Rachel Clarke, a palliative care doctor at a hospice in Oxford — former journalist, “talented author” and heavy-hitting Hunt critic. 

“Her tweets were so hostile to me that I ended up ‘unfollowing’ her, for the sake of my own morale if nothing else,” he writes. The constant sniping takes its toll.

“I also wanted to understand how you make things happen in the NHS — and why my own efforts to do so had not always been successful.” It is surprising that a Secretary of State who has suffered such a bruising at the hands of the service for which he is responsible should not simply wash his hands, mutter “good riddance” and push off to fresh pastures.

Hunt has clearly thought long and hard about his experience, drawn difficult conclusions, and seems keen to get his hands back on the levers of power, perhaps from a different vantage point (No 10), to make his fresh understanding bear fruit. 

The book lays out a catalogue of frustration with officials and entitled NHS staff who simply underperform. Bells rang. I served happily under two Secretaries of State (SoS), Virginia Bottomley and Stephen Dorrell, with specific responsibility for the NHS machinery of levers, controls, targets, Hunt describes — the lot.

All those Lilliputians in the book, tying down giant SoS, Jeremy Gulliver, barbing him with tweets, and the official Sir Humphreys who always seem to get the better of him, drifted through my office over nearly four years. One of the names I recognised as an official I had met on my first day in Richmond House — then NHS central. Still there? Blimey! 

History lesson. When I left the Department of Health (DoH) in 1997 the National Health Service (Primary Care) Act — my baby, two years in gestation — had just received royal assent. Budgets were to be devolved to GPs and then a body of leading innovators resolved to lead NHS reform, deployed in the interests of their patients. Some GPs had even met a patient. Happened quite often back then. The good old days. Now, they’re 90 per cent part-timers.

The threat to NHS pen-pushing apparatchiks was defanged by the incoming Blair government. Not revoked, but stifled by the sly interposition of layers of bureaucracy which snuffed out the innovations that Fundholding GP Practices had pioneered since Ken Clarke’s creation of the internal market. That’s it for All our Yesterdays. 

My point is that in Zero, Hunt also recognises that decision making needs to be wrested from the hands of the pen-pushers and box tickers who overpopulate the NHS, often ignoring blindingly obvious risk and meeting targets by cunningly arbitraging patients around the system. For example, inappropriately discharging patients early from Accident and Emergency to meet treatment time limits.

Zero comes in four parts: The Three Big Causes of Avoidable Harm; Culture Challenges; Solutions; and Making it Happen. The style is accessible, and Hunt does not make the mistake of writing a long mea culpa. It’s more an unusual — unique even — confession of having been thwarted at every turn.

The book begins with a comparison between the NHS and the aviation industry. Blame culture is causing cover-ups of shoddy clinical practice. Eliminating that culture within the NHS, as had been done in the civil aviation industry where deaths in 2017 were reduced to zero, would dramatically reduce errors, remove the temptation for shocking cover-ups and avoid scandals, like the 2010 Mid Staffs horror and the current Nottingham debacle.

The Francis Report into Mid Staffs suggested that between 400 and 1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at a small Stafford hospital, all connived at by self-protecting staff. 

On arrival at the DoH Hunt wanted to understand what was actually happening to patients. With great difficulty he got his private office to pop a complaint letter from a member of the public onto his desk every morning. He must have choked on his muesli. Real people!

Why was this catalogue of horrors happening? Cultural Challenges takes on the story, blaming targets (perhaps), impenetrable hierarchies (true), fear of litigation and the growth of groupthink. 

Our NHS is boxing itself into a corner of self-deception. Targets say little about the actual quality of patient care and skewed priorities. Eject someone from a hospital bed early, just to meet a discharge target and let them die at home. Box tickers win again.

Interestingly, since the Hunt era targets have moved from being a preoccupation to a fixation. And post-Covid politicians baying for waiting list reductions will make them an obsession. Zero is a timely omen.

Solutions focuses on the need for more transparency, continuity of care, the merging of acute care with community care to avoid patient dumping by the bed blockers local authorities are reluctant to admit to their care homes, prevention and the more rapid introduction of technology.

The dysfunctionality of community care has dogged the NHS since its inception. But Hunt makes the arguments with clarity and draws on graphic examples of failure to ram home his argument. With Hunt dictating policy, at last, the gulf between health and community care may be bridged.

The final section is Making it Happen. Hunt’s three-part solution is, Communication, Zero (eliminating harm) and Patient Power — always praised by politicians in public, but feared in reality. This is the blandest section of the book.

What is missing is a well-argued section for reform of the potluck financing system tussled over annually with the Treasury and any pathway to changing a structure which, according to current reports, has seen the lions’ share of post-Covid increased spending squandered on even more bureaucrats.  

Readers are left with the overall impression of a Secretary of State sometimes bobbing on a storm-tossed sea of uncontrollable events, but with the self-awareness to write a book admitting it, a willingness to learn from the experience and return to the battle refreshed.

Zero is a galloping read, and a brave book to write, for the man who would be Prime Minister. And, don’t blame me for bonkers Boris. In that Tory leadership election, I voted for Jeremy.