Thursday 19 July 2018

Goodbye Jeremy Hunt

Jeremy Hunt is finally no longer Minister of Health and Social Care (1). There is great rejoicing and celebrating in the NHS, or there would be but we’re far too busy with our ever expanding workloads.

At five years and 274 days (2) he has been our longest serving Minister for Health ever, but his length of time in the role is no indication of his ability to lead the NHS, it was far more of a reflection on the political times he served in and his ability to unquestioningly follow Government policy. He is the perfect Company Man, the perfect middle manager, always following the party-line and never making a fuss or trying to “rebel”, unlike a certain Mr Johnson. But this quality does not make for a good leader and Hunt was no leader.

Hunt was given the role Minister of Health after the mess Andrew Lansley made of the Health and Social Care act 2012 (3). He was obviously seen as a “safe pair of hands”, yet his experience of the NHS was low, previously he was the Culture Minister (4). His life before parliament didn’t him equip to be Health Minister either, running an educational publishing business and never working in the public sector (4). But his lack of any healthcare experience is not untypical of previous Health Ministers.

Hunt has repeatedly said, from as soon as he was appointed, that his passion has been patient safety (5), he was said to have a whiteboard in his office listing the recent “never events” in the NHS (6). Yet he has never seemed to grasp that poor working conditions breed unsafe conditions for patients. Errors happen when teams are overworked and understaffed. Yet repeatedly Hunt has refused to set minimum safe staffing levels (7, 8, 9 & 10), even after when he himself tweeted an image that showed how short staffed Ipswich Hospital was (11). A recent Nursing Standard survey, published this month, found that 76% of nurses didn’t have enough staff to provide safe patient care, and 69% didn’t have the time to provide safe patient care (12). This was after nearly six years of Hunt in charge.

An NHS winter crisis was once a term reserved for when there was adverse weather, cold spells and snow, or spikes in seasonal flu rates (13), now it seems to be the term for the over demand on NHS services every winter, no matter the weather. It is so regular now that it is in danger of becoming a Christmas tradition. This winter gone saw hospitals cancelling all routine operations (14), the 4 hour A&E target was not met and “trolley waits” of over 4 hours rocketed (15), record numbers of patients had to wait in ambulances because A&E departments were too busy to accept them (16), in the first week of January 44% of hospitals issued alerts that all their beds were full (17), and this all added £900 million to the NHS deficit (18). And what did Jeremy Hunt do? He said sorry to patients for the A&E waits (19), after 10% of NHS Trusts had called mayor incidents due to the winter pressures, but that’s all. He certainly hasn’t secured extra funding to prevent another winter crisis.  

But the NHS winter crisis has been a regular event for the last four years (13) and all Hunt seems to have done to prevent it was to issue public statements. In November 2016 Hunt claimed that the NHS was better prepared than ever for winter (20) and still there was a winter crisis that year (21). In a modern, western healthcare system, should we be lurching from one winter crisis to another?

Hunt has provided very poor leadership for the NHS, far too quick to blame NHS staff and far too slow to build up staff. The NHS’s staff is its greatest resource yet watching Hunt’s behaviour and you would often think that we are quite disposable. Shortly after he was appointment the British Medical Association passed a vote of no confidence in him (22) over derogatory comments he’d made about the NHS while he was Culture Minister.

The NHS is haemorrhaging staff, there are now 100,000 empty NHS posts (23), nearly 5,000 of these are empty doctors’ posts (24), 243 of them are A&E Consultants (24), and nearly 36,000 of them are empty nursing posts, which is just over 10% of all NHS nursing posts (25). If 10% of all MPs seats were empty there would be a public outcry, yet this high level of staff vacancy is barely rising any concern now, certainly not with Hunt. While he has been Health Minister there has been no high-profile NHS recruitment campaign, what campaigns we have seen have been at local levels by individual Trusts.

Hunt’s denial of the shortage of nurses is breath taking. When first in office, when the number of empty nursing posts was lower, Hunt would boast about the numbers of nurses he’d “put” on the wards (26), as if that was the only place nurses worked. Now, in the face of 36,000 empty nursing posts (25), he claimed to have create 10,000 more Registered Nurse training places and 5,000 more Associate Nurse training places (27), which would fill just half of the empty posts, as if that is all we need. He has no understanding of recruitment and retention, and that you cannot replace an experienced and skilled nurse with a newly qualified one. I could not do my current job, at my current role with all the extra clinical skills I have, when I first qualified. You also need a structure to support and mentor newly qualified nurses, you need to build up their skills and competences, and you need experienced and skilled nurses to do this. Hunt is also ignoring the fall in applications for nurse training since the scraping of the bursaries. This year saw a 32% fall in applications for nurse training (28). Hunt could have prevented this but he did not speak out or try to stop the government scrapping student nurse bursaries, the “loyal politician” he is he just sat back and let the government do this. His only policy for handling the shortage of nurses is to recruit more student nurses, yet his Government has caused a fall in the student nurse numbers and he did nothing to prevent this.

NHS staff’s pay has stagnated during Hunt’s time, one of the factors that has caused the NHS’s poor staffing levels (not the only factor) and again his handling of this has been very poor. His handling of the new Junior Doctor contacts, the one he wanted forced onto them, was borderline toxic and left a sour taste in the mouth (29).  His handling of nurses’ pay has been far less than transparent. Last year Hunt was saying how valuable nurses are and how we should be paid well (30), but his previous actions were the opposite. In 2014 Hunt scrapped the 1% pay raise the Independent Pay Review Body recommended (31), claiming that the NHS couldn’t afford it (He would receive a 10% pay rise, along with other MPs, the next year (32)). Several months later Hunt was forced into an embarrassing U-turn after nurses staged 4 hour strikes (33), and there were cuts to staff to pay for the 1% rise, as Hunt had predicted. Even after his claims that we deserve better pay, the pay offer Hunt made to NHS staff this year was anything but that, it took away far more than the small amount it offered (34). How can NHS staff trust him?

Since its formation in 1948, the NHS has seen average yearly increases in funding of around 3.7% (35), only slightly below this during the Thatcher and Major years. Under Tony Blair this rose to 5.7% (36), but it fell to 1.2% under the Coalition and David Cameron (37), in reality this wasn’t even matching inflation. In this time the NHS has seen a much higher rise in its costs and demands on its services. Between 2010/11 and 2016/17 NHS sending on medicines increased by 5% a year, a 30% increase during this time, while hospital spending on medicines increased 12% a year during the same time, now half of NHS spending on medicines is taken up by spending on hospital medicines (38). This is far higher than the rate of inflation during this time and gives a stark reflection of how NHS costs have risen (Medication expenditure it easier to calculate and therefore easier to access data on). Recent years has also seen a steep rise in the demand for NHS services. 2015/16 there were 40% more operations carried out in the NHS than ten years before (39 & 40), in 2015/16 there were 16.252m total hospital admissions, 28% more than ten years before (39 & 40), 23.5% more people attended A&E in 2015/16 than a decade before (39 & 41), there was a 4.4% increase in outpatient appointments in 2015/16 than the year before (39 & 42) and in April 2017 10.1% of people on NHS waiting lists had been waiting for over 18 weeks while it was 8.4% in April 2016 (39 & 43). This only paints a picture of ever increasing demand on the NHS and yet resources have not kept pace, in reality resources had fallen because the NHS yearly increase in funding has not kept pace with inflation (And medication costs alone have increased far faster than inflation). The NHS is now so underfunded that 65% of acute Trusts and 44% of secondary referral Trusts are in deficit (44), which collectively amounts to a £960 million of NHS deficit in 2017/18 (45), which is £160 million more than the previous year (46).

Yet Hunt has remained very quiet about NHS funding. We have never heard him calling for more funding or decrying the underfunding, in reality, of the NHS. If patient safety was so important to him why wasn’t he highlighting the biggest threat to it, underfunding? Because he is a true company man, and does not go against Government policy, in this case the austerity policy.

Jeremy Hunt’s history of dealing with healthcare issues and policies has been just as poor as his leadership of the NHS. There have been many incidences of him failing, check out the list of my blogs about Hunt , read them here (47), but these three below I feel personally are the worst examples of his failings.

The Nursing and Midwifery Council (NMC) is the regulatory body for nursing and almost from the day it was created it has been a failing, again (48), and again (49), and again (50) it has been called unfit for purpose. There is even a petition on Change Dot Org to that affect (51). To go into all the failings and problems of NMC would triple the length of this already long blog, but a previous blog does exactly that. It was written as a challenge to the NMC’s chief exe’s nearly £20,000 pay rise. It describes a litany of failures, which saddened me to write, and you can read it here (52). I have written other blogs on the NMC's failings, read them here (53), here (54), here (55), here (56) and here (57).

As you can there are many, many failings by the NMC and yet Hunt has remained very silent over them, you could have almost accused him of ignoring the problem. The only time Hunt responded to the NMC’s failing was to announce an enquiry in the NMC’s treatment of the Morecombe Bay scandal (58) but this was too big a scandal and NMC’s disgustingly poor handling it was also too big to be ignored. This was only a year and a half after Hunt had asked the NMC to regulate the new role of Associate Nurse (59). The NMC’s failing were well known when he did this and yet Hunt didn’t put any requirements for the NMC to improve their performance before taking on this new role. The NMC says they “exist to protect the public” (60) yet their repeated failings put this in question. If Hunt was so committed to patient safety why did he do nothing to improve a failing healthcare regulator, the biggest healthcare regulator in the country? Strong and functioning regulators protect patients. Why didn’t or couldn’t Hunt see this? Or was fixing the NMC just too expensive and far beyond his abilities?

Jeremy Hunt has spoken a lot about a creating “seven day” NHS since he first announced it (61), ignoring the fact that a large amount of the NHS is already a seven day a week service (Such as my job). He based his claim for a change to the NHS on statists that rapidly turned out to be questionable at best. He said 6,000 people died every year because of “poor” staffing at weekends but this was quickly proved to be questionable (62). There is no evidence that a “seven day” NHS would save lives (63) and that weekend staffing levels caused an increase in patient deaths (64). It felt as if Hunt was deliberately twisting statists to back up his policy and scare people into agreeing with him, when there was no real evidence to support it. At the time I wrote a blog taking apart Hunt’s claims, read it here (65). But Hunt is the loyalist of Government Ministers, the seven-day NHS was a Conservative party policy so he unquestioningly followed it, even using bogus rhetoric. Strangely, Hunt’s plan for a seven-day NHS has never materialised, though so much of the NHS is already a seven day a week service.

Not long after he started as Health Minister Hunt reacted in a way that first alerted me to his behaviour, to the type of Health Minister he really was. It was the scandal around the Liverpool Care Pathway (66). The Liverpool Care Pathway (LCP) was a care tool to improve patients’ end of life care and was found to clinical very beneficial (67), but several tabloids turned against it with scare stories (66). Hunt caved in to the tabloids very quickly, LCP was too badly damaged by the questionable and false tabloid stories and Hunt’s complete failure to respond to them, so we lost a very useful clinical tool. At the time I wrote a blog taking Hunt to task over his failure to act to shave the LCP, read it here (68).

These are just three of the times Hunt has failed with health policy, the three I consider the worst examples of his behaviour, but there are many more. Here (47) is a list of my blogs were Hunts features, and all of them highlight one or more of his poor decisions and poorer behaviour.

Jeremy Hunt has gone from the Department of Health, no longer will I have to watch his smug and often patronising face on television (Well, no longer taking about the NHS anyway), and no longer will he feature in this blog, as he has done for the last three years, and I will not miss him. His leaving tweet crowed about the “success” he has been (69), boasting about patient safety. But how can he claim patient safety was his aim when he has left the NHS in a position were patients are at greater risk then when he became Health Minister. An under resourced, under staffed and over worked NHS is a place were errors are more likely to occur, not less, yet Hunt has seen completely blind to this. Last year Sir Robert Francis, of the Francis Report, said that the only reason the NHS hadn’t had another Mid Staffordshire scandal was because of the “superhuman efforts of its staff” (70). He didn’t say it was because of Hunt’s leadership. I feel that Hunt’s leadership and this Government’s attitude and policy towards the NHS have created the perfect storm were another Mid Staffordshire scandal is just waiting to happen, fortunately the efforts of NHS’s staff have prevented it, so far.

So what will be Hunt’s legacy? Certainly not an NHS in better shape than when he was appointed Health Minister, NHS waiting lists are at a ten year high with 4.3 million people are now waiting for operations (71). As for patient safety? Shortly after Hunt was appointed the Francis Report was published, in 2013 (72). One of Francis’s recommendations was that the National Institute for Health and Care Excellence (NICE) was to develop safe staffing guidelines, nurse to patient ratios, yet five years later and we still do not have them (73). Instead this Government obstinately refuses to develop them, saying they want to concentrate on a “holistic approach” approach to staffing levels (73), whatever that means? California has had mandated nurse-to-patient ratios since 1997 (73).

So that is what Hunt’s legacy is, an NHS that is a place far less safer for patients than before he was appointed.

Drew Payne

The Path Away from Liverpool

In 2001 my mother died from cancer. The end of her life was a series of Chinese Whispers, what she wanted in her last days pieced together from what she’d said to different people at different times. It was stressful and messy, making a different time even more so, and I seemed to be the one having to pull all these different pieces of information together.

When I first used The Liverpool Care Pathway (LCP), several years later, I got a painful and nagging thought at the back of my mind, “Why didn’t we have this when my mother was dying?” Since then, every time I’ve used the LCP, as a Community Nurse, that nagging thought has been there, somewhere at the back of my mind. Now I’m to be free from that nagging thought, the LCP is to be phased out, but I’m far from happy.

Following sensationalist tabloid headlines last year (1), many of which were misleading or deeply inaccurate (2), the Government announced a review into the LCP (3). This review published their report on the 15th July 2013 and the Government’s main recommendation is the “phasing out” of the LCP (4).

The review didn’t find anything wrong with the LCP, certainly not the claims made in the tabloids (5). They did find examples of poor practice with it, the LCP being implemented incorrectly, being started in the middle of the night, being started without discussing it with patients or their families, of it being used simply as a tick-list with palliative patients. They found staff had not been suitably trained in the use of the LCP and the lack of availability of expert advice out of hours. The review certainly didn’t find any adverse affects of using the LCP, it certainly didn’t hasten the deaths of any patients (5). A 2009 audit, by the Royal College of Physicians, found the use of the LCP provided high quality care (6).

We still have a poor record of training staff, in British Healthcare. There’s more to using the LCP then just a quick read through it before implementing it. End of life care is complicated and multi-disciplined, it requires skills and experience, it’s more than filling out a check list. We need to invest in our staff and train them, enable them to deliver the high standards of care end of life patients need.

People don’t always die Monday to Friday, between 9 and 5, and yet that’s when most Palliative Care clinicians and experts are available. This isn’t just a problem faced only by palliative care, it is found in many specialist services.

Unfortunately, what really sounded the end for the LCP was poor leadership. When the first stories about the LCP appeared in the press we needed clear and strong leadership from the Department of Health and the Minister of Health, instead Jeremy Hunt bowed down to media pressure at the first turn.

The LCP, through no fault of its own, is to go, the review found it was too damaged from all the bad publicity it has received (5). End of life patients still require the highest standards of care. We now need to ensure they receive it. Whatever replaces the LCP will still require staff training, resources and leadership to back it up. As nurses, we need to put on the pressure to ensure this happens.

Drew Payne
July 2013

PS. This blog was originally written for and published on the Our World website