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Front line first

By Paul Waugh

 

Jeremy Hunt has been literally doctoring the figures and he’s rather enjoyed the experience. Just back from a trip to a GP’s surgery in Feltham, the Health Secretary proudly explains that he drew up the exact level of medication needed to treat a patient. “I issued my first prescription, it was for a diabetic,” he says cheerily. “I try and go out most weeks somewhere on the NHS frontline. I try not just to visit, but also to do the work.”

Informed by his visits to the sharp end, Hunt has certainly been busy prescribing his own solutions for the health service of late. And in everything from poor care and cover-ups to curbing migrant abuse of the system, he’s clear that transparency and reform is the best medicine.

It’s exactly 10 months since he was chosen by the Prime Minister to replace Andrew Lansley. Hunt has had to become a quick learner but is determined to turn his lack of experience in health policy into an advantage.

“I don’t have a background in health care,” he accepts. “I have a background as a patient who’s used the NHS and whose family use the NHS. So in a way my background was as a member of the public.

“What I hadn’t appreciated was just what an incredible privilege it was to work in healthcare and this is the single thing that matters most to most people. Everyone goes into politics because for better or worse they want to make the world a better place and you have the chance to do things that will touch the lives of millions of people. That is quite unparalleled anywhere else in Government.”

Promoted from one of the smallest departments in Government to one of the biggest, the former Culture Secretary readily accepts that switch to health was a big step up.

“There is a very big difference between this role and my previous role, which is that in DCMS I was an advocate for the arts, but I didn’t directly run any museums or galleries. I was an advocate for sport, but I didn’t run any sports clubs. Perhaps the closest I got to responsibility for delivery came with the Olympics, but we had a fantastic organisation in Locog who did that extremely well,” he says.

“But here there is day to day responsibility for one of our great national treasures, which sees three million people every week. It is a bit like an Olympics every day. It’s actually huge. And I have to say that the Olympics was an incredibly useful training. You might think there is nothing in common between the Olympics and the National Health Service, but they are both huge in their scale and in both cases you spend a lot of time trying to predict what the problems might be down the track and work out what you might do to head them off. In both there are superb people involved in making them happen.”

Yet there is one very important difference. “I suppose the biggest difference is the NHS is much more politically charged. The Olympics had cross-party consensus. We had one or two arguments over things like school sport but it wasn’t something that came back week in week out. Whereas with the NHS there are the operational challenges of a service that’s working very hard, but also the political battle that has to be won in Westminster.”

That battle includes not just political opponents but some in the medical professions too. Only last week, the British Medical Association passed a vote of no confidence in Hunt, with one critic claiming he was leading “a new political blame game, blaming frontline NHS staff for the predictable chaos resulting from his government’s reforms and cuts”.

Having survived the political near-death experience of the Leveson inquiry, Hunt is nothing if not battle-hardened. Asked about the BMA motion, he replies: “It was predictable. The BMA is a union and their job is to defend the rights of their members, my job is to speak up for the public. We both have different jobs. In the end if the Health Secretary doesn’t speak up for the patients who use the NHS, who will? I have to do that and it’s incredibly important that I should.

“All I’ll say is that I don’t meet a doctor who doesn’t think that we need to do a better job for patients. And who doesn’t agree that we need to have a better record on patients’ safety, do more to make sure that we don’t have problems like Mid Staffs and Morecambe Bay. And the way we will do that is by tapping into the very values that made them want to become doctors in the first place.”

And as for the personal attacks on him from the profession? “The BMA have passed votes of no confidence in Patricia Hewitt, Alan Milburn Andrew Lansley. I am afraid I’m not alone in the club,” he smiles. Those who thought he was simply brought in to the DoH as simply as a telegenic communicator and a safe pair of hands have been proved wrong: “I think in the end in politics you do have to decide if you want to change things or if you just want to be a steady hand on the tiller. And I think with the challenges that we face making the NHS sustainable, dealing with an ageing population, it’s my job to talk about the changes that need to be made.

“For all the BMA say, I haven’t met anyone in the health service who doesn’t think we need to do a better job looking after vulnerable older people outside hospital, which is what this big debate is all about. And indeed when you talk to any GP they say they would like to be freed up to spend more time [on that].

“The doctor I saw this morning does home visits regularly, he’s one of the few GPs who still regularly do home visits. It’s not that other GPs don’t want to but they don’t have time and we’ve created a contractual framework that makes it very, very difficult – they are working hard, they are rushed off their feet – for them to do what being a family doctor is all about.”

The surgery he visited in Feltham is run by Dr Ronan Moran, an inspiring GP who recently got won a Daily Mail Health Heroes award (and a trip to No.10) for his dedication patients, particularly the terminally ill who want to die at home.

“It was a pretty ordinary building in a fairly unremarkable corner of Hounslow and yet he delivers the most extraordinary service, I’ve really never seen anything like it,” says Hunt.

“And not just him. The receptionist knew the names of everybody who came through the door. There was this incredible feeling. The big thing that he does, which is something that I think we’ve lost in too many parts of the NHS, is there is this personal contact where he knew people’s background and he knew all about them and was asking to go and see them and check up on them. And I thought that was really impressive.”

But the visit also revealed some of the obstacles practitioners face, Hunt says. “You find out the problems. They were talking to me about the bureaucracy, they said they spend far more time than they ever used to filling out forms, they find that very frustrating, they have to spend far more time in central meetings than they ever used to before.

“Dr Moran’s partner said to me that ‘in order to hit our targets there are certain questions we have to ask every patient who comes through our door, which are nothing to do with the reason they booked an appointment’. And he said: ‘It does feel like we have our agenda and they have theirs. We have to ask these questions if we are going to get income for our practice. Our income is dependent on it.’ So, you see the reality of some of the structures that we have created.”

The problem of paperwork is a common theme across the NHS, in hospitals as well as primary care. Hunt thinks that a lot more can be done to use new technology to capture patient data and keep it. “The IT revolution has barely touched the NHS and I think it will make an absolutely huge difference. I think it will mean we can deliver much more personalised care because it will mean you can go anywhere in the system and they’ll know all about you.

“But I think the other thing which is very much following on from Andrew Lansley’s reforms is, I think we need to make sure that the incentives that we give people are based around outcomes and not processes. So at the moment, too much of the way we reward GPs is ‘have you asked this question 24,000 times in the course of your work last year?’ and not by looking at the service they give to people, particularly the vulnerable older people who are the heaviest users of GPs’ surgeries and hospitals. And that’s where I think needs change.”

One of Hunt’s predecessors, Aneurin Bevan, famously said at the birth of the NHS that its creation would mean that “the sound of a dropped bedpan in Tredegar [his constituency hospital] would reverberate around the Palace of Westminster”.

Thanks to his frontline visits, the Health Secretary hopes he can hear that clatter for himself.

“I’ve been washing beds in A&E departments, I’ve been photocopying forms, I’ve been issuing prescriptions, registering people,” he says. Civil servants are on wards too, as part of reforms to get them out of Whitehall and into hospitals, just as ministers now do. Since this spring, even the most senior mandarins in the DoH have to spend four weeks a year on the front line.

“We introduced it in the wake of the Francis Report which said that civil servants had not known what was going on on their own front line,” Hunt explains. Do civil servants literally empty bedpans? “Yep,” he replies. “And it’s a fascinating example of culture change, because we debated it endlessly before we decided to go with it, and the great worry was that the civil servants would really resent it and would feel they were being forced to do something they didn’t want to do and, quite the opposite, there is huge enthusiasm for it – they absolutely love it because they say we are here because we want to make things better on the front line, we want to devise policies that will make a difference on the front line and we can only do that if we know what’s happening on the front line. You now meet people who have come back, starting with the most senior people – because it’s a huge logistical challenge to organise it, it’s gradually percolating down – you meet senior managers who have gone out and they are full of stories and everyone is full of enthusiasm. It’s really interesting.

“You are not going to do your job well unless you actually know what your customers think. So in the Department of Health we need to be connecting with what our patients are experiencing day in day out, otherwise we are not going to devise the best policy. This is part of improving policy making. It’s not a scheme, it’s not a gimmick. It wouldn’t have been met by the enthusiasm it has by the department if it had been anything like a gimmick.”

The scandal at Mid Staffs and the Francis Report have certainly sparked a huge new debate about the care, or lack of it, in parts of the NHS. But doctors, nurses and midwives complain that in many cases, the root cause is not wilful neglect but a sheer lack of bodies on the ground. What does Hunt say to nurses, for example, who say that things go wrong at times when they just don’t have enough staff on a ward?

“Well, they’re right. Staffing is definitely a problem in some parts of the NHS,” he says. But there is at least one solution: “The best hospitals, like Salford Royal, they have an algorithm that checks the type of patients in every single bed in the hospital every night. And on the basis of the seriousness of their conditions, it changes the ratio of nurses and healthcare assistants and they change that every night to make sure there is safe staffing in every single ward in the hospital and it’s very, very impressive, and there are a few hospitals that do that. Other hospitals only check their staffing levels ward by ward every quarter. And so staffing is definitely one of the issues.”

Hunt stresses that there are 6,000 more doctors in the NHS than at the time of the last election, thanks to the Coalition protecting the health budget. Yet he is careful to add that numbers are not everything.

“The only thing I would say is it’s not just about staffing. There are financial pressures throughout the NHS and some hospitals, despite those financial pressures, deliver superb patient care. Other hospitals find it much harder. So I think we mustn’t be defeatist about this, financial pressures exist everywhere in the current climate. There’s rising demand and an ageing population, hospitals working harder than they ever were before, and what we need is a culture where of course targets matter but not targets at any cost. Individuals should always be more important than the system. Quality of care should always be more important than volume of treatment.”

Another area where the ‘care’ debate has ignited this year has been in the ‘Liverpool Care Pathway’ for dying patients. Some fear that the palliative system for the final days or hours of life has gone awry in some cases. Palliative expert and crossbencher Baroness Finlay said last week that the very name ‘pathway’ itself should dropped because it sounded like a ‘one-way ticket’. Does Hunt agree?

“I think that is a quite a good point. I think there is some difficulty with the terminology there. But I think the most important thing about the Liverpool Care Pathway is people come off it and don’t just go on it and stay on it, and also that it should only ever be done with full consent of the person and the relatives involved. And that’s what we are looking into to see whether that properly happens.”

It was not the end of life but its beginning that attracted controversy for Hunt soon after he moved into his office at Richmond House last year. Asked why he voted to lower the abortion limit from 24 weeks to 12 weeks, he said he’d seen evidence to support his view. The BMA, snapping at his heels again, this week said that no minister should interfere with the law. Does he still want the limit to come down?

“I’ve never commented on the issue as Secretary of State,” Hunt says. “I was just asked a question about why I voted the way I did in a vote that had happened before that. I have a view, it’s a matter of public record, but my job as Secretary of State is to implement the will of Parliament and that’s what I’m doing.”

Still, some doctors criticised him for saying there is evidence to lower the limit. Has he seen some evidence or is it more of a moral conviction? “I’m not going to go into that debate because I think that my job as Secretary of State is to respect the will of Parliament and Parliament has taken a view on the evidence and voted accordingly.”

But if a backbencher comes up with a bill is that separate, that’s nothing to do with Government as such? “When there is a free vote, I will always vote with my conscience. But as Secretary of State I will implement whatever it is Parliament decides on that, even if it’s not what I personally believe.”

As for Parliament itself, relations between Hunt and his Shadow Andy Burnham have appeared increasingly acrimonious in recent months. What lies behind the vitriol?

“I’m afraid there is an arrogance in the Labour party about the NHS which manifests itself in a refusal to accept that a number of the challenges we have in the NHS today are because of policy failures that happened when Labour was in power.” From the 2004 GP contract to the targets culture to the regulatory structure, the Opposition needs to admit its errors, he says. “I don’t want to point the finger at them for every problem that we have. But if we are going to have an intelligent debate then it won’t wash to say that every single thing that goes wrong in the NHS is the result of things the Coalition has done since 2010, which is the case that Andy Burnham is trying to make.”

He claims that Labour can see the health debate slipping away from them ahead of 2015 because of their failure to recognise failures in basic care. “They did make some very serious mistakes which meant that the culture of the NHS was not one of openness and transparency but too often of covering up problems. I think other Labour MPs understand that. But until Andy Burnham actually acknowledges those mistakes I don’t think he’s going to have any credibility in the care debate.”

His line of attack, demanding an apology for past mistakes, echoes the Chancellor’s wider attack on Labour’s record on the economy, welfare and cutting the deficit. Perhaps because of his softly-spoken bedside manner, Hunt was expected by some to simply ‘neutralise’ the NHS as an issue for the Coalition. Yet in many ways he’s proving more combative than Andrew Lansley. From the Commons chamber to doctors’ surgeries, he relishes the front line. And despite the brickbats from the medical professions and the Opposition, it’s clear he’ll keep on prescribing reform. 

 

 

HUNT ON… ALCOHOL PRICING/CIGARETTE PACKAGING

“We are committed to reducing tobacco consumption and we are committed to tackling alcoholism and violence in our town centres at night. The question is whether those two policies are the right way forward, and we are actively considering that at the moment.”

HUNT ON… SCHOOL FIZZY DRINKS BANS

“As far as I’m concerned that’s fine. The point of devolving it to a local area is to see which policies work better.”

HUNT ON… THE CARE DEBATE

“I’m incredibly proud to live in a country where it doesn’t matter what your financial circumstances, you can expect good treatment. But if we don’t deal with the problems over the quality of care we are betraying those NHS values.”

HUNT ON… LABOUR’S ATTACKS ON HIM

“They’ve got to be very careful they don’t become defenders of the health establishment when I think what the public are concerned about is some real problems with care.”

HUNT ON… ‘NUDGE’ V ‘NANNY’ IN PUBLIC HEALTH

“I think there’s room for both. There are some things in public health where you need to be a nanny, we’ve restricted the display of tobacco in supermarkets and shops, and there are other things where people need to take responsibility.”

HUNT ON… HOW HE RELAXES

“Relaxing is reading stories with my children – and very often finding that I end up going to sleep at the same time!”

 

 

 

 

 

 

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