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A Health System in Permanent Self-isolation

This week’s High Court judgement makes clear that NHS policy to discharge patients into care homes and not keep them apart was ‘irrational’.  But, as Dr Tony Hockley explains, no report to date, however shocking, has succeeded in prompting the cultural change needed to prioritise the nation’s health over the National Health Service.

How did England fail the plan to “cocoon” care homes from Covid? This week’s outcome from a Judicial Review into two of the 20,000 care home deaths during the pandemic’s first wave shed more light on a health system that had already spent 74 years in self-isolation from public health.

The Judgment described the government’s policy to discharge patients from hospitals to care homes with no requirement to try to keep these patients apart from other residents as “irrational”. The judgment makes for worrying reading. Amongst all the experts advising on Covid policy, it was the Minister for Social Care who seemed a lonely voice in Whitehall for the care sector. Twas ever thus.

Since its creation as a new national religion in the 1940s any other contributors to health have been demoted to foot servants of our hospitals. Critics have been treated as heretics and complainants shunned. We all owe huge debts to the bravery of those who have dared challenge the orthodoxy when their awful experience has not matched the rhetoric: From Barbara Robb’s campaigning in the 1960s, to Julie Bailey’s constant pressure on ministers to address scandalous care at Mid-Staffordshire, and to the parents determined to expose failings of NHS maternity care at Morecombe Bay and at Shewsbury and Telford. It takes extraordinary resolve to be a lonely voice in English health and care policy. Similarly, small groups of determined practitioners, care groups and charities work locally to buck the system as best they can.

It is NHS hospitals that get the attention, not those who work so diligently to keep us out of them. Of course, this is nothing new. It has been widely accepted for decades that we have a national treatment service, not a health service, in which public debate concentrates on the most tangible inputs (“How many new hospitals?”), not outcomes. Report after report has repeated this analysis, and the official reports keep coming. It is reported that the forthcoming Messenger Review will inform us that NHS leadership is overly “task focused”. And the news is?

Just as the latest health system reform bill ends its course through Parliament the rumblings of the next task-focused restructuring have begun. In March 2022 the Health Secretary announced his belief that what our health system needs is “one of the most comprehensive reform plans that this country has ever seen”. He’ll be hard-pushed to be more comprehensive than the 2012 reforms “so big you could see them from space”.

Reforms are popular because they look like “something is being done”. Inventing and re-inventing the wheels of health policy generate a frenzy of visible activity in response to the latest crisis. Meanwhile, of course, social care will be “fixed”, more nurses and doctors will be “produced”, and everything will be better “integrated”. Many of us thought, for a moment, that the latest special increase in National Insurance contributions (NICSs) was going to prompt a step-change in social care. Once again the NHS takes the vast majority of the funds raised, just a little better than Gordon Brown’s NIC increase 20 years earlier which was used wholly to fund a temporary NHS spending boom.

Despite the persistent rhetoric of reform and integration it is evident that health spending and health policy continue to take place in splendid isolation. The health consequences from the impact of this blinkered approach on other services are neglected, time and again. The harm done is made worse by a concentration within health policy on facilities not people. Will this change? Not one of the shocking reports produced to date has prompted the cultural change needed to prioritise National Health over the National Health Service. The next will be the UK Covid-19 Inquiry. We can but hope. If the inequities of the pandemic do not shake our health system from its self-isolation from public health then nothing will.

Dr Tony Hockley

Dr Tony Hockley is a Visiting Senior Fellow at the Department of Social Policy at the London School of Economics & Political Science. He is Director of Policy Analysis Centre Ltd and the co-author of Politeia’s Working Systems: Towards Safer NHS Nursing (2014) and A Premium on Patients: Funding the Future NHS (2010).

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