NHS Reforms: An insider’s view

Health care professional NELLI FINN provides an inside account of years of NHS reform, a tale of competing trusts, contracting out, cost-cutting and chronically low morale.

I have been working for the NHS as an occupational therapist since 1995 and, apart from a couple of brief sojourns abroad and in the private sector, have spent most of that time in elderly psychiatry. In addition, I spent most of my teens and early 20s in and out of hospital for the management of a chronic physical condition. I guess you could say I have seen the NHS from all angles – hospital and community, physical and mental health, older adults, younger adults and dementias.

One of the persistent things I hear about the NHS is how impressed people have been, personally, with the treatment they or a loved one has received. I often think that is due to the selfless dedication of staff, despite current changes and reforms, rather than because of them.

One of the persistent myths we have about the NHS is that it is still one big homogenous organisation, as it was when set up in 1948. Of course, this is no longer the case.

Since Margaret Thatcher’s reforms in the late 1980s, which were encouraged and pursued with much zeal by new Labour in the ‘90s, the NHS has become a series of competing companies called “trusts” which bid for contracts like any other business. Parts of their service may be lost to private contractors which have submitted a better business plan. For example, the trust I work for covers mental health services over a wide area. Most towns we cover are provided with psychology services from the trust but one town has private psychological services because in that town we lost the contract.

Health has very much become a post code lottery where private contractors are looking for the easy stuff – people who are going to get well and get back into the labour market sooner, because that’s what this is all about. That leaves the NHS to pick up the pieces with the long-term sick, the elderly, and the non-profitable. What medication and procedures are available to you depends very much on where you live. For instance, medication for rare conditions may be available from your local trust in England but not if you move to Wales where you may be prescribed a cheaper but less effective alternative. Similarly, if you have fertility issues due to a diagnosed medical condition you can get free IVF treatment if you live in Nottinghamshire but not if you live in Oxfordshire.

These inconsistencies came about due to attempts to make treatment better fit local populations. For example, towns with high south west Asian populations have higher instances of diabetes, because it’s more likely to occur in that community, and therefore their resources should reflect that. However, rare and incurable conditions cause the government a great headache because people who suffer from them do not return to the work place. One might think, in the current economic climate, that it would be pointless to worry about getting sick people back to work when we can’t find jobs for the healthy. However, disability rights groups have been campaigning for years to get more support to enable disabled people and people with long-term conditions to participate fully in the working community and be self-supporting.

Good intentions

Many NHS reforms start out from consultation with health care professionals and patient groups, and often have good intentions. Everyone had been saying for years that many groups, such as the elderly and people with long-term mental health problems, would be better cared for in the community rather than in hospitals and large institutions. If care in the community had been organised properly it would have cost more than care in hospitals, but the government of the time saw it as a cost-cutting exercise.

Similarly, routine operations, such as hip and knee replacements, might best be contracted out to private hospitals if it is quicker and we have an efficient way of paying that hospital. This would free-up NHS surgeons to do more complicated and life-saving surgery. But it needs to be properly regulated by the Department of Health and not left to chance, as was the case with the German locum, Dr Daniel Ubani, who came to work here in February 2010 and made some vital medication mistakes on his first night.

One of the bug bears of any NHS employee who has worked in a hospital or trust is the woeful lack of equipment, the abundance of faulty equipment, and the cost and time it takes to get basic maintenance done. Take asking for a whiteboard to be put up in an office. After numerous visits by workmen you may be given a quote for as much as £107, but cheaper, local contractors cannot be bought in because the trust has a contract with this particular company, one which may last as long as 30 years.

Indeed, many of the buildings and maintenance contracts stem from the 1990s when it was decided that non-medical work could be contracted out. This has led to some very awkward, bad business decisions that have cost the NHS untold expense and, in some cases, such as food and cleaning, have also compromised patient safety and health.

For example, in our day hospital we ended up with one cleaner instead of four. When she was on holiday the contract cleaners from upstairs would come down to empty the bins and fill up the paper towels but no other cleaning was allowed because they had plenty of wards to clean themselves. The result was that every time our cleaner went on holiday the day centre would be hopping with fleas from the elderly people attending with serious neglect and hygiene issues. We would try and give them a bath if they were willing but we couldn’t prevent the fleas without taking on the cleaner’s job, which we did not have time to do.

One of my most enduring memories of being a patient in 1984 was being woken every morning by a lady mopping under my bed at 6am making the whole ward stink of bleach. It was irritating at the time but we did not have MRSA infections then. These days, thanks to our risk-averse compensation culture, cleaners are not allowed to use any substance stronger than soap and water in case a patient has an allergic reaction.

Similarly, many hospitals and day centres (those that are still open) no longer employ cooks on site and all their meals are cooked at a larger hospital up to 50 miles away. The meals arrive frozen and are heated up by people with very little nutritional training. Once, when staff asked where the vegetables were, they were told the spaghetti hoops were the vegetables! One worries for diabetics and patients with eating difficulties.


It is these kinds of discrepancies that get staff and patients worked-up. We love our NHS. We want to save it, but we do recognise things need to change. Many of the reforms suggested by Thatcher, and instigated under Blair, need to be examined and reversed. Blair went further than Thatcher ever could in privatising and contracting out because he was more popular at the time and riding a wave of enthusiasm.

Blair’s government also continued with Thatcher’s idea of dividing social and health care. The idea was that patients should pay for the first so they could continue getting the second “free at the point of delivery”.

This led to artificial divides, particularly in terms of mental health where, in places like elderly day centres it is very difficult to say that a craft activity or a game of bingo is not contributing to someone’s health and well-being. In the view of the budget holder these activities are just “social” and need to be paid for. What we have found, however, is that people with dementia and/or long-term mental health problems do not always fit easily into ordinary social day care and require specialist mental health staff. This is one of the areas where we are going to feel the cuts most as the health sector will try to discharge long-term clients into social day care and social services which are themselves being cut, are operating under an ever narrower criteria.

There were some good things done by new Labour. The NHS received a lot more money under the Blair government and waiting times did go down. However, we became obsessed with targets and the tick box culture. So much of health care professionals’ time is now spent sitting at a computer fulfilling outcome measures as part of the payment-by-results system that there is less and less time to see patients and service users.

We are also witnessing a rise in safeguarding referrals. The declining morale and numbers of social workers and police officers means that health care and teaching staff, like any number of public sector professionals, are increasingly expected to take on substantial amounts of work around investigations into different types of abuse. At one time such cases would have been dealt with by social services or the criminal justice system.

What’s more, in the interests of cost, some trusts are moving towards recruiting generic, lower-paid staff to cover all health care work without having to pay a qualified nurse or Allied Health Professional. Typically, now all the interesting and creative work done with individuals on community rehabilitation is no longer carried out by nurses and occupational therapists but by health care assistants who survive on the minimum wage, or just above it, and who are often propping up the NHS by using their own mobile phones and cars, not claiming expenses, and not claiming petrol or bus fare. This is either because they have not been told they can claim, or they simply do not have time to fill in all the paperwork and gather up the receipts.

Contracts, top-heavy management, unrealistic targets, and a huge and impossible bureaucracy are what breaks staff morale and makes them leave in droves. What I would like to see is:

  1. quicker decision making to get things done at all levels
  2. better community resources particularly for elderly people and all those with mental health conditions
  3. more time to treat and innovate rather than just assess and outcome
  4. cleaning, maintenance and nutrition brought back within the NHS remit – to say that none of these is to do with health is to miss the point.
  5. an end to the artificial divide between social and health care. Quite often you can’t have one without the other.

These are just a few thoughts from the inside. It will be interesting to see where the coalition government takes us next. Union activity has tended to focus on staff pensions whereas wider campaigns have been trying to stop privatisation. Many health staff just want to do the jobs they were trained to do, and get the best for their patients regardless of who is in government.

The author is writing under a pseudonym.