David Oliver: Outdated rants provide no solutions for a modern NHS

Earlier this week, Norman Tebbit, a high profile cabinet minister and spokesperson during Margaret Thatcher’s government, used a Daily Telegraph column to share his views on solutions for the crisis in the NHS

It makes for grim reading. I am not sure what relevant expertise Tebbit has to imbue his opinions with such certainty. He has not been a cabinet minister since 1987, never had a ministerial health portfolio, and has never worked in the NHS. Although his piece made comparisons between the NHS and the armed forces, he has not worked in the military since he left the Royal Air Force in the 1950s. Still, let’s see what he has to say. 

Lord Tebbit starts by noting that the NHS was the issue he found voters to be most exercised and energised by. (Here the newspaper helpfully inserts an Ipsos Mori polling graphic showing that the NHS does, indeed, repeatedly top the public’s  list of concerns.)

He goes on to argue that hospitals are facing the challenges imposed by an increasingly ageing society, with more and more people beset by the physical, mental, financial, and social problems of old age, “exacerbated by a weakening of the family structure.” 

Tebbit asserts that “just pouring in more [money] without major reforms will not make things much better,” before describing health and social care as if the entire model is hospital wards, rather than primary and community care—where most services are delivered and most consultations occur. 

Tebbit omits any mention of social care—an issue that, after 10 years in power, the Conservatives have failed to provide meaningful solutions for. We all know that the “weakening of the family structure” he finds fault with is unsubtle code for “unpaid family members should do more caring.” Yet families are already providing the vast majority of care to older people, often with little support and at cost to their own wellbeing or employment. Their input represents a massive, free public good. 

Nor is Tebbit minded to discuss the role of inequalities or wider social policy in the causation and prevention of long term conditions. Deprivation contributes to the early onset of ill health in people still well below late old age, yet this reality is bypassed here. 

And what of funding for the NHS? Tebbit acknowledges that increased funding is important, yet there has certainly been no “pouring in” of cash in recent years. Since the NHS was established, it has on average seen annual funding increases of around 4% in real terms, yet this fell to around 1.5% in the years after the 2010 election and the imposition of austerity. With funding for local government, social care, and public health serially slashed, this has had predictable effects on services for the very people, whether older or from broken family units, that Tebbit seems to think are behind the crisis. 

But what were his two big ideas? 

Firstly, “All too many of the hospitals facing those challenges are poorly organised and would benefit from the introduction of the disciplines taught to Army officers under training at Sandhurst.” Alongside managers trained in the “Sandhurst style,” matrons who would be more like “sergeant-majors” would “transform” hospitals. 

I am not sure that a demoralised and increasingly depleted nursing workforce will respond well to 1950s, national service style shouting and square bashing to knock it into shape. In reality, the NHS already has a well established management training scheme and a whole cadre of people with operational and financial management skills, many of them with strong clinical backgrounds and a string of qualifications. It also invests in local and national leadership development. Healthcare and its organisations are every bit as complex and safety critical as military organisations. 

Secondly, Tebbit trots out a well worn trope for the Telegraph and Daily Mail in his vilification of nursing degrees. These qualifications, he argues, leave nurses unwilling and “ill-suited” to face the “messy business” of “giving intimate personal care” to “seriously ill or dying patients in a hospital bed,” and has allegedly “led to a fall in standards of patient care.” We should, he claims, “return to the former system of training would-be nurses in training hospitals. There, spells acquiring bedside skills alternated with desk-based technical and medical training.”

Not only is there no credible evidence to support his claims about falling care standards, but peer reviewed research has shown that across several EU nations, outcomes and patient safety improve in clinical teams with a higher percentage of graduate nurses. His notions of nurse training requirements in 2020 (rather than the middle of the last century) don’t seem to take into account that nursing degrees require 2300 hours of ward based practice. And doesn’t he understand that “seriously ill” patients require highly educated, technically competent nurses—not just in acute hospital beds, but in a variety of other settings where nurses practice autonomously.

The military comparisons are doubly unhelpful. With a workforce crisis intensified by austerity, reports of former troops suffering ongoing moral injury and post-traumatic stress, dilapidated accommodation blocks, issues with over-costly procurement of outdated equipment, reports of suppressed scandals involving bullying, and transient government ministers with no senior experience of the sector, the military has many parallels with the NHS. 

I suspect that Tebbit and his views will go down very well with sections of the Telegraph readership. It will generate lots of clicks, comments, and letters from people whose biases have been confirmed. Yet it has nothing informed, insightful, or useful to add to the serious debate about the present or future state of UK health and social care.

David Oliver has been a NHS doctor for 30 years, is a former government adviser and vice president of the Royal College of Physicians, and writes a weekly column in The BMJ. Twitter @mancunianmedic 

Competing interests: None declared.