tag:theconversation.com,2011:/fr/topics/department-of-health-21498/articlesDepartment of Health – The Conversation2023-06-27T14:52:52Ztag:theconversation.com,2011:article/2080902023-06-27T14:52:52Z2023-06-27T14:52:52ZHow the NHS’s original vision to design healthier hospitals fell into disrepair<figure><img src="https://images.theconversation.com/files/534381/original/file-20230627-21-xd13tl.jpg?ixlib=rb-1.1.0&rect=5%2C2%2C1764%2C1114&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When St Helier Hospital in Carshalton opened, it was viewed as the last word in modernist design.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Student_Nurse-_Life_at_St_Helier_Hospital,_Carshalton,_Surrey,_1943_D13888.jpg">Imperial War Museum Archives via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><blockquote>
<p>Outpatients at St James’ Hospital feel better even before they see the doctor – thanks to a new note in hospital design. ‘Comfort while you wait’ is the new policy, and that means an informal atmosphere, extra comfy chairs, concealed lighting, heated cork floors, and an ultra-modern design throughout. No shades of depressing institutions here.</p>
</blockquote>
<p>You might think this description comes from the glossy marketing material for one of today’s cutting-edge private hospitals. In fact, it’s from a <a href="https://www.youtube.com/watch?v=qygR9TwXHbU">1954 Pathé News clip</a> celebrating one of the earliest buildings designed for Britain’s fledgling National Health Service (NHS) – launched six years earlier on July 5, 1948.</p>
<p>What St James’ Hospital in Balham, south London, lacked in size, it made up for in ambition. The new central complex embodied the stated ideals of the NHS, to provide an equitable service for all citizens, free of charge and of the highest standard. The new buildings contained consulting rooms, staff offices and waiting rooms, and a children’s room that was lauded by the Pathé commentator:</p>
<blockquote>
<p>In the children’s room, the longer the youngsters have to wait, the better they like it. They can play as loudly as they like, for in their own room their chatter and high spirits can’t worry other patients … It’s no wonder that in this hospital, some of the children and their parents come a little early for their appointments on purpose!</p>
</blockquote>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/qygR9TwXHbU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A tour of the newly opened St James’ Hospital in Balham (1954)</span></figcaption>
</figure>
<p>As we take stock of the NHS on the occasion of its 75th anniversary, most attention is focused on staff pay demands, lengthy waiting lists for treatment, and the intolerable pressures on staff during and beyond the pandemic. But the design and upkeep of NHS hospital buildings, and the impact these can have on the patients and staff who inhabit them, is another <a href="https://www.itv.com/news/2023-02-21/patient-safety-at-risk-from-crumbling-nhs-hospitals-in-urgent-need-of-repair">pressing</a>, if less widely publicised, issue.</p>
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<img alt="" src="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533674/original/file-20230623-7118-vgag2i.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>To mark the 75th anniversary of the launch of the NHS, we’ve commissioned <a href="https://theconversation.com/topics/how-to-fix-the-nhs-140880?utm_source=TCUK&utm_medium=linkback&utm_campaign=UKNHSseries">a series of articles</a> addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.</em></p>
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<p>I believe we can find answers to at least some of today’s health service problems by looking at the history of these buildings, and the shifting design priorities they reflect.</p>
<p>The story of St James’ Hospital is a case in point. Less than 40 years on from the proud launch of its new central complex, the entire hospital stood empty and ruinous – a symbol, perhaps, of the failed ambitions of the early NHS. The buildings were demolished in 1992, and the site was redeveloped for housing.</p>
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<a href="https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Overgrown and disused hospital building with graffiti" src="https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=546&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=546&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532864/original/file-20230620-25-e74oss.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=546&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">St James’ Hospital outpatients department in 1991, prior to its demolition.</span>
<span class="attribution"><span class="source">Harriet Richardson Blakeman</span>, <span class="license">Author provided</span></span>
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<h2>Parts of this hospital are sinking</h2>
<p>Another south London hospital was in the news recently. “Patient safety at risk in crumbling hospital Boris Johnson promised to replace,” read a <a href="https://www.theguardian.com/society/2023/may/13/patient-safety-at-risk-in-crumbling-hospital-boris-johnson-promised-to-replace">headline in the Observer</a>, describing conditions in St Helier Hospital, Carshalton.</p>
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<a href="https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Crumbling hospital building" src="https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=685&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=685&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=685&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=861&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=861&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532895/original/file-20230620-24-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=861&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">St Helier Hospital, Carshalton.</span>
<span class="attribution"><span class="source">Harriet Richardson Blakeman</span>, <span class="license">Author provided</span></span>
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<p><a href="https://en.wikipedia.org/wiki/St_Helier_Hospital">St Helier was built</a> just before the outbreak of the second world war, constructed on reinforced concrete foundations with a steel-frame and brick infill, faced in white-painted cement render. At the time, it was regarded as the last word in up-to-date modernist design, with “accommodation of the highest class in any part of the world”.</p>
<p>Now, parts of this hospital are sinking. The basement floods, wards are sometimes forced to close, and the hospital has become “dilapidated and unpleasant”, <a href="https://www.theguardian.com/society/2023/may/13/where-are-the-tories-promised-40-new-hospitals-we-cannot-afford-to-wait-any-more">according to Ruth Charlton</a>, chief medical officer of Epsom & St Helier University Hospitals NHS Trust. In a recent commentary, she wrote:</p>
<blockquote>
<p>Our ageing estate looked awful even when I joined, and over the years it’s decayed further before my eyes. Healthcare standards are getting higher while our hospitals are sliding into even more disrepair … Only last week we had to close one of our wards because the lift wasn’t working.</p>
</blockquote>
<p>Nor is this an isolated case. In April, a <a href="https://twitter.com/doctor_oxford/status/1643894825182285827?s=20">tweet</a> by palliative care doctor and author Rachel Clarke showed “an actual interior corridor of a major NHS hospital”. The photograph looks like the bowels of a particularly unsavoury multi-storey carpark, yet the reflection in the mirror clearly shows it is an internal space. The paint is peeling, the damp so bad that a streak of green algae is running down the corner of the room.</p>
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<p>Along with such images of decay and dereliction, we have also seen images of egregious overcrowding over the past few years, as COVID-19 put extreme demands on NHS facilities that were already creaking badly. <a href="https://www.theguardian.com/society/2022/jul/14/hospital-patients-being-treated-in-corridors-and-waiting-areas-says-rcn">Accounts</a> of patients being treated in corridors and even in <a href="https://www.thetimes.co.uk/article/patients-treated-in-car-parks-as-a-e-crumbles-under-pressure-lnxqgd6nf">hospital car parks</a> continued last winter, even when the COVID threat had receded somewhat.</p>
<p>In January 2023, Alice Kenny, a junior sister at Queen’s Hospital in Romford, east London, who had been redesignated as a “corridor nurse”, <a href="https://www.bbc.co.uk/news/uk-england-london-64226656">told the BBC</a>:</p>
<blockquote>
<p>We don’t train to give care in corridors. It is really not nice and if we were in [our patients’] shoes, we’d be really upset as well. We’re supposed to look after patients like we do our own family, and we’re not able to do that.</p>
</blockquote>
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<figcaption><span class="caption">Interviews with staff forced to look after patients in corridors at Queen’s Hospital, Romford.</span></figcaption>
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<h2>The ideas and ideals of early NHS designs</h2>
<p>As the architectural history of the NHS is such a huge subject, I have mainly focused on Scotland where I live and can access the official records – some of which have only become available to researchers in recent years. This has provided fresh insights into the ideas and ideals behind the design of the first purpose-built hospitals built by the NHS.</p>
<p>The problems back then were not dissimilar to those faced today: old worn-out buildings, staff shortages, rising costs and economic austerity. Take Old Monkland Home in Coatbridge, to the east of Glasgow – one of the 3,000-or-so hospitals that were transferred to state ownership when the NHS came into being in July 1948. A review of this <a href="https://www.workhouses.org.uk/OldMonkland/">former poorhouse</a>’s facilities, published in a <a href="https://archive.org/details/b32179121_0005">national hospital survey</a> before the end of the second world war, was damning:</p>
<blockquote>
<p>Old Monkland Home occupies a depressing site in Coatbridge. The hospital part now contains 69 beds, and there is also an asylum for milder types of lunatic … The impression is one of general neglect. The dining-room is very gloomy, the hospital is very little better than the main house, and the asylum block is totally unsuitable for patients of any kind. We are of the opinion that this institution is quite unsuitable for the care of the sick, and should be abandoned.</p>
</blockquote>
<p>The NHS had inherited a patchwork of hospitals, predominantly over half-a-century old, that had been built to meet the medical needs of the time: sanatoria for tuberculosis, isolation hospitals for once-common infectious diseases such as measles and diphtheria, and cottage hospitals run by country GPs who carried out routine surgery, delivered local babies, set bones and treated wounds from accidents.</p>
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<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
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<p>There were also large urban workhouse infirmaries full of chronically ill elderly patients, huge mental hospitals, teaching hospitals, and convalescent homes. Funding to build and run them came from a wide range of sources, including public donations, church collections, the rates, government loans, and work-placed insurance schemes.</p>
<p>These buildings had been “built to last” 100 years or more (brick or stone buildings that were expensive to construct were only economically viable if they had a long lifespan). But they suffered from a lack of structural maintenance and redecoration during the war, and afterwards from the severe shortages of labour and materials.</p>
<p>The UK-wide survey of hospitals had been intended to inform post-war reconstruction and the development of a “<a href="https://wdc.contentdm.oclc.org/digital/collection/health/id/208/">national hospital service</a>”, which aimed to “ensure that every patient requiring hospital treatment could obtain it without delay in the hospital most suited to their needs”. In reality, it painted a picture of uneven distribution and poor facilities, with the worst of the buildings being the old workhouses:</p>
<blockquote>
<p>Wigtownshire Home, Stranraer, has not undergone any appreciable change since it was built about 1850. The building is worn out and dreary … This is a very poor place, and is quite unsuitable for housing the sick or aged, or indeed for any other purpose.</p>
</blockquote>
<p>In the immediate post-war years, new housing was the most urgent requirement throughout Britain, along with new schools after the <a href="https://www.nationalarchives.gov.uk/cabinetpapers/themes/butler-act.htm#:%7E:text=The%20Education%20Act%20%2D%20or%20'Butler,into%20primary%20and%20secondary%20schools.">Butler Act of 1944</a> raised the school-leaving age to 15 (with a post-war baby boom to follow). Yet there was also a widespread consensus among the public that the current level of healthcare provision was no longer acceptable. A new type of hospital facility was needed to reflect the scientific advances of medicine and the aspirations of post-war Britain.</p>
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<figcaption>
<span class="caption">A postcard extols the futuristic design of Vale of Leven, the NHS’s first new general hospital.</span>
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<h2>A five-star ‘hospital of the future’</h2>
<p>These aspirations found physical form in the <a href="https://historic-hospitals.com/2016/04/10/vale-of-leven-hospital-the-first-new-nhs-hospital-in-britain/">first new general hospital</a> built in Britain for the NHS, which <a href="https://www.facebook.com/savethevale/videos/aother-old-video-of-the-vale-hospital-thank-you-for-these/209682076082610/">opened</a> in Scotland in 1955 at Vale of Leven to the north-west of Glasgow. One of its most striking features were the wards, which were dramatically different from the traditional “Nightingale-style” open wards that offered no privacy to patients.</p>
<p>At Vale of Leven, the beds were grouped in bays separated by glazed screens. Ceiling heights were lower to create a more homely feel. The day room was furnished like a domestic sitting room, with comfortably upholstered armchairs. Windows were set low enough in the walls for patients to be able to see the grounds while lying in bed – and they also provided natural ventilation, allowing fresh air and the sound of birdsong to enter each ward.</p>
<p>Facilities for staff were an important consideration, as <a href="https://archive.org/details/sim_architect-building-news_1955-09-29_208_13/page/n35/mode/2up?q=%22Vale+of+leven+Hospital%22">the Architect & Building News</a> explained:</p>
<blockquote>
<p>A nurse’s station is an L-shaped counter containing knee space, drawers, filing cabinets etc, with a dwarf glass screen to cut off draughts, record board and shaded reading light, and small cupboards behind in the storage wall. The station is raised on a low step so that, when sitting, the nurse has a view of her 13 beds and, in fact, is only 25 feet away from her farthest patient and is quickly conscious of any movement or disturbance. Signal lights from beds are placed so that they can be seen from either of two nurse’s stations in case one is temporarily unoccupied.</p>
</blockquote>
<p>The subject of hospital design was now a hot topic among architects, health professionals and administrators alike – with an emphasis on the collaborative planning processes and research-led design that had evolved in more progressive architecture schools before the war. Schools such as the Architectural Association in London and Liverpool had developed a belief in social theory and managerial efficiency. Architects sought specialist advice on every aspect of the hospital, from the wards to catering and even laundries. As the regional architect for the South Eastern Regional Hospital Board wrote in 1951 about his new building schemes:</p>
<blockquote>
<p>It would be futile for medical science to progress and leave in its wake a dull, unimaginative architecture.</p>
</blockquote>
<p>Another reason for the extra care being taken over these new buildings was that, in the period of full employment in the 1950s and ‘60s, it was often proving difficult to attract enough hospital staff. The shortage of nurses, traditionally a female role, was especially acute because the rate of pay was lower than for many office jobs in the private sector – jobs that also offered shorter hours and fewer pressures than nursing.</p>
<p>To entice new recruits and enhance retainment levels, local management boards pushed hard to get well-appointed nurses’ homes built and to provide generous staff social and recreational facilities – from tennis courts to swimming pools, coffee bars to halls for cinema shows and dances.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/RMlFYzcJS78?wmode=transparent&start=2" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">An introduction to High Wycombe General Hospital: ‘Medical science, 1967-style’.</span></figcaption>
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<p>At this time, the opening of a new hospital was a newsworthy event, featured in the architectural and medical press, national and local newspapers, and in newsreels. The opening of the new High Wycombe General Hospital in the mid-1960s was met with another <a href="https://www.youtube.com/watch?v=RMlFYzcJS78">gushing tribute</a> from the Pathé News team:</p>
<blockquote>
<p>The spaciousness of the entrance and reception hall will give patients confidence that here they are meeting medical science 1967-style, equipped as it should be. Gone is the old atmosphere of healing on the cheap, gone too is the belief that staff of the hospitals should put up with third-rate food and bad quarters. The menus in the nurses’ dining room are varied and make eating a pleasure deserved by women whose devoted service goes far beyond the minimum they could get away with.</p>
</blockquote>
<p>I remember this hospital (more commonly known as Wycombe General) from not long after the film was released. It was where I had a tonsillectomy – then a routine operation – at the age of seven. I recall the hospital being shiny and modern, with toilets that were spotlessly clean and, unlike our loo at home, heated!</p>
<p>I remember the children’s ward being a bright sunny room with about eight beds, and a small dayroom where we had breakfast that was made rather cramped by an enormous toy cupboard, where a kind nurse hid my bowl of porridge which I could not eat. I had no trouble with the ice cream we were allowed to have in bed after our operations, though.</p>
<p>Our parents only visited for a short time during the day, but we didn’t seem to mind or feel anxious about it – perhaps in part because of the atmosphere in the hospital, where modern architecture conveyed, even to a young child, confidence in medical science. As the Pathé commentator concluded:</p>
<blockquote>
<p>There is a good reason for High Wycombe General being called a five-star luxury hospital. It’s part of the new approach to the art and science of getting sick people well.</p>
</blockquote>
<p>Fast-forward just over half a century, however, and Wycombe General is now <a href="https://www.bbc.co.uk/news/uk-england-beds-bucks-herts-65913081">“approaching its end of life”</a> and in “dire need of replacement”, according to the NHS trust that runs it. While confirming to the BBC that the hospital is still “safe”, the hospital’s ongoing repairs and maintenance now cost the trust around £2 million a year.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="External view of general hospital building" src="https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532896/original/file-20230620-28-46ld25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Wycombe General in May 2020: the hospital is ‘in dire need of replacement’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/high-wycombe-buckinghamshire-uk-05-18-1737902921">Ben Molyneux/Shutterstock</a></span>
</figcaption>
</figure>
<h2>The ambitious plan quickly comes off the rails</h2>
<p>Wycombe General was built following a period when funding for hospital building had increased by over 50%. In 1962, the UK government had published its <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1467-9515.1981.tb00662.x">Hospital Plan</a>, which promised that 90 new hospitals would be commenced in England and Wales by 1971. The plan was to provide a network of new district general hospitals evenly distributed around the country, so that everyone would be in easy reach of all the main hospital services, with just a few of the more unusual specialities based at a regional centre.</p>
<p>However, it did not take long for this ambitious plan to come off the rails. Not enough money had been pledged by the government to fund all the schemes that were proposed, the process of planning and design took a long time, costs escalated, and by 1964, comprehensive revisions had to be made. In successive years, the plans were scaled back.</p>
<p>By the mid-1960s, relatively little had been achieved and the policy of concentrating on district general hospitals was questioned. The <a href="https://hansard.parliament.uk/Commons/1969-05-23/debates/bc336ab2-a648-4657-82eb-8790c4de9597/Scotland(HospitalBuildingProgramme)">1966 revision</a> of the Hospital Plan refocused the building programme towards creating units for the elderly and mentally ill. Start dates for new hospitals were postponed and, to try to combat rising costs, stricter financial controls were introduced.</p>
<p>Despite this, there was still a belief in producing good quality buildings designed to meet the needs of modern medicine in attractive surroundings. As the Architects’ Journal put it when discussing the new staff restaurant and stores building at Kingston Hospital in Surrey:</p>
<blockquote>
<p>The matter of nurses’ meals is almost a household topic and, along with spectacles and false teeth, has been giving the health ministry a bad press.</p>
</blockquote>
<p>At Falkirk Royal Infirmary in Scotland’s central belt, meanwhile, an experimental surgical ward unit was designed around new ways of organising nursing on the lines of progressive patient care, while also making the nurses’ routines easier and reducing the amount of walking they would have to do. Hospital infection and resistance to antibiotics were already a concern in the 1960s, and engineers designed more sophisticated heating and ventilation systems to control the movement of airborne infections and prevent cross infection.</p>
<p>Unfortunately, such considerations cost more than the government was willing to spend, and no health minister of either political persuasion was able to convince the cabinet or the Treasury to provide the amount of money that the rebuilding programme was going to cost.</p>
<p>The 1970s was a period of devaluation of sterling, strikes and war in the Middle East that caused an oil crisis. There was a three-day week, petrol rationing and power cuts. This led to public spending cuts that only worsened the position for the hospital building programme. At the same time, there was widespread criticism of the amount of time it was taking to build each hospital, and concern that a number of recently completed hospitals had been found to have structural defects.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="View of hospital building with hills in the distance" src="https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532897/original/file-20230620-30-yaztzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Inverclyde Royal Hospital: the brutalist building took 15 years to finish and ran way over budget.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scottish-hospital-brutalist-architecture-greenock-inverclyde-2270853881">Richard Johnson/Shutterstock</a></span>
</figcaption>
</figure>
<p>A case in point is the saga of Inverclyde Royal Hospital in Greenock, west Scotland – one of the new district general hospitals promised in the original Hospital Plan. After a provisional cost limit of just over £4 million was approved in 1964, a design team was appointed the following year. However, the UK government halted the project for nearly two years due to a shortage of funds – a time when lots of large national projects were being halted. At the same time, the design brief had to be revised to keep up-to-date with technical guidance.</p>
<p>Amid new tenders, spiralling budgets and a further cost reduction exercise, work finally started on site in 1970, but the official contract completion date of March 1976 was missed, and the fabric of the building was eventually completed in November 1977 – only for the ventilation systems to be found to be defective.</p>
<p>It was not until the very end of 1979 that Inverclyde Royal Hospital was finally completed, at a cost of over £13m – more than three times the original cost limit. There was no single reason for the vastly increased cost, but the era’s high inflation rates were a significant factor. Each delay led to the cost going up, cancelling out the cost reduction exercise. Time and again on new hospital schemes, such exercise led to the use of poorer-quality materials and inferior heating and ventilation systems, which would cause problems with the building later on.</p>
<p>But more fundamentally, the new hospitals being built were now anticipated to last only between 40 and 50 years at the most. The reasons why this changed from the Victorian era when hospitals were built to last for a century or more, are many and complex. The main reason was the increasingly rapid advances being made in medical science, which led to a widespread view that the buildings would become obsolete as medical needs evolved.</p>
<p>But 40 is no age to be consigned to the scrap heap. We do not expect our homes to expire after such a short timespan – but equally, we understand that we need to invest in maintenance to keep them in good condition.</p>
<p>As the NHS celebrates its 75th anniversary, many of its hospitals built in the 1960s, ‘70s and early ‘80s have reached the end of their anticipated lifespan. As a result, the UK is now having to tackle the problem of large numbers of hospitals that have reached the end of their predicted lives.</p>
<p>Part of Johnson’s 2019 general election manifesto promised that <a href="https://www.gov.uk/government/news/pm-confirms-37-billion-for-40-hospitals-in-biggest-hospital-building-programme-in-a-generation">40 new hospitals would be built by 2030</a>. There was talk of “levelling up our NHS” and a determination “to build back better”. However, this plan was later exposed as something of a numbers trick or “<a href="https://www.bmj.com/content/381/bmj.p1259#:%7E:text=In%202020%2C%20when%20he%20was,of%20his%202019%20election%20manifesto.">mirage</a>”, with many of the “new” hospitals turning out to be extensions or refurbishments. In February 2023, <a href="https://www.theguardian.com/society/2023/feb/04/only-10-of-boris-johnson-promised-40-new-hospitals-have-full-planning-permission">the Observer reported</a> that only ten of the projects had secured full planning permission, with one NHS trust leader warning that: “Some hospitals are literally falling down.”</p>
<h2>Downgrading ambitions from ‘ideal’ to ‘adequate’</h2>
<p>Search for King’s Lynn’s Queen Elizabeth Hospital online, and you are likely to find multiple <a href="https://www.edp24.co.uk/news/health/20676118.behind-scenes-britains-dilapidated-hospital/">news</a> <a href="https://uk.news.yahoo.com/first-phase-replacing-crumbling-queen-110000118.html">items</a> about its dilapidated condition, demands to hasten its replacement, and images of ceilings being <a href="https://twitter.com/RootlessCosmo/status/1643896998771269632?s=20">held up by acrow props</a>.</p>
<p>“Isn’t it lovely,” the Duchess of Kent had told the Lynn Advertiser when she first entered the new hospital in July 1980. According to the same newspaper, the public had been similarly impressed when given guided tours of the newly completed building:</p>
<blockquote>
<p>Guides pointed out bright wards … most with outlooks over landscaped gardens. Mouths dropped as guides said patients would be able to choose the main course of their meals from a menu offering 17 options – and every three weeks, that menu would be changed.</p>
</blockquote>
<p>Yet, just 43 years later, the Queen Elizabeth has been described as “Britain’s most dilapidated hospital”. According to a report on the <a href="https://www.norfolklive.co.uk/news/norfolk-news/queen-elizabeth-hospital-kings-lynns-8062752">Norfolk Live website</a>:</p>
<blockquote>
<p>Patients lie in bed looking up at the [roof] supports … Regular checks take place every day to make sure the roof is not at more risk of collapse through holes in the concrete described as being ‘like an Aero chocolate bar’.</p>
</blockquote>
<p>The Aero bar analogy refers to the <a href="https://www.lboro.ac.uk/news-events/news/2023/march/reinforced-autoclaved-aerated--concrete-raac/">reinforced, autoclaved aerated concrete</a> (RAAC) used in the hospital roof’s construction, and in many other public buildings. In 2018, the roof of a primary school in Kent collapsed only a day after “signs of structural stress” had appeared in the staffroom ceiling. It transpired that the roof had been constructed of RAAC, which has an estimated shelf-life of just 30 years.</p>
<p>An initial investigation into the use of RAAC in schools has recently been <a href="https://www.theguardian.com/education/2023/jun/14/uk-public-buildings-feared-to-be-at-risk-of-collapse-as-concrete-crumbles">extended to look at public buildings more widely</a> – including hospitals. In May, a report on the Conservative government’s promise to build 40 new hospitals suggested that just five – <a href="https://www.theconstructionindex.co.uk/news/view/raac-crisis-prioritised-in-hospital-programme-reorganisation">those that had used RAAC in their construction</a> – were now being prioritised.</p>
<p>The Queen Elizabeth was one of the so-called “best buy” hospitals designed by the Department of Health & Social Security (DHSS) as a complete package. These were introduced in 1967 to remedy the problems of drawn-out design processes and escalating costs that had been derailing the NHS hospital building programme. It was a budget version of the district general hospital envisaged in the 1962 Hospital Plan, providing fewer beds per head of population in more confined spaces using simpler construction methods.</p>
<p>Standardisation and prefabrication were the principles of this design process, which was intended to provide an “adequate” rather than “ideal” hospital amid the country’s deep financial challenges of the 1970s. Hospital design was pared back to its essentials – a policy that has largely continued ever since.</p>
<p>The “nucleus” hospitals that followed from the mid-1970s were designed to limit new developments and major extensions to a nucleus of departments costing no more than £6 million (at 1975 prices). Every possible means of economising space and services was explored by the Hospital Building Division within the DHSS.</p>
<p>Crucially, a lower complement of beds per hospital was provided, based on the justification that earlier patient discharges would create a more intensive use of diagnostic and treatment facilities. In other words, Britain’s hospitals were now becoming high-turnover factory lines.</p>
<figure class="align-center ">
<img alt="External view of unusually designed visitor centre" src="https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532900/original/file-20230620-29-in15vt.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pushing architectural boundaries: the Frank Gehry-designed Maggie’s Centre in Dundee.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Maggies_centre_Dundee.jpg">Ydam via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<h2>Good design can be life-enhancing</h2>
<p>As hospitals at the end of their lifespan struggle to deal with patient overcrowding amid crumbling facilities, have decades of cost-cutting exercises when it comes to hospital design and construction turned out to be a false economy? Can a price be put on the damaging effects of poor hospital design on staff morale or patient health?</p>
<p>While we can put a figure on the cost of buying in agency staff to cover staff shortages or even major building repairs, less quantifiable is the impact on health and wellbeing of the buildings themselves.</p>
<p>But we know that good design <a href="https://www.maggies.org/media/filer_public/78/3e/783ef1ba-cd5b-471c-b04f-1fe25095406d/evidence-based_programme_web_spreads.pdf">can be life-enhancing</a>. Within the NHS, Maggie’s centres are a network of cancer drop-in centres unified by a groundbreaking commitment to <a href="https://www.dezeen.com/tag/maggies-centres/">pushing architectural boundaries</a>, with their multi-award-winning buildings having been designed by some of the world’s leading architects such as Frank Gehry and Zaha Hadid.</p>
<p>These centres, located throughout the UK and also in Hong Kong, offer “unique physical environments” created on the basis of a wide body of evidence that shows how aspects of physical space affect us.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/QtCTqRge5Bk?wmode=transparent&start=17" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Explaining the ethos of Maggie’s Centre in Manchester.</span></figcaption>
</figure>
<p>The impact of design on inpatient wellbeing has been a growing focus of research for many years, highlighting the importance of obvious elements such as access to nature, attractive surroundings, artworks on walls, single rooms for patients. There is, for example, <a href="https://www.sciencedirect.com/science/article/abs/pii/S1618866716303089">evidence</a> for the therapeutic benefits of “healing gardens”, and gardening or outdoor exercise is sometimes prescribed by GPs.</p>
<p>More recently, consideration of therapeutic spaces has broadened to include hospital staff as well as patients, in order to tackle the high levels of sickness absence, <a href="https://bolt.nuffieldtrust.org.uk/media/summit-2023-solving-the-workforce-burnout-crisis">distress and burnout among healthcare professionals</a> – levels that are higher in this sector than any other. Yet most solutions so far offered have been <a href="https://pubmed.ncbi.nlm.nih.gov/29200422/">short-term interventions</a>, rather than a fundamental reassessment of <a href="https://eppi.ioe.ac.uk/CMS/Portals/0/IPPO%20NHS%20Staff%20Wellbeing%20report_LO160622-1849.pdf">how the workplace should be designed</a> with staff wellbeing placed on the same footing as patient wellbeing.</p>
<p>Designing a hospital in which it is a pleasure both to work and be a patient is surely a goal worth achieving, and one which it is possible to justify on economic grounds. Spending more now on hospital buildings can save having to rebuild, at higher costs, in 20 or 30 years’ time. If done in such a way as to attract new staff, it can reduce the amount spent on agency fees.</p>
<p>Good design does not have to mean a new hospital, even if that is what people believe they want. Promising to build new hospitals is good publicity for any government, but it can also lead to <a href="https://www.theguardian.com/society/2023/may/25/broken-pledge-over-40-new-hospitals-will-leave-nhs-crumbling-ministers-told">damning headlines</a> about wildly increased costs and failed promises further down the line.</p>
<p>Good design can also be achieved through <a href="https://www.cam.ac.uk/stories/a-retrofitting-revolution">retrofitting</a>, by altering and adapting existing buildings. It is a more sustainable route and ideally would be the first option considered in the face of the present climate emergency. It is a complex issue, and retrofitting may be impossible in some cases – and very probably more expensive than a new-build in almost every other case. However, it addresses the issues of the embodied carbon in existing buildings.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/W1oiC4PG4Zw?wmode=transparent&start=10" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Finalists discuss their approach to the big question: how would you design and plan new hospitals to radically improve patient experiences, clinical outcomes, staff wellbeing, and integration with wider health and social care?</span></figcaption>
</figure>
<p>Political pressures to win public votes favours the quick fix. We need a new way of thinking about building, adapting and retrofitting hospitals that can deliver comfortable environments in a sustainable way for the long term, and to understand that cost-cutting today often leads to greater expense in the future.</p>
<p>In 2021, the <a href="https://policyexchange.org.uk/wolfson-economics-prize-2021/">Wolfson Economics Prize</a> set as its challenge the planning and design of the hospital of the future, specifically with a view to “radically” improving patient experiences, clinical outcomes, staff wellbeing and integration with wider health and social care.</p>
<p>The designers of British hospitals in the 1950s and ‘60s – in the early years after the launch of the bold new NHS – might be surprised to find we are still asking the same questions they set out to solve all those years ago.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p class="fine-print"><em><span>Harriet Richardson Blakeman receives funding from AHRC for doctoral research. </span></em></p>Today’s reports of crumbling, dilapidated and dangerous hospital buildings are a far cry from the design ambitions extolled by early NHS architects and planners.Harriet Richardson Blakeman, PhD Candidate, Architectural History, The University of EdinburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/865012017-10-30T17:16:31Z2017-10-30T17:16:31ZWannaCry report shows NHS chiefs knew of security danger, but management took no action<figure><img src="https://images.theconversation.com/files/192431/original/file-20171030-18689-132a24x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/wannacry-ransomware-attack-on-notebook-screencyber-644143564">supimol kumying/Shutterstock</a></span></figcaption></figure><p>A report from the parliamentary <a href="https://www.nao.org.uk/report/investigation-wannacry-cyber-attack-and-the-nhs/">National Audit Office</a> into the WannaCry ransomware attack that brought down significant parts of Britain’s National Health Service in May 2017 has predictably been reported as blaming <a href="https://www.nhs.uk/NHSEngland/thenhs/about/Pages/authoritiesandtrusts.aspx">NHS trusts</a> and smaller organisations within the care system for failing to ensure that appropriate computer security measures such as software updates and secure firewalls were in place. </p>
<p>But the central NHS IT organisation, <a href="https://digital.nhs.uk/">NHS Digital</a>, provided security alerts and the correct patches that would have protected vulnerable systems well before WannaCry hit. This is not a cybersecurity failure in the practicalities, but a failure of cybersecurity management at the top level. </p>
<p>Despite the extensive news coverage it received, WannaCry was a major wake-up call for the NHS rather than a downright disaster. It <a href="http://www.npr.org/sections/alltechconsidered/2017/05/16/528570788/from-kill-switch-to-bitcoin-wannacry-showing-signs-of-amateur-flaws">wasn’t a sophisticated attack</a>. But any attack based on an actual <a href="https://www.fireeye.com/current-threats/what-is-a-zero-day-exploit.html">zero-day exploit</a> – a software flaw creating a security hole that is not yet known to the manufacturer or has not been made public, and so no defence or patch exists to prevent the attack succeeding - could hit the NHS much harder than WannaCry did. </p>
<p>Given the lessons learned discussed in the NAO report, hopefully the NHS will be better prepared next time. And as there will definitely be a next time, the NHS had better have learned its lessons, because the implications of not doing so could be much greater.</p>
<h2>Failing to plan is planning to fail</h2>
<p>As it happened, much of the damage caused by WannaCry - including many of the more than 19,000 missed appointments – did not relate directly to the attack. The NAO report makes it clear that the NHS as a whole lacked a proper response to a national cybersecurity incident. The business continuity plan had not been tested against such a serious attack. Although <a href="https://www.nursingtimes.net/opinion/what-happened-when-the-nhs-was-affected-by-the-wannacry-ransomware-attack/7020962.article">only a relatively small number</a> of NHS organisations were actually infected by WannaCry, other parts of the NHS shut down their systems as a precaution to prevent WannaCry spreading until they were sure what to do. Email systems were switched off without first establishing alternatives, leading to improvisation by telephone and WhatsApp.</p>
<p>More broadly, it has become clear that decentralisation has left NHS cybersecurity very exposed when under attack. NHS Digital provides alerts and patches, of course, but there appears to be no mechanism for anyone to check, let alone enforce, that they are implemented. In any case, security alerts run a risk of being drowned in the stream of “cry wolf” messages from the cybersecurity industry. The NHS trust boards take little ownership of cybersecurity matters, and are not being held accountable because the <a href="http://www.cqc.org.uk/">Care Quality Commission</a>, the NHS regulator, has not included it in their inspections.</p>
<p>The official reaction from NHS Digital to the report was <a href="https://digital.nhs.uk/article/7908/NHS-Digital-responds-to-report-on-WannaCry-cyber-incident">brief</a> – no wonder, as it emerges from the affair having performed what was expected of it. NHS Digital offered on-site cybersecurity assessments at 88 NHS trusts in the years before the WannaCry incident, failing all of them. But without powers of enforcement, it was unable to press for the changes and preventative measures required to improve security. NHS Digital’s own review of the WannaCry incident (as mentioned in the NAO report) had established that most trusts did not even think that cybersecurity was a risk to patient outcomes – a naive and dangerous view in an organisation heavily dependent on integrated digital systems.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/192442/original/file-20171030-18700-1dxhffw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/192442/original/file-20171030-18700-1dxhffw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192442/original/file-20171030-18700-1dxhffw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192442/original/file-20171030-18700-1dxhffw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192442/original/file-20171030-18700-1dxhffw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192442/original/file-20171030-18700-1dxhffw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192442/original/file-20171030-18700-1dxhffw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The decentralisation of the NHS means that no one is in charge of enforcing the cybersecurity practices that would have prevented WannaCry.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/warrington-uk-march-6-2016-view-393927661">Marbury/Shutterstock</a></span>
</figcaption>
</figure>
<h2>No one left holding the reins</h2>
<p>The NAO report acknowledges that NHS trusts could not be blamed for some of the missing software updates. Some medical instruments such as MRI scanners are controlled by software written for old and unsupported versions of Windows, for example, or in some cases by companies that have since gone out of business. Decoupling these machines from the network would solve the most immediate cybersecurity problems, but at the expense of complicating their use and increasing the chance of human error. Neither the NAO nor NHS Digital appear to have a solution yet. </p>
<p>For small NHS organisations, such as individual GP practices, there is likely to be an issue of resources. Who will have the time, and at what point in their already full working day, to ensure computers are updated? Should the many NHS receptionists wait for their Windows updates to complete at the start of their day, or help their patients?</p>
<p>If the lack of resources doesn’t already point at government underfunding of the NHS, the report certainly points to failures at the national level, to <a href="https://www.england.nhs.uk/">NHS England</a> and the <a href="https://www.gov.uk/government/organisations/department-of-health">Department of Health</a>. Provided with cybersecurity recommendations by both <a href="https://www.gov.uk/government/publications/review-of-data-security-consent-and-opt-outs">the National Data Guardian</a> and the <a href="http://www.cqc.org.uk/publications/themed-work/safe-data-safe-care">Care Quality Commission</a> by July 2016, <a href="https://www.gov.uk/government/consultations/new-data-security-standards-for-health-and-social-care">neither body responded until July 2017</a>, months after WannaCry. The urgent need for effective, national-level cybersecurity incident planning in such a decentralised system as the NHS must be clear by now. </p>
<p>The NHS was spared the full impact of a cyber-attack this time, mainly because the technical solution – a “kill-switch” in the ransomware – was quickly discovered by <a href="https://www.malwaretech.com/2017/05/how-to-accidentally-stop-a-global-cyber-attacks.html">MalwareTech researcher</a> <a href="http://uk.businessinsider.com/marcus-hutchins-is-the-22-year-old-who-saved-the-world-from-a-malware-virus-2017-5?r=US&IR=T">Marcus Hutchins</a>. Next time the NHS might not be so lucky, though new research has been commissioned to this end. Projects such as EPSRC <a href="http://gow.epsrc.ac.uk/NGBOViewGrant.aspx?GrantRef=EP/P011772/1">EMPHASIS</a> will look at not only the technical aspects of ransomware attacks, but also their economic, psychological and social aspects to obtain a more rounded understanding of Ransomware. </p>
<p>Not only will this interdisciplinary approach increase our understanding of ransomware attacks, but it will also help us to quickly ascertain whether or not the attack is socially engineered – triggered by users opening attachments or clicking on infected web sites – or triggered through technological means such as by a worm, as was the case with WannaCry and <a href="https://securelist.com/expetrpetyanotpetya-is-a-wiper-not-ransomware/78902/">not-Petya</a> – the latter seeking to <a href="https://securelist.com/destructive-malware-five-wipers-in-the-spotlight/58194/">disrupt and destructively wipe data</a> without even attempting to extort money. It’s also important to understand the new means of payments via <a href="https://www.forbes.com/sites/forbestechcouncil/2017/08/03/how-cryptocurrencies-are-fueling-ransomware-attacks-and-other-cybercrimes/#8b9ef543c152">cryptocurrencies such as bitcoin</a>, because <a href="https://theconversation.com/cryptolocker-has-you-between-a-back-up-and-a-hard-place-20687">ransomware</a> is usually crime of extortion. With a better understanding of our attackers and their motivations we will be better placed to defend against them.</p><img src="https://counter.theconversation.com/content/86501/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eerke Boiten receives funding from EPSRC EP/P011772/1 EMPHASIS (EconoMical, PsycHologicAl and Societal Impact of RanSomware).</span></em></p><p class="fine-print"><em><span>David S. Wall receives funding from EPSRC EP/P011721/1 EMPHASIS (EconoMical, PsycHologicAl and Societal Impact of RanSomware) and he is a member of the RUSI SHOC (Strategic Hub on Organised Crime).</span></em></p>It turns out you can’t ensure cyber-security in the world’s fifth-largest employer if there’s no one in charge of making it happen.Eerke Boiten, Professor of Cyber Security, School of Computer Science and Informatics, De Montfort UniversityDavid S. Wall, Professor of Criminology, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/689342016-12-05T10:32:57Z2016-12-05T10:32:57ZMental health services should not be paid by outcomes<figure><img src="https://images.theconversation.com/files/148144/original/image-20161130-17044-qd8kvy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tell me about your outcomes.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/pic-490506961/stock-photo-psychotherapy.html?src=HlUEdfo2cGqLs8G-xL2dsg-1-75">Pressmaster/Shutterstock.com</a></span></figcaption></figure><p>The UK government <a href="https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf#page=27">promised</a> a “drive towards an equal response to mental and physical health” in England as part of a five-year plan. Two years later and there is little sign that any progress has been made. Calls to improve mental health services peaked this month when 20 years’ worth of former health secretaries wrote an open letter <a href="http://www.bbc.co.uk/news/uk-politics-38025401">criticising</a> the government for “warm words” but no action.</p>
<p>There is a consensus that more funding should reach mental health care. But what should be funded and exactly how? From April 2017, payments to adult mental health services must be linked to the quality and outcomes of care provided. National guidance published by <a href="https://www.england.nhs.uk/about/">NHS England</a> and <a href="https://improvement.nhs.uk/about-us/who-we-are/">NHS Improvement</a> <a href="https://improvement.nhs.uk/uploads/documents/Linking_quality_and_outcome_measures_to_payment_for_mental_health_FINAL.pdf#page=4">claims</a> that doing so will improve care, “ensuring value for money and the best use of limited resources”. But there is worrying evidence that doing so might have little impact and, at worst, actually be harmful to services.</p>
<h2>How will payment for performance work?</h2>
<p>The money flows are complex. Here is a picture showing key parts of the system.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/147737/original/image-20161128-22748-1n2iiil.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/147737/original/image-20161128-22748-1n2iiil.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/147737/original/image-20161128-22748-1n2iiil.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/147737/original/image-20161128-22748-1n2iiil.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/147737/original/image-20161128-22748-1n2iiil.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/147737/original/image-20161128-22748-1n2iiil.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/147737/original/image-20161128-22748-1n2iiil.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How funding flows to mental health services.</span>
</figcaption>
</figure>
<p>At the top end is the <a href="https://www.gov.uk/government/organisations/hm-treasury/about">Treasury</a>, which determines how much money health care receives, alongside all other public services. The Treasury does not directly determine how much money goes to mental health, however – <a href="https://www.whatdotheyknow.com/request/mental_health_budgets_2">it receives advice from below</a> in the hierarchy so it can calculate a total including all other areas of health.</p>
<p>The money flows on to the <a href="https://www.gov.uk/government/organisations/department-of-health/about">Department of Health</a>, <a href="https://www.england.nhs.uk/about/">NHS England</a>, then <a href="https://www.england.nhs.uk/ccg-details/">Clinical Commissioning Groups</a> which are distributed across the country. They may choose to commission an <a href="https://www.gov.uk/government/publications/nhs-foundation-trust-directory/nhs-foundation-trust-directory">NHS Foundation Trust</a>. They may also commission a commercial company such as Virgin Care, which <a href="https://www.theguardian.com/society/2016/nov/11/virgin-care-700m-contract-200-nhs-social-care-services-bath-somerset">recently won</a> a £700m contract.</p>
<p>Payment for performance will be at this final stage between commissioner and provider, and will be agreed locally between them. <a href="https://improvement.nhs.uk/uploads/documents/Linking_quality_and_outcome_measures_to_payment_for_mental_health_FINAL.pdf">National guidance</a> on how to implement the approach suggests that the chosen targets should be achievable yet stretching; informed by clinicians and people with experience of mental health problems; avoid creating an adversarial relationship between commissioners and providers; and should be used for the “reinforcement of positive behaviour”.</p>
<p>Oxford Health NHS Foundation Trust is <a href="https://improvement.nhs.uk/documents/234/MH_outcome_based_commissioning_update_note_v2.pdf">provided as an example</a> in the guidance. A fifth of its income will be linked to performance, which will include ensuring that people “improve their level of functioning”, determined using two measures. </p>
<p>One is the <a href="http://www.outcomesstar.org.uk/about-the-outcomes-star/">Mental Health Recovery Star</a>, which tracks the progress of people who use mental health services by their ability to manage their mental health and feelings of hopefulness. This measure is completed jointly by people who use mental health services and staff providing care (such as psychiatrists, psychologists or nurses). </p>
<p>The other measure is a checklist <a href="http://www.rcpsych.ac.uk/traininpsychiatry/conferencestraining/resources/honos/workingageadults/introduction.aspx">rated only by staff</a> which is used to track changes in symptoms such as depression and self-injury. The service has also promised its commissioners that it will ensure people live longer.</p>
<h2>Does payment for performance improve services?</h2>
<p>A recent systematic review of research <a href="https://www.ncbi.nlm.nih.gov/pubmed/27640342">found no evidence of impact</a> when payment was linked to health outcomes, such as how long people live – which makes Oxford Health’s choice of outcomes puzzling. There was a small benefit when payment was linked to what services actually did, for example, providing cancer screening or recording whether someone smokes, as this was much easier for services to control than were the consequences of care.</p>
<p>Given national advice to involve people who use mental health services in decisions about outcomes chosen, it is also curious that the recovery star has been chosen. An increasingly influential group who use mental health services, called <a href="https://recoveryinthebin.org/">Recovery in the Bin</a>, singled out the measure as “redundant, unhelpful, and blunt”, and suggested an alternative focusing more on the social causes of mental distress which are often ignored in outcomes.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=503&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=503&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=503&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=632&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=632&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146683/original/image-20161120-19371-1g7lvnl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=632&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">UnRecovery Star, developed by Recovery in the Bin as an alternative to an outcome measure used in services.</span>
<span class="attribution"><span class="source">Recovery in the Bin</span></span>
</figcaption>
</figure>
<p>Putting high-stakes targets on measures tends to mean that the measures stop measuring what they are supposed to measure because people cheat to achieve the targets. The effect is so common that it has a name: <a href="https://en.wikipedia.org/wiki/Goodhart's_law">Goodhart’s law</a>. For example, ambulance services had a target to get to the patient in eight minutes for life-threatening emergencies. This led to a third of services <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-985X.2008.00557.x/full">fiddling their timings</a> towards the target. </p>
<p>There are various subtle ways to cheat outcome measures in mental health, such as by not bothering people who drop out of services with questionnaires to complete. People who drop out are <a href="https://doi.org/10.1017/S0033291707001869">less likely to have benefited</a> from treatment, so excluding their answers from data analyses will improve a service’s apparent outcomes. Given the complexity of people’s experiences and predicaments, reducing them to scores on questionnaires can feel absurd, so it might be easy to justify this kind of gaming if it results in more funding which could improve the care provided. It seems especially easy for measures completed by staff who are under pressure from management to tick the right boxes.</p>
<p>Outcomes measures have <a href="http://onlinelibrary.wiley.com/doi/10.1111/camh.12086/abstract">an important role to play</a> in understanding and improving the care people receive and should be tracked as part of care, but linking them to payment risks demoralising staff and making the measures meaningless. This seems a dangerous path to take given the state mental health services are in. A better solution might lie further upstream at the Treasury when it decides how much money is available for mental health.</p><img src="https://counter.theconversation.com/content/68934/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andi Fugard has worked on projects funded by the Department of Health on mental health outcomes and payment systems and was a member of the NHS England/Monitor Quality and Cost Benchmarking Group. Andi is a member of the Labour Party.</span></em></p>From April 2017, payments to adult mental health services in the UK must be linked to outcomes. But it’s a bad idea.Andi Fugard, Co-Director of the Centre for Evaluation, National Centre for Social ResearchLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/625722016-07-21T10:18:44Z2016-07-21T10:18:44ZIs proposed strategy on childhood obesity really ‘pathetic’?<figure><img src="https://images.theconversation.com/files/131237/original/image-20160720-31134-nnf4cv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/s/overweight+child/search.html?page=2&thumb_size=mosaic&inline=148110578">bikeriderlondon/Shutterstock</a></span></figcaption></figure><p>If the UK’s obesity epidemic is not reversed, many people will endure avoidable illness and early death, at a huge cost to the NHS. The UK therefore urgently needs an obesity strategy. A draft of the government’s childhood obesity strategy, promised for <a href="http://www.bbc.co.uk/news/health-35640299">last autumn</a>, has just been leaked to a campaigning group called <a href="http://www.actiononsugar.org/index.html">Action on Sugar</a>, revealing that a few small steps forward may be proposed. But they will be far from sufficient. A bucket of water can’t put out a forest fire.</p>
<p>The problem of obesity first came to the attention of British government ministers in the early 2000s. It was not the Department of Health that was worried; it was the <a href="https://www.gov.uk/government/organisations/hm-treasury">Treasury</a>. Ministers realised that much of the extra resources allocated to the NHS were being used to treat a growing number of overweight and obese people. But the prime minister, Tony Blair, assumed that the problem could be left to <a href="https://www.theguardian.com/commentisfree/2014/jul/25/tesco-blair-hubris-power-delusional">supermarkets to put right</a>. </p>
<p>When Gordon Brown became prime minister, he wanted to initiate <a href="http://www.foodsecurity.ac.uk/assets/pdfs/cabinet-office-food-matters.pdf">fundamental reforms</a> to the UK food system, so in 2008 he commissioned a report. By the time the report was finally published, a coalition government, led by Conservative David Cameron, was in power. </p>
<p><a href="http://www.foodsecurity.ac.uk/assets/pdfs/cabinet-office-food-matters.pdf">The report</a> was in two parts: the first showed that the UK food system was ecologically, economically and nutritionally unsustainable. The second sketched a delightful future in which all problems had been solved. What was missing was any plan to get from here to there. Coalition ministers were not interested in the report’s contents. Within a month of its publication, they had forgotten about it. </p>
<h2>Education and information are not enough</h2>
<p>The Conservative health secretary, Andrew Lansley, promised the food industry he would not impose regulations they disliked. Instead of requiring the food industry to provide significantly healthier foods and drinks, in 2011 he invited them to participate in “<a href="https://www.gov.uk/government/news/public-health-responsibility-deal-announces-new-food-pledge">a responsibility deal</a>”, under which food companies pledged to reduce calories in their products. </p>
<p>Many signed up, but <a href="http://www.theguardian.com/politics/2015/may/12/food-industry-responsibility-deal-little-effect-health-study">very little was accomplished</a>. The government’s approach assumed that obesity could and should be solved by providing the public with <a href="http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4105709.pdf">education and information</a>. </p>
<p>Food labelling was slightly more informative than previously, especially with so called front-of-pack labelling. While consumers preferred traffic light labelling on the front of many food and drink packs, firms did not want <a href="http://adage.com/article/global-news/marketers-split-u-k-s-traffic-light-food-labeling-system/243054/">red warnings</a> on their products. They preferred numerical estimates of <a href="http://www.foodwatch.org/en/what-we-do/topics/traffic-light-labels/more-information/10-arguments/">nutrient levels in neutral colours</a>. Lessons on healthy eating were introduced into the <a href="https://www.gov.uk/government/publications/national-curriculum-in-england-design-and-technology-programmes-of-study/national-curriculum-in-england-design-and-technology-programmes-of-study">national curriculum</a> and advice on healthy eating was available on government websites. </p>
<p>Some restrictions were also introduced on the advertising of junk food during <a href="http://www.sustainweb.org/childrensfoodcampaign/junk_food_marketing/">children’s television programmes</a>, but similar restrictions did not apply to family programmes, such as soap operas, which many children watch. </p>
<p>Those measures were insufficient to reduce rates of overweight and obesity among children. The number of school-age children receiving treatment for obesity and related problems, such as type 2 diabetes, <a href="http://www.hscic.gov.uk/catalogue/PUB16988/obes-phys-acti-diet-eng-2015.pdf">continued to rise</a>. Small amounts of education and information were clearly insufficient, especially for children. </p>
<h2>Leaked strategy</h2>
<p>Reluctantly, ministers conceded that while their approach to adults would continue to focus on education and information, children need more. So a <a href="http://www.nationalhealthexecutive.com/Health-Care-News/ticking-time-bomb-childhood-obesity-strategy-delayed-to-summer">childhood obesity strategy</a> was promised, but has not yet been delivered.</p>
<p>The leaked strategy focuses mainly on one type of change, namely reformulation by manufacturers of processed foods, to cut the calories their products deliver. The draft only suggests a voluntary 20% reduction in added sugar by 2020, but consumer campaigners had been calling for a compulsory <a href="https://twitter.com/actiononsugar?ref_src=twsrc%5Etfw">50% reduction in sugar and for 20% less fat</a>. </p>
<p>The draft fudged the issue of introducing more effective controls on advertising and promotions of junk foods to children. It merely suggests another consultation, delaying further any action. </p>
<p>Reformulation may help a bit, but far more fundamental changes will be needed. Agricultural policies in the UK and Europe have encouraged the over-production of fats and sugars, and food processors have made a lot of money from buying cheap, plentiful and nutritious ingredients, and transforming them into relatively scarce, expensive and nutritionally impoverished products. Solving the problem of obesity in the UK will require far more than reformulation to cut sugars and fat by 20% or even 50%. </p>
<p>Action on Sugar has called David Cameron’s draft strategy “pathetic”. That description is not misleading, and my concern now is whether anything less pathetic will emerge from Theresa May’s government. Many who argued for Brexit want regulations weakened not strengthened, but that would mean the problems of obesity getting worse, not better.</p><img src="https://counter.theconversation.com/content/62572/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erik Millstone has received funding from the European Commission, and the Foresight division of the Government Office for Science. He is affiliated with numerous consumer and public health organisations.</span></em></p>Action on Sugar doesn’t think much of David Cameron’s childhood obesity strategy, but will May do any better?Erik P Millstone, Professor of Science Policy, SPRU, University of Sussex Business School, University of SussexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/594792016-05-17T10:04:10Z2016-05-17T10:04:10ZAre NHS patients really more likely to die at weekends? Here are the facts<figure><img src="https://images.theconversation.com/files/122698/original/image-20160516-15924-1qzze24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People admitted to hospital on the weekend tend to be sicker.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=kSbwT8GtuWbq0uWOvABszA-1-1&clicksrc=download_btn_inline&id=406082761&size=medium_jpg&submit_jpg=">spatuletail/shutterstock.com</a></span></figcaption></figure><p>Jeremy Hunt, secretary of state for health, and Philippa Whitford, a Scottish surgeon and MP, had a row about seven-day services during Hunt’s appearance before the Health Select Committee on <a href="http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news-parliament-20151/spending-review-health-minister-evidence-15-16/">May 9</a>. The issue has also featured in the acrimonious dispute about the junior doctors’ contract <a href="http://www.nhsemployers.org/your-workforce/need-to-know/junior-doctors-contract">negotiations</a> which reopened on the same day. </p>
<p>Hunt and Whitford tussled about the quality and interpretation of evidence about weekend mortality rates and whether we need a seven-day hospital service to set things right. Hunt referred to <a href="https://www.gov.uk/government/publications/research-into-the-weekend-effect-on-hospital-mortality/research-into-the-weekend-effect-on-patient-outcomes-and-mortality">evidence</a> compiled by the Department of Health. It comprises eight studies, of which only four are peer-reviewed articles, the others being reports. Hunt claims that these studies prove that hospital mortality rates are higher for those admitted over the weekend than during the week. Other studies have also found a “weekend effect”. But the effect is smaller when accounting for how sick patients are and it isn’t evident for all conditions. For instance, there is no weekend effect for <a href="http://bit.ly/1TgrYRj">stroke care</a>.</p>
<p>Whitford didn’t dispute the existence of a weekend effect, but said the higher weekend mortality rate is not because more people are dying. Rather the rate is higher because fewer people are admitted at the weekend and they tend to be sicker. This was the conclusion drawn by authors of a <a href="http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html">study</a> published a few days before the committee hearing. Unlike other studies, this made use of both accident and emergency and hospital data. It found a weekend effect only among those admitted to hospital, and it was mainly because they are sicker. The authors conclude that expanding services to seven days a week may cause the mortality rate to fall, but most likely because admissions will increase, not because fewer people will die.</p>
<h2>Hunt’s solution</h2>
<p>Hunt brought out a different message from the same study, saying that more stringent admission criteria shouldn’t be applied at the weekend. He wants four <a href="http://www.parliament.uk/documents/commons-committees/Health/Correspondence/2015-16/Letter-from-the-Secretary-of-State-for-Health-to-the-Chair-on-seven-day-NHS-hospital-services.pdf">priority clinical standards</a> to be met every day for all patients requiring urgent and emergency care. All emergency admissions should have a thorough assessment by a consultant within 14 hours of arrival at hospital; everyone in hospital should have access to consultant-directed diagnostic tests, and to consultant-directed interventions; and high dependency patients must be seen and reviewed by a consultant twice daily, and once a day after transfer to a general ward.</p>
<p>Notably, these standards all relate to the presence of consultants (senior doctors). But, to meet them, a whole range of diagnostic and support services must be made available as well as clinical cover provided by junior doctors. Junior doctors, however, object to plans to consider Saturday a <a href="https://fullfact.org/health/junior-doctors-pay-short-introduction-dispute/">normal working day</a> for calculating their pay.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Seven-day service is a central feature of the dispute about the junior doctors’ contract.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=7rfstA2OwnA3TqQS_KUN3g-1-27&clicksrc=download_btn_inline&id=412141594&size=medium_jpg&submit_jpg=">Ms Jane Campbell / Shutterstock.com</a></span>
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<p>The four standards were chosen as priorities by NHS England and the Academy of Medical Royal colleges set out by NHS England’s <a href="https://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf">Seven Days a Week Forum</a>. These are being rolled out across the country, the aim being that they will have been adopted by all hospitals by March 2020.</p>
<p>The standards have already been implemented in some hospitals. The day after the Hunt-Whitford debate, a <a href="http://bit.ly/22dn4tW">study</a> was published in The Lancet comparing hospitals that have implemented the standards with those that have not. This found that patients admitted on Sundays get less than half the attention from consultants than those admitted on Wednesdays. But it also found that variation across hospitals in how much time consultants spend with patients is not associated with the hospital’s mortality rate. So it cannot be said that mortality rates can be reduced simply by increasing consultant cover.</p>
<h2>Where does this leave us?</h2>
<p>Clearly, more evidence is required. First, it remains unclear whether the weekend effect is just a <a href="http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html">statistical artefact</a> or whether there is a real problem with a clear cause. </p>
<p>Second, studies should capture a broader array of <a href="http://bit.ly/1YuC6cw">outcomes</a> than just mortality. Even if seven-day services don’t reduce mortality rates, patients may still be better off.</p>
<p>Third, we need to know the costs of the policy. On May 11, the Public Accounts Committee offered <a href="http://bit.ly/1ZEdLBt">harsh criticism</a>, saying: </p>
<blockquote>
<p>no coherent attempt has been made to assess the headcount implications of major policy initiatives such as the seven-day NHS … It beggars belief that such a major policy should be advanced with so flimsy a notion of how it will be funded…</p>
</blockquote>
<p>Finally, implementation of seven-day services was a <a href="https://www.gov.uk/government/news/prime-minister-pledges-to-deliver-7-day-gp-services-by-2020">manifesto commitment</a>. But mortality rates for patients admitted <a href="http://bit.ly/1TgrYRj">overnight</a> are higher than for those admitted during the day; and they are higher for <a href="http://www.nets.nihr.ac.uk/projects/hsdr/11200439">poorer</a> than richer patients. If we want to reduce hospital mortality, perhaps policy could be directed at correcting these differences as well.</p><img src="https://counter.theconversation.com/content/59479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Street receives funding from the National Institute of Health Research and the Department of Health's Policy Research Programme but the views expressed are his own.</span></em></p>While politicians and doctors argue over the data on the weekend effect, it’s important to remember that there are other ways to reduce hospital deaths.Andrew Street, Professor, Centre for Health Economics, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/577042016-04-18T14:35:01Z2016-04-18T14:35:01ZHow to start nudging people to drink less alcohol<figure><img src="https://images.theconversation.com/files/118907/original/image-20160415-11182-1h02sfc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">I drank how much more than my peers?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=K_f__S7rlY4_Yf1Aim9PvQ-1-91&clicksrc=download_btn_inline&id=330353657&size=medium_jpg&submit_jpg=">www.shutterstock.com</a></span></figcaption></figure><p>Millions of pounds are spent each year to bombard us with information on the risks of alcohol. But do such campaigns work? <a href="http://psycnet.apa.org/journals/hea/34/12/1200/">Our research</a> shows that some simple tweaks to how the message is delivered – by applying findings from behavioural science – could help government campaigns have a far bigger impact. And cost savings might even go some way to filling the <a href="http://www.theguardian.com/society/2016/mar/15/nhs-22bn-funding-black-hole-report-public-accounts-committee">£22 billion funding black hole</a> the NHS finds itself in.</p>
<p>Excessive drinking is a big problem. Although between 2010 and 2013 household spending on alcoholic drinks in the UK <a href="https://www.drinkaware.co.uk/about-us/research-and-impact/databank/data-and-facts-on-alcohol-consumption-and-the-consequences/consumption">fell by 5.7%</a>, liver disease in those under 30 <a href="http://www.alcoholconcern.org.uk/wp-content/uploads/2014/10/APPG_Manifesto.pdf">has more than doubled</a> over the past 20 years with Alcohol Concern estimating that <a href="http://www.alcoholconcern.org.uk/wp-content/uploads/2014/10/APPG_Manifesto.pdf">1.2m people a year</a> are admitted to hospital for alcohol-related problems.</p>
<p>The recent fall in spending on alcohol has been attributed to a rise in drinks taxes and the economic downturn, but that <a href="http://www.bmj.com/content/353/bmj.i1860">could be reversed</a> with the recovery and the duty on drinks being dropped in 2014.</p>
<h2>Using a new tactic</h2>
<p>The health sector needs a new tactic to change people’s behaviour and this is where behavioural science, or “nudging”, can help. Behavioural science has worked in other areas. The Cabinet Office’s <a href="http://www.behaviouralinsights.co.uk/">Behavioural Insights Team</a> or Nudge Unit, as it is popularly known, experimented with income tax reminder letters and how they were framed. They found that the repayments rate <a href="http://www.bbc.co.uk/news/uk-politics-16943729">increased by 15%</a> when people were told most people living in their town or area had already paid. At a cost of very little, an extra <a href="http://www.behaviouralinsights.co.uk/tax/behavioural-insights-tax-trials-win-civil-service-award/">£210m of tax revenue</a> was brought into HMRC.</p>
<p>We looked at how framing the message could affect how excessive drinkers responded using theories from behavioural economics. There is a large body of work that has shown that people are influenced by how they rank relative to others, rather than by their perception of how they <a href="http://bit.ly/1MCPxpO">differ from the average</a>. </p>
<p>We applied this knowledge to the problem of excessive drinking and found that people were much more likely to seek advice when ranked against their peers than when their drinking was compared with the official guidelines or the group average. </p>
<p>We sent a group of 101 students, who drank excessively, four text messages over four weeks. One ranked how much they drank in a week compared with others (the rank comparison) – for example: “You are in the top 10% of heaviest drinkers.” A second message compared their drinking with the official alcohol guidelines (absolute comparison), while a third showed their consumption compared with the average of the group being tested (mean comparison). And the final text detailed the official alcohol consumption guidelines (absolute framed).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/118909/original/image-20160415-11188-uovfza.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/118909/original/image-20160415-11188-uovfza.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/118909/original/image-20160415-11188-uovfza.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/118909/original/image-20160415-11188-uovfza.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/118909/original/image-20160415-11188-uovfza.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/118909/original/image-20160415-11188-uovfza.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/118909/original/image-20160415-11188-uovfza.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Alcohol consumption may go up as the economy improves.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=XMMl9HCuyAh9ibu9XLcKUA-1-32&clicksrc=download_btn_inline&id=127896002&size=medium_jpg&submit_jpg=">www.shutterstock.com</a></span>
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<p>The rank comparison text that showed how much they drank compared to others led to half the excessive drinkers asking for expert recommendations on alcohol consumption, and nearly 45% requested links to alcohol education websites.</p>
<p>The absolute comparison text that compared their drinking with the official alcohol guidelines saw just 5% do this. This figure rose to just over 11% when drinkers were sent the average comparison text, comparing their drinking to the mean average.</p>
<p>The absolute framed message, detailing the official alcohol consumption guidelines did better, with 20% wanting links to helpful websites and around 15% seeking experts’ help.</p>
<p>In addition, 25% who saw the rank comparison text requested details for services for people worried about their alcohol intake. The other texts saw just 5% ask for this, with nobody asking for any details after the absolute comparison text.</p>
<h2>Reframing the message</h2>
<p>Our findings suggest that future interventions might benefit from focusing on telling people how their behaviour ranks among others. It shows more consideration should be given as to how messages can be improved through presenting information in ways in which it is naturally processed.</p>
<p>It is important, however, to emphasise this intervention did not lead to a reduction in participants’ alcohol consumption; this is likely to be because reducing alcohol use is a complex change needing lots of different interventions.</p>
<p>But we found that a minor “reframing” of the message greatly increased its effectiveness at persuading people to seek help. Excessive drinkers typically <a href="http://www.sciencedirect.com/science/article/pii/S0277953615003494">underestimate their consumption</a> relative to that of others, but if we rank them, citing, for example, that they are in the top 10% of heavy drinkers for their age group then it is more likely to give them the impetus to find out more to both educate them on what alcohol does to their bodies and to seek advice on how to reduce their drinking.</p>
<p>Although the sample size was small, this is the first test of whether rank framing is a superior method of presenting information rather than comparing people to the average.</p>
<p>Most public health information compares people to the average, but our study shows that ranking people will be far more effective. This is how people naturally process information, by comparing themselves with others, and could lead to a reduction in drinking in the long run.</p><img src="https://counter.theconversation.com/content/57704/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ivo Vlaev does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Excessive drinkers are more likely to seek help when their drinking habits are compared with their peers than when they are simply given the guidelines.Ivo Vlaev, Professor of behavioural science, Warwick Business School, University of WarwickLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/529922016-01-14T11:05:21Z2016-01-14T11:05:21ZAre the government’s new alcohol guidelines an assault on freedom? Just ask John Stuart Mill<figure><img src="https://images.theconversation.com/files/107819/original/image-20160111-6988-18jaomw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Free to take our own risks</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=4NmeINXyVHyQ92t2jIU2UQ&searchterm=drunk%20person&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=187711592">www.shutterstock.com</a></span></figcaption></figure><p><a href="https://www.gov.uk/government/news/new-alcohol-guidelines-show-increased-risk-of-cancer">New guidelines</a> on the consumption of alcohol have been announced by the British government. These recommend no more than 14 units a week, adding that there should be some drink-free days each week, and stressing that there are no safe levels of alcohol consumption.</p>
<p>While health campaigners have welcomed this move, others have described this as “nanny state” interference, or <a href="http://www.telegraph.co.uk/comment/telegraph-view/12087850/The-new-drinking-guidelines-are-hyperbolic-and-puritan.html">hyperbolic and puritan</a>, with Nigel Farage <a href="http://www.bbc.co.uk/news/uk-politics-35261968">advocating mass protest</a>. </p>
<p>When the state seeks to direct us for our own good, it treats us as if we are children, unable to take responsibility for our own lives. This is what many find objectionable.</p>
<h2>Inform. Don’t restrict</h2>
<p>Objections to the “nanny state” have a long history. The Victorian social reformer and MP <a href="http://plato.stanford.edu/entries/mill/">John Stuart Mill</a> argued, <a href="http://oll.libertyfund.org/titles/233">in 1859</a>, that the only legitimate purpose for restricting a person’s freedom is to prevent harm to others. Mill’s insistence that people should not be restricted for their own benefit was influential in bringing about many social changes, such as the decriminalisation of homosexuality.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/107814/original/image-20160111-6986-7ki3p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/107814/original/image-20160111-6986-7ki3p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=885&fit=crop&dpr=1 600w, https://images.theconversation.com/files/107814/original/image-20160111-6986-7ki3p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=885&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/107814/original/image-20160111-6986-7ki3p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=885&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/107814/original/image-20160111-6986-7ki3p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1112&fit=crop&dpr=1 754w, https://images.theconversation.com/files/107814/original/image-20160111-6986-7ki3p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1112&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/107814/original/image-20160111-6986-7ki3p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1112&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Would John Stuart Mill approve?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=zuZszUpPV9Gi7po_N8xVzg&searchterm=John%20Stuart%20Mill&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=252141700">www.shutterstock.com</a></span>
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<p>But not all state interference is objectionable, as Mill recognised. We should distinguish between cases where the state compels us to behave in a particular way (for example, by banning unhealthy substances) and cases where it offers advice or information. If the state were to prohibit alcohol, as some have tried to do in the past, this would deprive people of the freedom to decide for themselves whether or not to drink. A similar <a href="http://eprints.soton.ac.uk/370384/">objection might be made against minimum pricing</a>, since it makes alcohol less affordable.</p>
<p>On the other hand, to warn citizens of danger, without preventing them from exposing themselves to it, does not threaten their freedom. In fact, being aware of the health risks associated with alcohol is a precondition for making an informed choice. If people were unaware of such risks, they could not decide for themselves whether the pleasures of alcohol were worth the danger. So, for people to exercise control over their own lives requires that they are informed about the options open to them.</p>
<p>Since the government’s guidelines are merely informative, rather than restrictive, they don’t restrict individual freedom. But there is one respect in which objectors may be right to criticise them. The guidelines do not simply impart information; they also recommend what level of risk people should be prepared to accept. The figure of 14 units was chosen, not because it is risk-free, but because this level of consumption is supposed to involve similar levels of risk to many other daily activities, such as driving.</p>
<p>This is ill-advised because competent adults should be able to decide for themselves what levels of risk to accept. Some of us actively seek out risks, while other are more cautious. The amount of risk that we’re willing to tolerate depends on both individual tastes and circumstances. It’s absurd to suggest that there’s a “one size fits all” answer to questions about how much risk we should accept and all the more absurd to think that the government can tell us what level this is.</p>
<h2>Not much help</h2>
<p>While people need to be told about the dangers of alcohol so that they can make responsible choices, the new guidelines aren’t of much help. The 14 units a week recommendation doesn’t tell us how much more risky 14 units a week is than 7, nor how much safer it is than 21, so it’s little help to anyone deciding what risk is acceptable to them.</p>
<p>A more liberal set of guidelines might compare the risks associated with various levels of consumption to the risks of other daily activities. This would give citizens a better idea of how risky different patterns of consumption are, allowing us to choose how much risk we wish to face.</p>
<p>Such potential guidelines could respect both the need for citizens to be informed and the right of each person to make decisions over his or her own life, including decisions about what risks to take. The government’s actual guidelines are to be applauded, to the extent that they simply educate people about the dangers of alcohol, but objectionable in seeking to decide for us how much risk we should face.</p><img src="https://counter.theconversation.com/content/52992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben Saunders does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Victorian reformer was something of an expert on the “nanny state”.Ben Saunders, Senior Lecturer/Associate Professor in Political Philosophy, University of SouthamptonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/484212015-10-13T12:45:38Z2015-10-13T12:45:38ZJeremy Hunt can’t win his fight with doctors – they have always held the power in the NHS<p>The health secretary, Jeremy Hunt, has <a href="http://www.theguardian.com/politics/2015/oct/08/jeremy-hunt-nhs-doctors-contract-pay-strike">capitulated to threats</a> of a damaging strike by junior doctors. After vocal protests from the medical profession, Hunt has modified <a href="http://www.theguardian.com/society/2015/sep/26/junior-doctors-to-be-balloted-for-strike-action-bma">his plans</a> to scrap overtime pay rates for junior doctors.</p>
<p><a href="http://www.bbc.co.uk/news/health-34383677">Their proposed action</a> does not threaten the treatment of acute, life-threatening emergencies. But it did have <a href="http://www.bbc.co.uk/news/health-29560083">recent precedents</a> that produced mass disruption of outpatient clinics and the cancellation of non-urgent surgery. In threatening to impose a punitive <a href="http://www.theguardian.com/society/2015/sep/18/junior-doctors-new-contract-cut-pay-40-per-cent">new contract</a> on junior doctors without prior discussion, the health secretary underestimated both the contribution and the power of these essential staff. Indeed, he may have to make <a href="http://www.theguardian.com/society/2015/oct/11/junior-doctors-demand-more-concessions-from-jeremy-hunt">further concessions</a>.</p>
<p>Hunt has high ideals for the NHS. <a href="http://www.theguardian.com/society/2015/jul/16/nhs-consultants-given-ultimatum-on-weekend-working">He wants</a> an efficient, consumer-friendly seven-day service with fewer bureaucratic targets and more public transparency. Laudable aspirations, but improving the NHS while having to make <a href="http://www.independent.co.uk/news/uk/politics/ministers-wont-rule-out-nhs-staff-cuts-as-part-of-33bn-health-service-efficiency-savings-10293971.html">£22bn of savings</a> is asking a lot of the good will of its staff.</p>
<h2>Messing with the backbone</h2>
<p>Hunt’s problem was that he didn’t see the value of this medical good will. He has already tested that of consultant doctors by threatening to force them to work any day of the week, in order <a href="http://www.bbc.co.uk/news/health-33542940">to address claims</a> that 6,000 people die every year because of inadequate service at weekends (consultants can currently opt out of non-emergency weekend work).</p>
<p>He has now similarly antagonised their junior colleagues. Juniors are the diagnostic backbone of all the out-of-hours work the NHS does. Being invited compulsorily to do the same work for what they claimed was 40% less cash was, <a href="http://www.theguardian.com/society/2015/sep/29/junior-doctors-contract-row-nhs-explainer-health">they said</a>: “Bad for patients, bad for junior doctors and bad for the NHS”.</p>
<p>The medical profession has legally sanctioned control over everything the NHS does. It has unrestrained clinical freedom in diagnosis, admissions, discharges, prescriptions and operations. It polices its boundaries relentlessly and nothing it does, however simplistic, can be delegated to any other professional if it is in the medical interest. Tasks such as pre-anaesthetic screening or ordering blood tests have only been given to nurses because medical staff have come to recognise these as low status. This closed-shop process masquerades always as “patient interest” on the pretext that “doctor knows best”.</p>
<p>Medicine is the unmistaken spending agent of the NHS and governments have yearned to bring it under political and managerial control since Aneurin Bevan founded the service in 1948. He quickly discovered the British Medial Association to be the most cohesively coldblooded negotiating body in civilisation. Why? Because it manipulates its scarce skills resource precisely to secure the rewards it believes its superior quality deserves.</p>
<p>Bevan captured medical cooperation in 1948 only through massive contractual concessions, stating: “<a href="http://blogs.independent.co.uk/2011/04/14/stuff-their-mouths-with-gold-part-iii/">I stuffed their mouths with gold</a>.” So “buying off” is an institutional norm in the NHS: governments threaten doctors’ pay and conditions – and, in response, they promise strike action that ministers cannot allow for fear of political fallout. So the doctors win whatever sized “inconvenience allowance” they believe they warrant. And the whole charade creates the fantasy that the politicians have won and we all carry on as if nothing had happened.</p>
<h2>Professional unity</h2>
<p>Doctors may squabble fiercely among themselves but any perceived threat from outsiders – be they politicians, managers or whomever – provokes intense <a href="http://www.theguardian.com/healthcare-network/2015/sep/29/junior-doctors-strike-support-poll-contract-nhs">professional unity</a>. Hunt should have realised, as Bevan did, that he would not just aggravate the junior doctors but the whole profession.</p>
<p>Hunt’s attempt to resolve the recent conflict was absolutely predictable. It entirely followed the Bevan formula that unfailingly unlocks the gate to medical “capitulation”. The junior doctors have not yet agreed to Hunt’s offer but his flattery and applause has somewhat neutralised the ill intent that threatened their wallets. When it comes to settling the next little difficulty of weekend working for consultants and GPs, Hunt will need all the same charm and an even heftier remunerative donation to the medical satchel.</p>
<p>Making a success of being health secretary and handling the doctors well is usually a step towards promotion. In the previous decade, <a href="http://news.bbc.co.uk/1/hi/health/2984352.stm">the turbulence</a> Alan Milburn experienced as health secretary was instantly calmed when his successor, John Reid, pacified the profession with <a href="http://news.bbc.co.uk/1/hi/health/3004750.stm">generous contracts</a>. After this success, Reid went on to become defence secretary. Likewise Alan Johnson managed to <a href="http://www.theguardian.com/society/2008/feb/09/health.health">come to an agreement</a> with GPs and became home secretary. So if Hunt values his political career in the way his <a href="http://www.theguardian.com/politics/2015/oct/05/hunt-tax-credit-cuts-make-britons-work-like-chinese-or-americans">recent conference performance</a> indicates, he will benefit little from a defeat in a doctors’ dispute on his record.</p><img src="https://counter.theconversation.com/content/48421/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Bradshaw does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The health secretary should consider the history of his predecessors all the way back to Aneurin Bevan when it comes to keeping doctors happy.Peter Bradshaw, Emeritus Professor in Health Policy, University of HuddersfieldLicensed as Creative Commons – attribution, no derivatives.