London Eye: ‘A period of not very well managed decline’

“A period of not very well managed decline.” These were the words of one long-serving NHS chief executive in the capital when asked what the effect of 14 years of Conservative national leadership had meant for London’s NHS.

By Friday we will very likely have the first non-Conservative prime minister since 2010.

The effects of some national policies loomed larger here than elsewhere.

The capital’s broken housing system is part of why staff retention is so woeful. A band six nurse can afford a house in the rest of the country; in greater London, they can’t, really. This competition winner is probably the only nurse who got a house in zone one last year.

A former Royal Free chief executive told me when they started at the Hampstead Trust in 2009 their admin staff lived in the surrounding London boroughs; by 2014 they were commuting in from the cheaper bits of Hertfordshire.

The slow, agonising decline in the city as a place for staff to live was not unforeseen.

When former UCLH boss Sir Robert Naylor was given the job of telling the government what it should do with/about NHS property, one of the ideas was that London’s NHS put up some land and a third of the cost of new housing, the Treasury did another third and private capital fund the rest. This housing, or a proportion of it, could be reserved for nurses.

That way the NHS could have disposed of some estate (the idea being that this vast enterprise has too much), and private investors got a near risk-free steady return.

Needless to say, it didn’t happen. The pension funds, with their massive endowments and preference for low-risk, long-term returns, could not be persuaded. Neither could the Treasury (the pension funds might have done better going with the NHS than staying with commercial office space). And why would the market reserve it for nurses? They don’t earn enough to make it worthwhile for an investor.

But a less chaotic period of government (Naylor was hired to do the review in February 2016 and it was published in in March 2017) might have pushed this through.

The consequences are that thousands of managers have to play a game of patient-harm chicken just to roster, for nearly every shift. A higher proportion of nurses visiting food banks, trust-run hardship funds, that kind of thing.

That’s not to say the NHS didn’t sell a lot of land. A minister-led group oversaw the acceleration of that very process. South West London and St George’s Mental Health Trust is still working through disposals of more than £200m. New housing has sprung up (not much for nurses) and the work has paid for the replacement of some of the trust’s dreadful old estate.

What didn’t happen

Similarly elsewhere, the hand of ministers in London’s NHS was felt more in what didn’t happen than what did.

Promised rebuilds at St Mary’s, Hillingdon and Evelina Children’s Hospital all came to nought. Rightly or wrongly, chancellor Philip Hammond’s ban on private finance initiatives protected a lot of crummy estates in London.

One figure close to the property/estates issues in London said the lack of progress wasn’t even ideological.

“I think they actually wanted those things to happen, especially Boris,” they said, “But they didn’t know how to do it. They didn’t know what instructions to issue to simplify NHS bureaucracy and to curb Treasury influence. And in the end, they allowed HMT to drive the establishment of a programme team which didn’t understand health and actually stopped progress, instead of accelerating it.

“They listened to the wrong people and created a huge fee windfall for selected consultancies but achieved nothing.”

The other great interaction between ministers and London’s NHS has always been reconfigurations.

Managers thought bold action was needed to reduce the number of accident and emergency and centralise services (this was the late 2000s/early 2010s) – after all, where was this possible, if not in London?

Labour nixed A&E closures in Kingston and the Whittington – imagine how even more overwhelmed urgent and emergency would be now if they had gone ahead.

Closure of Sidcup’s A&E limped across the line with no small sleight of hand: “The General Medical Council say the lack of senior staff means its too dangerous for junior doctors so are withdrawing them, now it can’t be staffed at all, ah well, we better close it,” went the attempted justification.

This, Central Middlesex and Chase Farm’s A&E closures did go ahead under Conservative governments and their neighbouring hospitals have never been the same since on urgent care performance.

Mostly they didn’t though. Ealing’s A&E survived, as did King George in Ilford and Charing Cross in Hammersmith. As did Lewisham’s, about which the government asked managers to think the unthinkable, then thought better of it.

“In those early years they definitely bottled some tough decisions, which have in hindsight been the right decisions”, said one manager. High praise.

Aside from A&Es, ambitious reconfigurations to improve services were few and far between. Nothing with the urgency and impact of the stroke reconfiguration of the 2000s was attempted.

There is now proton beam therapy at University College London Hospitals Foundation Trust. Even Sir Robert, when UCLH chief executive, wondered whether the £250m might not have been better spent improving access to primary care in the city.

The government’s neutering of public health nationally had an outsize effect on London as home of the starkest health inequalities, while council public health budgets have been eroded as much as anywhere else.

Meanwhile, the destruction of strategic health authorities has seen integrated care boards try and take on the hard stuff which London’s regional command used to do, but not spend much time trying to pull together public health. One London leader told HSJ: “The withdrawal of investment in public health has been ruinous, particularly for children.”

Covid absolutely battered parts of the city, revealing and exacerbating a declining level of health, especially in the east.

Ministers could have also supported the clean air initiatives coming out of the Mayor’s office. Hard to see how motorists are more important than the lungs of young Londoners.

The more things change

NHS managers on either side of May 2010 described total opposition to trying to reform/centralise primary care in London in any way. However, London saw GP at Hand’s flower bloom to a degree not seen anywhere else, with its sheer population density and the city’s younger demographic. This kind of project may soon enjoy a higher profile again.

One veteran manager urged NHS leaders to go and meet their new MPs, whoever they were, sooner rather than later. “New MPs can be quick to want to strut their stuff,” he said. Making contact before a complaint comes in often helps when things get more difficult.

He gave the example of a patient who refused a quack treatment and had gone to their MP who had promised to sort it out for them. When told, that the trust could not in fact do that, the patient then haunted the MP’s constituency office for many years. A better relationship would have served all three parties better.

Nearly all the good stuff achieved by London’s NHS in the past 14 years has been directed, resourced and realised by London’s NHS, rather than Whitehall. There is no reason to think that will change on Friday.