Nigel Crisp believes that when Labour inherited the NHS in 1997 it was ‘falling apart’. After four years away from the service the former chief executive reflects on the successes of the last 13 years - and the missed opportunities. By Alastair McLellan
Nigel Crisp, chief executive of the NHS from 2000-06, is clear what the New Labour years have meant for the service.
It is pretty clear that nobody is going to start dismantling the NHS now - even covertly
“Their biggest achievement is that the NHS will survive. In 1997 people were debating whether it would. The place was falling apart, our accident and emergency departments were crap…”
“[Saving the health service] was an act of political will and it is pretty clear that nobody is going to start dismantling the NHS now - even covertly.”
Lord Crisp, who combined the role of NHS chief executive with the permanent secretary’s post at the Department of Health, offered his views on New Labour as part of his first major interview on his time at the DH since his controversial departure.
He has deliberately kept his distance from the NHS - “I had my go”, he states - and has focused instead on international health development (see box).
As a result, he readily admits to not knowing how many of the reforms that he set in motion have played out since 2006. He did not, for example, know that Monitor executive chair Bill Moyes had moved on or that the social enterprise movement, in health at least, appears to have run into the ground.
Despite that, Lord Crisp is confident the New Labour years were a lifesaver for the NHS in its traditional form.
“My biggest fear was that we would become like education - where, by and large, the middle classes take their kids out [of the system]. They don’t do that in health. They have health insurance - but they know the highest standards are in the NHS.”
Lord Crisp points to a wide range of performance indicators which “shifted” under Labour.
“When I became chief executive, mortality on cardiac waiting lists was 4 per cent; within three years it was effectively zero. You could wait 18 months for cataract surgery in some parts of the country and now you don’t wait at all.”
He smiles as he remembers the “wonderful period” during 2002-03 where falling waiting lists caused private health providers to “panic” as they saw their business plans, based on restricted NHS access, go up in smoke. The grin widens as he adds that this mistaken belief about the continued rise in NHS waits caused UK private health companies to shun the original independent centre contracts or to make overpriced bids.
“They [UK private health firms] hadn’t understood things were changing, which is why we got the foreign firms [to fulfil the independent centre contracts].”
Lord Crisp speaks fondly of the commitment of Tony Blair to NHS reform and of the energy of Alan Milburn - secretary of state from 1999-2003. He also recalls “genuine interest” in health from Cabinet big hitters like David Blunkett and Charles Clarke. He describes the DH’s relationship with the Treasury as “significant, but distant”.
In one of the few passages that touch on the NHS in his new book Turning the World Upside Down, he speaks about New Labour’s modus operandi with the health service during the middle of the decade.
“Health secretary John Reid [2003-05] was fond of quoting Gramsci’s aphorism that the optimism of the will needs to be matched by the pessimism of the intellect. Politicians had… the ability to have visions and build castles in the air and change the political climate, but they needed other people, and by implication me and my colleagues, to be aware of the problems, to be pessimistic and to find practical ways to make things happen.”
Out of focus
Lord Crisp readily admits Labour’s reforms did not always produce the right answers.
Ironically, given New Labour’s love of focus groups, he thinks the biggest mistake may have been to ignore public views on a major issue. He refers to the consultation exercises that shaped the seminal NHS Plan in 2000. There were two main strands, one with the public and one with NHS staff. Lord Crisp remembers much consensus between the two - except in one notable area: only the public prioritised clean hospitals.
The failure of policy makers to “pick up and push” the need to tackle the threat of healthcare acquired infections resulted, in his view, in the NHS allowing MRSA to become a big problem.
He also expresses his disappointment New Labour was not “particularly radical with staff”, although he admits “it may not have felt like it”.
In his book he comments: “We missed the opportunity to change the conventional mindset about education, training and the roles of health workers.”
He lays the blame for this at a number of doors; for example, Labour’s traditional closeness to the unions and the energy spent on attempting to control consultants’ private practice.
Lord Crisp also cites the desire to create consensus among health’s varied interest groups to provide backing for the NHS Plan: “The NHS Plan was an attempt to agree a way forward. And when you do that, you lose some of your manoeuvrability. If you’ve got them in the tent you can’t be too radical in how you duff them up.”
He then, however, admits that too much time was spent “negotiating” with bodies like the British Medical Association, “when maybe it would have been more helpful to concentrate on cooperation”.
Learning from the poorest nations
Lord Crisp was at the helm of the NHS during its most radical period of reform. However, the mild mannered chief executive was most commonly found explaining in practical terms the challenging ideas of others.
But after four years’ examining health services in developing countries, he is now championing his own challenge to healthcare’s received wisdom.
Put simply, Lord Crisp believes western healthcare systems have a lot to learn from the culture and organisation of services in countries such as Bangladesh and Ethiopia.
This belief is the product of his work for the British government, the World Health Organization and the philanthropic foundation set up by Microsoft founder Bill Gates. It is captured in a book called, appropriately, Turning the World Upside Down.
Lord Crisp explains its central thesis: “Poor countries export health workers and richer ones export ideas and ideologies. [This] should be turned round, so that richer countries export part of their great wealth of health workers and poorer ones export ideas they have learned from their experience in a much harder environment for the delivery of healthcare.”
The book contains numerous examples of how this could happen, but he singles out one as the most appropriate to an NHS facing the need to find significant efficiencies.
He draws a contrast between the health workforce in Ethiopia and the UK and questions which is the right model to tackle chronic and lifestyle inspired diseases facing the western world (see diagram).
“All over Africa you see these mid level workers, who are trained to do a specific task,” reports Lord Crisp. “Cataract surgeons with three years’ training or technicians who carry out the majority of caesarean deliveries.”
In his book, he quotes a UK consultant working in Ethiopia who was surprised “to see the local staff had such good clinical skills, better than many, if not most, UK doctors”.
Lord Crisp stresses he is not suggesting the UK should copy any of these specific examples, simply that “we should realise what can be done and don’t automatically always assume that greater professionalism is the answer”.
“One question I would ask if I were in the NHS now is what proportion of an ophthalmologist’s time is spent doing cataracts? You train them for a minimum of nine years, but what proportion of their time is spent doing something they could have learned in three?” he says. “I’ve had this conversation with [shadow health secretary] Andrew Lansley and I’m seeing [health secretary] Andy Burnham next week. I’m asking them what they’re going to do to make the NHS more effective by making its people better understand other cultures and approaches.”
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