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The elephant in the room

November 4, 2014

Those of you who are accustomed to my habitual cynicism might be surprised to learn that I really, really want to love Simon Stevens’ plan – outlined in the NHS Five Year Forward View – to combat rising obesity rates by turning NHS staff into ‘health ambassadors in their local communities’. The nostalgic, all-in-it-together picture it paints for me of nurses, doctors, pharmacists and the population at large helping each other towards the sunlit uplands of a happier, healthier future is one I find strangely appealing. Am I just going soft? Or could it actually work?

Firstly, it’s important to be clear that if Stevens’ vision comes to pass – and the funding increases on which the whole shebang is resting do indeed materialise – the NHS of 2020 will look substantially different from the NHS of today. There will be more investment in primary care, for instance, and greater integration between primary and acute care systems. For nurses, this will mean opportunities that we must be ready to exploit and develop. And because the Forward View quite rightly places such enormous emphasis on healthy lifestyles and disease prevention, it’s reasonable to assume that amongst those opportunities will be an expansion in the number of nurses for whom health education and health monitoring is all part of the day job.

So – so far, so good. But Stevens’ proposals seem to go further. When he talks about health care professionals acting as ‘health ambassadors in their local communities’ (or ‘agents of social change’ as the Guardian put it), what exactly does he mean? We search the NMC Code in vain for restrictions on practitioners’ individual lifestyle choices, yet implicit in the Forward View is the idea that even when we are off-duty, we should continue to set a public example by ordering our lives in accordance with some kind of new Healthy Lifestyle Code of Conduct. Is this fair? And how far is it going to go?

Speaking as an abstemious vegetarian who maintains a normal-range Body Mass Index, takes exercise and has never smoked, you might say I have little to fear (apart from dying of boredom). But even I wonder if we’re just handing the public, not to mention the media, yet another stick to beat us with. So much is already expected of nurses. The much-trumpeted ‘compassion’ for one thing. Silently absorbing real-terms pay cuts year-on-year for another. Now it seems we’ve got to be beacons of healthy living as well. And doubtless there will those for whom reporting nurses’ dietary indiscretions becomes practically a civic duty: ‘the nurse attending my father was already borderline obese. Imagine our disgust, therefore, when we observed her in the restaurant, gorging herself on what appeared to be a large plate of sausage and chips! I ask you, if someone is so careless of themselves, what confidence can one have in their care of others?’ But this is small beer compared to a different problem – one that the Five Year Forward View doesn’t even mention.

As I’ve said already, the Forward View places a lot of emphasis on using education to improve health and reduce pressure on the NHS. There’s nothing wrong with this. Expecting health professionals to health-educate is a no-brainer. And it can deliver considerable gains. But as everyone acknowledges, the real predictors of ill-health in Western societies are poverty and inequality. Add to this the huge imbalance between the marketing budgets of the multinational companies that sell us their fat- and sugar-laden products, and the health-education budgets of local and national government agencies, and you begin to see that the problem is far too big and far too complex to be solved by a conscript army of demoralised NHS staff.

But just how demoralised? According to the Credit Suisse Global Wealth Report 2014, the United Kingdom was the only country in the G7 group of industrialised nations to register rising societal inequality for the whole of the twenty-first century so far. Years of pay real-terms salary cuts in the public sector mean that NHS workers have, albeit unwillingly, contributed to this situation.

To his credit, Simon Stevens has accepted that downward pressure on NHS pay cannot continue indefinitely. Just this week, the Unison union reported that ‘most patients would be shocked to know that one in five of the NHS workers who care for them need to do a second job just to survive and many have to borrow money every month to make ends meet or resort to foodbanks’. But we already know the Tories’ record in this area, and now Labour’s shadow Health Secretary Andy Burnham has told the Health Service Journal that were he in government, he would ‘of course’ use pay restraint to address the health service’s long term financial challenges. So at the same time as NHS staff are involuntarily enduring the very conditions that stoke up ill-health, they are being told they have to become paragons of healthy living. People, this is the politics of Alice in Wonderland!

In my view, the strength of the Five Year Forward View is also its weakness. Simon Stevens deftly avoids overt discussion of polarising topics like competition. Instead, his focus on areas where political consensus is at least theoretically possible – localisation, funding and more contentiously, the consolidation of existing organisational structures including the clinical commissioning model – is a bold attempt to free the NHS from the vicissitudes of party politics. The trouble is that sidestepping party politics unfortunately means sidestepping the wider politics also. The result is a health promotion policy that because it’s unable to address these big issues, looks and feels half-baked.

Simon Stevens is a far from stupid man. He must realise that he’s trying to square a very difficult circle here. The mantra of consumer choice, one of the main elements of free-market economies, has now also been injected into UK health care and health promotion. The flaw is that when people have no money, little time, bad housing and limited access to shops and infrastructure, their choices are necessarily extremely limited.

But Stevens can’t admit this, because to do so would undermine the primacy of consumer choice as the driver of NHS reform. It’s the elephant in the room. To avoid talking about it, he has had to re-invent the NHS as a ‘social movement’ and advance the tangled logic of NHS workers as a new breed of cut-price lifestyle guru. You have no idea how much I want this to work. I really, really want it to work. But I can’t help feeling it’s just fudge.

The NHS Five Year Forward View:

For the Unison Press Release:

For the Andy Burnham interview (Nursing Times version):

And for the really keen, the Credit Suisse report: pdf



  1. Barbara Bradbury, Halland Solutions permalink

    “People, this is the politics of Alice in Wonderland!” I love your turn of phrase! There is something depressingly naive about the Forward View I can’t help but feel: the handing of greater financial power to the GPs is an obvious issue, with their conflict of interest and the fact that everything they do they need to be “incentivised” for it; the fact that there is huge sickness-absence in the NHS, often as a manipulation to avoid performance management; people working the system to ensure they are paid substantial amounts in overtime; the large number of interims at managerial level …… these are contentious issues and not things that people raise in public. However, these and other things need to be addressed and to do so requires strength of character and a willingness to act in the best interest of others and not self. Definitely not suitable for Alice!

  2. Hi Barbara, thanks for commenting. I agree that the Five Year Forward View is a bit naive. I think that that gives the impression of a charming, but also a very frustrating document. As I said in the piece, I would love to see it all work out, but it seems to take for granted so many unknowables. And without a lot more appreciation of the burdens they already carry, I think it’s very unfair to expect NHS staff to become ‘role models’ for the wider society.

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