When Dr Dan Poulter entered parliament in 2010, the NHS was recording the highest public approval ratings in its history. Fully 75 per cent of respondents in the British Social Attitudes (BSA) survey declared themselves satisfied with the way the health service was running. Poulter, then a 32-year-old NHS doctor, had been impressed by the Blair government’s sustained investment in the service; he had voted Labour in 2001 and 2005. But like many in the political centre ground, he had been wooed by David Cameron’s compassionate makeover of the Conservative Party and reassured by the then leader’s commitment to the NHS, rooted in the care afforded to his profoundly disabled son, Ivan. When Poulter was elected to represent the Central Suffolk and North Ipswich constituency, it was as a Tory MP.
Fourteen years later, the annual BSA survey starkly quantifies the extent of the NHS’s decline. Barely a quarter of people reported satisfaction in 2023, an historic low. The service is in turmoil: riven by industrial action, with record waiting lists, declining productivity in hospitals, GP appointments almost impossible to obtain in many areas, controversy over unregulated new practitioners plugging gaps in the medical workforce, staff turnover high and morale at an all-time low.
And it is not just the NHS that is in dire trouble: as a society, we are sicker. Life expectancy, which has been steadily increasing since the mid-19th century, began to stall from 2011 and now stands below its 2019 level. Equally importantly, the number of years that we can expect to enjoy of good health remains lower than a decade ago. As Rishi Sunak himself has noted, claims for long-term sickness benefits have rocketed, and there is an epidemic of mental ill-health among the young.
For Poulter, who served under Cameron as under-secretary of state for health between 2012 and 2015, the Conservatives’ record on health was a major factor behind his decision in April to defect to the Labour Party. He will stand down as an MP at the next election and return to work as a psychiatrist specialising in addiction, while advising Keir Starmer and Wes Streeting on policy relating to mental health. Who better, then, to ask: how and why has it gone so disastrously wrong?
PW: In the spirit of fairness, a good question to start with would be: what have the Conservatives got right about health and the NHS over the past decade and a half?
Dan Poulter: I think the Conservative Party’s direction of travel has not been a particularly positive one. The Conservative Party today is very different to the Conservative Party I was elected into. David Cameron presented the Conservatives as a more compassionate party, one that was focused on the NHS, on his own experience of the NHS with his son. But as time went on, the rhetoric around prioritising the NHS and the reality were moving further and further apart, as the Conservatives became focused on Brexit and immigration. Health became much less of a priority.
I think the focus of the Cameron government on health visiting, for example, and giving children the best start in life, was a good thing. We increased health visitor numbers from about 8,000 to 12,000. Those numbers haven’t been sustained. Recognising that there was variability in care, as we saw in Mid Staffs, and focusing on trying to drive up care quality through enhancing the role of the Care Quality Commission – those were good things that the Conservative government did.
I don’t think the Health and Social Care Act of 2012 did a great deal of good for the health service. It encouraged a move towards fragmentation rather than integration of services and care. I have to say, hand on heart, I voted for some things that I now would not have voted for. For example, addiction services and public health services were given to local authorities to commission, and that has been to the detriment of the ability of those services to deliver and support people with alcohol or drug dependency. Many of the patients I look after have got a dual diagnosis of mental health, or have other physical health needs [alongside their mental health conditions], and the fragmentation of commissioning key services under that act makes it much harder to treat patients in the right way.
Increasingly, I found it very hard to feel valued as a doctor by the government, and I know my nursing colleagues feel very much the same. We also felt that we didn’t have the resources to do our job properly. When I was working at St Thomas’ Hospital during the strike last year, I couldn’t get beds for patients with acute psychotic presentations, not just for hours, but for days. That was not the service that the last Labour government left, and that change is, I think, a very poor testament to 14 years of Conservative government.
PW: You were a minister from 2012 to 2015, when the Cameron/Osborne government was pursuing austerity. The NHS budget was falling in real terms; year-on-year, the health service was being squeezed. David Nicholson, the chief executive of the NHS at that time, talked about needing to catalyse a change from hospital-based practice into the community, and this manifestly failed to materialise. Why do you think that policy failed?
DP: I’ve always been a great advocate of integrated care, and one of the problems has been that the rhetoric around integrated care has not lived up to the reality of what’s been delivered. Integration, fundamentally, is about moving away from picking up the pieces in the acute setting, and towards community care and preventative care: having the right housing, looking at social determinants of poor health. Pushing competition can become a race to the bottom: you try to get the person who offers the service for the least amount of money. What’s best for the patient is what is going to deliver the most holistic care and keep people well in their own homes and communities. The only way you’re going to get that is by pooling budgets, so commissioning becomes a joint endeavour among health, care and other service providers.
If you are looking at producing productivity savings, the failure to harness the collective buying power of the NHS advantages the supplier, because they might say to one hospital, “I’m giving you a fantastic deal, this is the price,” but offer a higher price to another hospital. It’s a problem that could have been very easily tackled as a priority in 2010, but it wasn’t.
PW: I’m a general practitioner, and the 2015, 2017 and 2019 Conservative manifestos were very explicit about recruiting and retaining higher numbers of GPs. Looking at the figures from 2010 to now, the sort of numbers of over-65s – the highest users of health services – have gone up by about a third. But the number of GPs has gone down by about 8 per cent. And, since 2019, that manifesto commitment seems to have been dropped. There is a strong body of evidence that the way to run a good health service is to have strong general practice, medical generalists, in the community. But there seems to be a drive to replace GPs with lots of other different types of professional. Is that just a horrible accident, or is that a policy?
DP: I remember sitting in countless conversations where GP numbers were discussed, and ministers would say, “The numbers have actually gone up.” But they weren’t quoting full-time equivalent numbers, to get to a like-for-like comparison in terms of the day-to-day workload or GPs per number of patients. I think the government has been very disingenuous in the way it’s approached this, but there has clearly been a lack of political imperative to make it happen. More and more demand is put on GPs – with more patients to deal with, more patients with more complex needs than 15 years ago, people are living longer with multiple medical co-morbidities – but without the additional workforce numbers or resources to match that need. That is a failure of political leadership, and of understanding what’s needed on the front line.
PW: What is the role of government in trying to break that cycle of poor public health and the impacts on the NHS where corporate profits are involved? We’ve perhaps got a food industry, for example, that is driving obesity, and we’ve got a pharmaceutical industry that’s helping to mop up the consequences and making profits out of it.
DP: On smoking, obesity and alcohol, the government has a duty to act firmly. The plans to stop people under the age of 18 from smoking are the kind of things that government should be doing. Obesity is a major contributor to all sorts of poor health, particularly in poorer communities, and more could be done to take on some of the food and drink companies that are pushing unhealthy food. The consequences of alcohol dependence and harmful drinking are the issues I come across most, and we should be looking at minimum prices. There is a reluctance in the Conservative government to go down that route, because business pushes against it. But if we care about the next generation and taking some of the burden off of the NHS, these are the sort of things the government’s really got to do more.
PW: Rishi Sunak was recently in the headlines castigating the younger generation for being on long-term sick leave from what he described as mild mental-health problems. Given your role as a psychiatrist, I am interested in your view – are we seeing something of an epidemic of mental health issues, and if we are, what are the drivers of it?
DP: The Conservatives are trying to create a political dividing line before an election over an issue that should be bigger than politics. The reality is that, for people who have mental health problems and are off work, you can’t just declare them fit for work. Certainly work, initially part-time, can be an important part of their recovery. Early-intervention teams in psychosis are well-resourced, with vocational support workers getting people back into education and training. But that’s a very gradual process, and it’s a process of assessing. If it doesn’t work, you have to stop. The government is going to try to reclassify people who are experiencing mental ill-health as not having mental ill-health, by moving the goalposts. A health-based approach – helping get people into recovery, into education, into training, into work, in a gradual way, then building things up – is the way to do it. But community mental health services are completely hollowed out and there’s not the resource to do that.
PW: If you were advising Wes Streeting and Keir Starmer about what you could do to improve mental health prior to it becoming a problem that presents, what areas would you be focusing on?
DP: Definitely schools. I think Labour are looking at that very seriously. If you can tackle poor mental health at a younger age and prevent it becoming entrenched, you’ve got a much better chance of improving life options. We know that a high proportion of young people experiencing poor mental health go on to experience that in adulthood. Working with schools isn’t necessarily putting more burden on teachers, but putting some of the NHS resource to work in an integrated way.
We also need to recognise where there may be wider social challenges for some families, because there’s a strong association between poverty and poor mental health. Some of those interventions may be about supporting the family more broadly. I’ve spoken to Wes and I know that he’s got that on his radar.
I would also say – from experience – there’s been a big focus on expansion of talking therapies, but it’s almost all been cognitive behavioural therapy [CBT]. For younger people who tend to present in hospital with self-harming or having tried to take their own lives, it’s about helping them to improve their emotional regulation and distress tolerance. I think a focus on different types of talking therapy – dialectical behaviour therapy [DBT], mentalisation-based therapies – has been needed for a decade, but it’s just not happened. CBT is important, but it’s not all CBT.
PW: Many SureStart centres that offered help and advice on child and family health in disadvantaged areas have closed. Should we be reopening them?
DP: We had a SureStart centre closed in my constituency in North Ipswich a few years ago, and I think undoubtedly it was detrimental to supporting some of the most disadvantaged and poorer families in terms of helping link them in with support from services from the NHS. They also offered broader family support, which is important to giving children the best start in life.
PW: I was struck earlier by you talking about your own experience of working as a doctor and feeing unvalued. When you were a minister in 2012 to 2015, workforce was one of your areas of responsibility. What are your observations about workforce morale, where are we and where do we go?
DP: The first thing I did as a minister, which I don’t think I was very popular with George Osborne, was getting rid of the talk about ending national pay scales and moving towards regional ones. It would have meant that a consultant would be paid less in Cornwall than they might have been in London. That was all about cost-cutting. Being able to stop that was something I was very proud of, even though it wasn’t an achievement in that it shouldn’t have happened in the first place.
I always enjoyed a good working relationship with the NHS Staff Council, and with Rachael Maskell, who’s a Labour MP now, who was head of health at Unite. I got on reasonably well with Mark Porter as well, from the BMA. We tried to work through things and avoid any talk of strike action, and we got into a place where, because I was still a member of NHS staff, they knew that I understood them and had that same understanding of how government should engage with the healthcare workforce.
There’s always been a lot of ideology in the NHS pay rows – we don’t want to put up public sector pay – rather than pragmatism and valuing staff. It feels as if recently that ideology has got in the way of doing the right thing by patients. They lose out if there is a dispute. And while I am very squeamish personally about striking, I completely understand why colleagues have felt driven to do so. That was a mechanism of last resort, it wasn’t a reflex action. The government could have dealt with the issue in a much more effective way and showed more respect for staff by offering a sensible pay deal in the first place, rather than starting off with the bare minimum. It was bad healthcare economics. What’s the temporary staffing bill in the NHS? £5bn? £6bn? You’re going to encourage more people to leave and work as agency staff because you won’t give them a pay rise.
PW: There’s controversy at the moment about the NHS introducing medical associate professional services – physician associates (PAs), anaesthesia associates, surgical care practitioners – who aren’t qualified as doctors or nurses but are trained to carry out routine procedures and administrative tasks. There have been lots of instances where these new type of professionals are undertaking work that would ordinarily be done by a medically qualified doctor. We’ve had some instances of patient harm reported. There are no definitions of what these professionals’ scope would be, no consultation has been done with the medical profession, who are then expected to be supervising them and carrying medical responsibility. It feels like yet another instance of being undervalued and devalued.
DP: I had an adjournment debate on this very issue: I raised the points you’re raising in the House and got a very unsatisfactory answer from the minister. I’ve worked with some very good physicians’ associates, but we need to properly define what a PA or anaesthesia associate may be, and understand the scope of the role, the accountability structures and what the training and education programme is before we step on the accelerator and expand numbers. It feels to me as if the government has decided to pursue this policy because it’s a way of expanding the workforce at pace and at relatively low cost, rather than thinking it through in any sort of detail.
The first concern should be about patient safety. The expansion of a poorly defined workforce in which there’s a lot of variability and safety concerns with some practitioners strikes me as being not in the interest of patients – or of physician associates either.
PW: Andrea Leadsom, who is now the minister responsible for primary care, had a column in Pulse, the GPs’ paper, saying how important general practice is and announcing the formation of a task force into the future of general practice. In 2021, Jeremy Hunt, then chair of the Commons Health and Social Care Select Committee, spent a year looking into the future of general practice and produced a brilliant report that gave some fantastic recommendations for how to resuscitate that part of the NHS. Can you shed any light on the failure to learn from a thorough report and act on its recommendations, rather than just commissioning another?
DP: The government’s way of showing it’s thinking about something is often to launch a task force. We know what needs to be done, because there have been good reports already; there’s a very good understanding of what is needed in terms of workforce planning, properly supporting general practice with the right capital investment in IT systems, integrating IT systems with the secondary sector and other parts of the health and care system. We also know what needs to be done in terms of supporting the delivery of good community healthcare, including moving some hospital specialists to working more alongside GPs.
There is a tendency, particularly currently, to not want to do that thinking or planning. Instead the answer is, “Let’s launch a task force, let’s have another review,” which often leads nowhere. It’s again an example of rhetoric over delivery. When we know what’s to be done, and we’ve known that for probably a decade, we’d better get on and do it.
Phil Whitaker is the New Statesman’s medical editor and a practising GP. This conversation has been edited for length
[See also: Teresa Thornhill: “The system keeps some children safe, but fails others”]
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This article appears in the 22 May 2024 issue of the New Statesman, Spring Special 2024