Book review by Glenda Santana de Andrade

The Health and Social Care Bill, which supposedly proposes to create an independent NHS Board and to reduce NHS administration costs, is about to be read for the 3rd time at the House of Lords, later this month. This fact puts once again the National Health System in evidence. In England, if you are looking for health advice, treatment or reassurance you will probably end up using the NHS, the biggest integrated health system in the world, today with an annual budget of more than £100 billion and 1.4 million directly employed staff. However it was not always like that. At the end of the 20th century, the service, that was created 50 years before to provide free health care to everyone, no matter how poor or ill they are, had been in decline, with falling standards and failing public support.

During the General Election in May 1997, the Labour Party and its young leader, Tony Blair, came up with a political slogan “24 hours to save the NHS” that proposed a profound reform to help the NHS to survive and to prosper in the 21st century. As you already know, Tony Blair won the election and the reform that he was proposing took place. The account of this reform, which helps us to understand the NHS today and the new Bill, was scrutinized by Nigel Crisp in his book “24 Hours to Save the NHS – the Chief Executive’s account of reform 2000 to 2006”.

In 220 pages Lord Crisp, who was the Chief Executive of the NHS from 2000 to 2006 and also the Permanent Secretary of the UK Department of Health, tells the inside story of the reform, including many successes and a few failures, and also tries to draw some lessons for the future and some lessons for other countries, that could take the English case as a model.

According to Crisp, there were four areas of reform. “In the first we concentrated on improving services by redesigning them. (…) We also needed to reform the way the system itself operated by changing organisational structures and incentives. (…) The third area of reform was changing the way people worked in the NHS: restructuring the workforce and introducing new roles and new terms, conditions and pay in an effort to increase flexibility, effectiveness and efficiency. The final reform was to make it easier for health workers to be certain what is the best treatment and improve the way knowledge, technology and science were used in the NHS.”
As Crisp highlights most of the time the progress achieved by these areas of the reform were not complete and linear, however they were quite consistent in some cases. For instance, the NHS Plan set targets for 2005 of maximum inpatient waiting times reducing to six months and outpatient waiting to 13 weeks. All these targets were successfully met. In addition, most of A and E Departments now have good systems and processes and they are meeting the four hour target. Besides that, by 2006 the NHS already had the largest digital imaging network in the world and the ability to pass CT scans and other images around the country.

Even that this is a book of a man proud of his work as a CEO of the world’s largest integrated health system, fortunately the author does not leave out criticisms of himself or his own work, and takes care to show how he learned from this experience. It is very important, for example, that he recognizes that the NHS may have been saved but it is not yet sustainable, thus it still needs a radical approach which will enable the transition from a service that focus on hospitals, doctors and disease treatment to one which is community based, people centred and geared towards prevention and promotion. For Crisp, while NHS England’s core principles are still relevant, NHS England exists to do more than curing illness, helping people to be healthy and providing good health services when needed. For him, the NHS needs a deeper and wider vision to help people have as much independence as possible to live the life that they have reason to value. This sounds as a very sincere point of view.
Truth and attention to detail were also key themes in “24 hours to Save the NHS”. Lord Crisp values having had people around him who told him the truth, people like Judy Sweeting, his driver. He also believed that small changes could make large scale improvements. As a book that proposes to review how the NHS has progressed from being a relatively overrated service in 1997 with long consultant waiting lists to a better and more integrated service in 2010, “24 hours to save the NHS” is a good reflection and an interesting reading.

However, it must be said that sometimes Crisp misses some important points. In the beginning of the paper for instance, he proposes a discussion about the role of government, but he does not define it. The discussion remains superficial. In relation to the role of private sector in the NHS it seems that he also does not have a clear position. One the one hand he proposes some integration and more competitiveness inside the NHS, on the other he does not discuss the implications in the long term of the presence of the private sector inside the National Health Service. Maybe this is because he is not a member of any political party, but even though it seems that he does not want to take sides. During a comparison with other countries, like Brazil, he also seems pretty naive. It is very honorable that he accepts the Brazilian experience and other underdeveloped experiences in the health sector as a model for developed nations like England. Even because that it is truth that sometimes they can make much more with less money. However it is clear that he has only an official discourse about the Brazilian achievement in the sector.
Apart from that, “24 Hours to save the NHS” is a must-read for people working in the NHS and its critics. The book is also pretty informative for those seeking for more information to finally understand better the Health and Social Care Bill, still under discussion in the parliament. The only problem it is that we do not know anymore how many hours left do we have to save the NHS. The third reading is the final chance to amend the Bill. The question now is: is this bill going to help the NHS to be more sustainable? The later reform, as described by Crisp, made improvements but still was not sufficient. Will this bill be able to do that? Or will this bill makes things worse?

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