How betrayal forced us to fight for NHS

MICHAEL Mandelstam is an unlikely agitator. The 50-year-old used to work for the Department of Health machine and would later be one of the millions enticed by Tony Blair's New Labour vision.

As befits someone steeped in the detail of law and good practice at a professional level, his words are measured rather than rabble-rousing. All in all, a very middle-class sort of revolutionary.

But his careful phrasing is misleading, for underneath there's a man feeling betrayed by what's happening to the National Health Service.

The flashpoint came in the summer of 2005. Sudbury, where Michael lives, had long been looking forward to a new community hospital, and it finally appeared within sight. It was all systems go before May's General Election; but, by June, the dream was dead. Worse, health chiefs wanted to take away all Sudbury's inpatient beds, as well as many of the outpatient services.

“One minute we'd been promised what they called a reconfiguration of services and a new community hospital” - fewer beds, but there was a rehabilitation unit as part of the mix - “and a new balance between inpatient services and services in people's homes. We could agree with that. Then, suddenly, once the General Election was out of the way, the plug was pulled on that.

“The plan was modern, according to the PCT (primary care trust) and it said the Sudbury area needed it more than most because of issues about deprivation, mortality and rurality.

“Literally overnight it all changed. Suddenly that view of a hospital that was modern and the future of health care for 20 or 30 years was old-fashioned. Nobody in the community could swallow that.”

West Suffolk wasn't alone. Around the country a significant number of NHS trusts that were in debt were talking about cuts - hospitals, jobs, services and beds - to help claw back the money.

The water was also being muddied in some places by suggestions that care had to be reorganised to make it better for patients; it needed to become more community-based, with patients treated at home rather than enduring long stays in hospital.

Many an observer wondered where the money would come from to bankroll what appeared a more expensive way of treating the sick.

Back in Sudbury, opposition came together quickly under the banner of WHAC - Walnuttree Hospital Action Committee - and, says Michael, drew cross-party support at parish, district and county council levels. South Suffolk MP Tim Yeo and Lord Phillips gave their backing, as did the unsuccessful Labour candidate at the election. Clinicians and church leaders opposed the changes.

“It was a gauge of how drastic this was and how important health care was to everybody,” says Michael, who would become a core member of the campaign.

Facts were gathered, documents dissected, letters written, phonecalls made.

The group set up a large board game on the Market Hill in Sudbury called Hunt the Hospital Bed. People picked up wooden squares and tried to find a bed, a therapist, a doctor or a nurse. Most of the squares were hospitals bearing a “for sale” sign or a manager with a flip-chart and a hatchet.

The father of two youngsters smiles at the memory. “The children made me laugh because they viewed Thingoe House, the headquarters of the PCT, as Nottingham Castle and the PCT chief executive as the sheriff of Nottingham, and WHAC as the outlaw band.”

Michael claims the former Suffolk West PCT - now swallowed up in yet another health service reorganisation - tried to write off WHAC as an unrepresentative bunch of fanatics.

He became increasingly angry. Precious few officials - locally or nationally - could explain to his satisfaction how the suggested changes would make life better for patients or how they would be paid for. Also, the language used was to his mind meaningless.

At the heart of the matter were the elderly and vulnerable.

Michael's wife, Halcyon, works at Sudbury's threatened Walnuttree Hospital as a senior physiotherapist, helping with the rehabilitation of older patients with more complex problems. For six years, he says, he's watched her trying to run a grossly under-resourced service. Now no-one is certain what the future holds. Proposals have been challenged and final decisions have yet to be made.

“The thing that really meant I had to get involved was the fact it's not being admitted. There's no transparency; despite huge cuts being made not just here but in other parts of the country, the local primary care trusts and the acute trusts will never admit that patient care is being affected.

“It means you can't even talk about the problems that will be created, because they're denying there will be any problems. I think this disingenuousness is really unforgivable.”

Officials were prone to “retreat into abstraction” when asked for concrete details about how a patient with condition X or Y would be treated after reorganisation, he says.

“The book is as much about this gloss as it is about the actual cuts. A system gets rotten if the decision-making process itself goes rotten; and that's why you have to look behind the cuts to see how this whole form of discourse and lack of transparency has arisen.”

Betraying the NHS: Health Abandoned doesn't pull any punches, but the author denies he's “grinding a party-political axe that I had previously. I suppose you could argue it's grinding one now, because of what, in my view, New Labour's doing”.

Care closer to home is just another name for care in the community, which has been tried out in different areas and in different forms for years, he argues, and has always resulted in cost-cutting and a lack of proper services in the community.

“There are some people for whom home treatment is appropriate and desirable. But first of all you do need very well resourced teams, particularly in a rural area, and there is no sign whatsoever that the PCTs are in any position to fund those teams adequately, because they hadn't got any money and have got big deficits.”

There will still be a large number of patients for whom home treatment is not appropriate, he says - so we will still need effective inpatient services. Besides, he's seen no evidence to suggest widespread home-based treatment works in practice.

Michael can sympathise with the chief executives, because they've effectively been commanded to make huge savings. But the

fear is - and he says he's heard this from doctors - is that once people are pushed out into their own homes, they go off the NHS radar and probably into the orbit of social services. “And that whole window of rehabilitation, where the person could have become more independent again, is lost”.

Unable to present evidence that policies will work, trusts come up with phrases such as delivering the right care in the right place at the right time and by the right people, he says.

“It's actually entirely meaningless. First of all, how could you sensibly aim to do anything else? And, secondly, how can you verify and measure it? Short of evidence, you resort to a mantra and hope the local population get fooled by it.”

Michael suspects the costs of looking after an ageing population have prompted many of the proposals. He stresses he's not singling out for blame local individuals within the NHS. What we're looking at is widespread systemic failure, “and the line of command runs back to (Health Secretary) Patricia Hewitt”.

National targets encouraged trusts to throw money at certain areas - to the detriment of other parts of the NHS.

The bodies under the umbrella of NHS East, our regional strategic health authority, have a forecast deficit of £150 million. “That is Patricia Hewitt's failure, because the whole system is the Department of Health's system. So it's absurd of her to blame the locals.

“It's like a perfect circle: reason or discordant voice or debate can't break into it. Nobody will take ultimate responsibility. Without getting too high-minded about it, when you're living in a democracy, and it's something as important as health care, that just won't do.”

Nagging away, too, is the thought that NHS services are being softened up for the private sector.

“You might think this is a wild claim, but we know in June the Government got caught out, placing this contract in the Official Journal of European Union.” Reports spoke of a contract to manage the purchasing of NHS services and supplies worth up to £64billion.

“So, unfortunately, the more you look at it, you can begin to see some patterns - but the patterns aren't reassuring at all. They're horrifying.”

At one time the NHS was the envy of the world, he says, and we could get back to that position by investing in it in the right way.

Out of 320 community hospitals in England, 110 are threatened with closure or cuts, he points out. “When you think the national policy is to develop community hospitals, you realise the extend of the spin and the disingenuousness.”

He fears detrimental changes to the acute hospitals could be next: affecting cornerstones such as accident and emergency departments, minor injury units, maternity services and paediatric care. (Indeed, NHS East is due to consider soon the results of a review of the region's acute services.)

“What I've tried to explain in the book is the sheer enormity: to try to say that when all these local groups are protesting, it's not local nutcases or local Luddites. This is something fundamental that's happening, and it's very serious.”

He warns the issue of the NHS could be enough on its own to sink Labour at the next General Election.

Does he get depressed by it all?

“When I have time, when I stop trying to decipher and translate what the NHS is saying to us locally, I would, if I let myself, get very depressed about it. Yet on the other hand it makes you think that somebody has to do something.

“I grew up thinking that people in power are there because they know what they're doing - and that's been a hard lesson.”

Michael admits that he, and other West Suffolk campaigners, worry they might be painting too gloomy a picture.

“Are we all wrong in fighting? I keep asking myself 'Did I do the right thing writing the book?' But then I open a newspaper the next morning, or hear the Today programme, and I know that I was right.”

MICHAEL Mandelstam admits that standing up for the NHS has changed his life. It's consumed “absolutely colossal quantities of time” as he and fellow campaigners combed through board papers and tried to work out their implications. They also “have to find out what's not in the board papers . . .

“It's affected the family as well. I haven't seen them for 18 months!”

He describes it as David versus Goliath stuff, because the Government has all the spin machinery, money and power. “For local communities to fight this on all the different levels is a huge undertaking.”

Michael's seen the NHS and social care from the perspective of both the voluntary sector and from within the Government machine.

For 10 years or so he worked for a national voluntary organisation called the Disabled Living Foundation. Then, in the 1990s, he worked with the social services inspectorate at the Department of Health.

For the past decade he's worked largely independently, providing parts of the NHS, local authorities and voluntary organisations with legal advice and training on health and social care matters.

Betraying the NHS: Health Abandoned is published by Jessica Kingsley at £14.99. ISBN 1 84310 482 2