NHS in the News
An Analysis of News Coverage of the Health Service
August 1991 - May 1992
A Report for the King's Fund Institute
By David Miller, Jacquie Reilly and Lesley Henderson
Glasgow University Media Group
61 Southpark Ave
Glasgow G12 8LF
NHS in the News
An Analysis of News Coverage of the Health Service
August 1991-May 1992
Sample and Method
This research examines the coverage of the National Health Service and health policy in the months of August and November 1991 as well as February and May 1992. The four week period from the beginning of the month leading up to the OPCS omnibus opinion survey, was taken as the sample period. The sample included the national press (Star, Sun, Mirror, Express, Mail, Today, Times, Telegraph, Independent, Guardian and the Financial Times) and the main network television news bulletins (BBC1 Nine O'Clock News, ITN News at Ten, Channel Four News and BBC2's Newsnight). We also monitored Current Affairs and documentary programmes which dealt with health policy or the Health Service. Because of the major political controversy which arose in the months of September and October we have also looked at three of the key events in these months which helped to shape the debate in November. These were the controversy over the length of Waiting lists in September, the debate over the 'privatisation' of the NHS at the time of the Conservative Party conference and the announcement in November by the government of the second wave of hospital 'opting out'.
The object of this study is to track the major themes in stories on the health service and in particular assess the reporting of the current government health reforms. Our analysis looks firstly at the range of arguments which existed at this time, and then at the manner in which they were processed into news accounts. This is likely to vary between different news sources - for example with the political complexion of different newspapers. It is therefore important to understand the manner and context in which different views are highlighted in order to assess their potential impact on public belief.
Understanding the NHS
In the debate over the Health Service there are clearly contending views on the proper function, actual condition and proposed solution to the problems of the Health service. For the government, the reforms are intended to break up and modernise what was seen as the monolithic and inefficient bureaucracy of the NHS and introduce a market mechanism. A key element of the reforms is the devolution of health care budgets to individual doctors and hospitals from Health Authority control. This refounding of the health care system with a more 'rational' model of management will ensure that money will remain in the hands of those best equipped to know how to spend it. This can only serve to increase patient choice, allow more efficient patient treatment, bring waiting lists down and boost staff morale.
For the Labour party the problems of the health service are primarily the result of underfunding. The solution is simply to make more resources available. They claim that the reforms are privatising the NHS, with hospitals and GP practices becoming more like businesses. Market forces should not be introduced because, it is argued, it puts financial considerations before people. The Labour party argue that the consequences of the reforms will be that patient choice will become a low priority as the system is forced to revolve around budget constraints. They also argue that a whole new layer of bureaucracy will be created to manage the new financial and administrative systems created by the reforms. Hospitals 'opting out' of Health Authority control are seen as part of a policy of 'creeping privatisation' which promotes the formation of a 'two- tier system' of Health care.
The Conservative response to allegations of underfunding is to emphasise that they have increased spending on the Health Service in real terms every year they have been in office and that accordingly the Health Service is 'safe in their hands'. Allegations of 'Privatisation' are simply a Labour scare tactic.[See Mohan, 1991 for an account of Conservative thinking]
Labour emphasise that the reforms are not having their desired effect; That waiting lists are increasing; patients are being denied operations; Wards closed; Patients are forced to pay for treatment that was previously free and that staff are demoralised. The Conservatives are attacked for massaging and manipulating health statistics.
We need to understand these general perspectives and the way that they use different evidence to support their cases or can actually dispute the accuracy of evidence used by the other side.
The next part of this report reviews the main issues of the months of August, November, February and May 1991/2 as determined by media attention and briefly considers the coverage of the major political controversies of September and October in order to set the November coverage in context.
Coverage of the Health Service was severely limited in this month by the amount of attention given to other world events. The attempted coup in the (then) Soviet Union dominated the news for much of August. Appendix I illustrates the contours of coverage for August. There were a total of 119 items in the press and on television until the end of the fourth week of the month. The announcement of the second wave of opting out hospitals and the launch of Labour's counter proposals were the main stories, accounting for 57 items or almost 48% of all coverage. Other related stories were the controversy over waiting lists (15 items) and the question of GP fundholding contracts (10). There were also stories on the hours worked by junior doctors (8), private health insurance (6), Management finance and training in NHS (6), creation of the Supplies Authority (5), Consultants use of private care (4) the 'gagging' of Health Authority staff (3), the quality of nursing care (2), food in hospitals (1), Labour Charter for the elderly (1) and wage levels in the NHS (1)
The headlines on the second wave of optouts give a flavour of the perspectives on the reforms from supportive to oppositional:
'Opt-Out cure for the NHS' [The Sun, 7.8.91]
'Top Hospitals cleared to join the revolution - Trusts work wonders for waiting lists' [Daily Mail, 5.8.91]
'New row over 'private' NHS' [Sunday Express, 4.8.91]
'Accelerated NHS reforms condemned by Labour' [Daily Telegraph, 5.8.91]
'Opting out of Duty' [Today 5.8.91]
'Making too many waves' [Guardian 6.8.91]
There was much comment on the speed of the reforms in the press, with the junior Minister of Health reported as saying he was confident that by April 1993 half of all patients will be treated in trust hospitals [Sunday Times, 4.6.91]. It was suggested that an incoming Labour Government would find it hard to dismantle the reforms which would by then be solidly in place.
The government's position was that they were making the NHS more efficient by removing unnecessary layers of management and localising control and finances. Ministers repeatedly argued that the government was not intent on privatising the NHS, an idea which was attacked as a Labour smear. Harriet Harman, the shadow health spokesperson spelt out the Labour argument:
The Government will not listen to the doctors and people working in the NHS, or to what local people are saying. The reason people are against this is that they know it is the first step towards privatisation, the breaking up of the NHS. That is why the Government is doing it. [Daily Mail, 5.8.91]
August opened with reports from the Public Accounts Committee that waiting times for outpatients had increased. These findings were reported in the Daily Telegraph, The Times, Independent, Daily Express, Today, and the Sun. This was assumed by some papers to be bad news for the government's reforms, Today reported, for example, that 'The much trumpeted NHS reforms are failing to cut hospital lists with some patients having to wait almost two years for appointments' [2.8.91]. Other papers such as the Express, simply reported that waiting lists had got longer. The Sun and the Times however reported the figures with more sympathy to the government. The Sun reported that the Public Accounts committee had 'blasted 'inefficient management'', while the Times reported that part of the reason for the 'inefficiency' was that 'Five million patients a year fail to turn up for hospital appointments' thus contributing to long waiting lists [Times, 2.8.91]
The nine stories on GP fundholding contracts included the debate on the value of the three yearly health checks which GPs were being asked to carry out [5.9.91]. There were five reports suggesting that GPs were reaching preventive care targets set by the Government for immunising children and cervical cancer screening. The Guardian, however, argued that the scheme was less effective in urban and inner city areas. [9.8.91]
The coverage for November was greatly increased with a total of 257 items in the press and on television, compared with 119 in August. The seven largest categories of stories included the progress of the reforms (61), the Opt-out leak controversy (26), the Patients Charter (25), funding the NHS (23), the operation of trust hospitals (19), public opinion (18) and Waiting lists/times (16). Appendix II illustrates the distribution of stories.
The reforms were again the major story of the month and they provided the rationale for covering most of the 57 health stories in the press. The central issue here was a concern with whether the reforms were working. These can be broken down into three main areas 1. the quality of patient care (35 items) 2. staff morale and conditions (9 items) 3. The question of privatisation and the creation of a two tier health service (13 items)
Stories in these categories included claims of queue jumping in trusts, problems with extra contractual referrals, budget restraints, restriction of patient choice and a lack of public voice in decision making.
Privatisation was a significant issue with items relating to the debate about the creation of a two tier service. These included an opinion piece in the Guardian by Harriet Harman [7.11.91] and an item on a report by the Kings Fund on the impact of the reforms on hospital costs. [Independent on Sunday, 10.11.91]
Stories on staff morale and conditions included items on a shift towards temporary contract staff in a London hospital, stress on GPs as a result of the reforms and low morale amongst GPs.
The opt out leak controversy
Twenty six stories related to the leak of a draft report by the Commons Select Committee on Health to Secretary of State William Waldegrave. The report included a call for a slowing down in the creation of trust hospitals. This section of it was subsequently voted out by Tory MPs on the Committee. This gave rise to suspicions that the government had been improperly involved in 'nobbling' the committee. The Independent argued that:
If the Tory dominated committee had approved the report, it would have been damaging to the Government when it was under heavy fire from Labour over NHS changes. But after being leaked to Mr Waldegrave, the Tory members of the committee voted to omit the most damaging sections... Members of the Committee believe the leak opened the Committee to the charge of being 'nobbled' by Ministers, undermining confidence in its investigative powers. Labour MPs said the Government was guilty of complicity. [8.11.91]
Jerry Hayes, Tory MP for Harlow resigned from the committee following the disclosure that one of his researchers was involved in the leak and Labour and Tory MPs demanded the sacking of Ian Taylor, Parliamentary Private Secretary to Mr Waldegrave, who admitted receiving and passing on the critical report. Labour used the controversy to demand the resignation of William Waldegrave.
Waiting Lists/Patients Charter
Many of the stories which related primarily to waiting lists came under the heading of the Patients Charter in November. The charter was part of the government attempt to show that the health service was not being privatised. Comments on the size of waiting lists or on waiting times were measured against the claims in the patients charter.
Funding the NHS
The nineteen stories on funding in November peaked on the seventh when Norman Lamont made his Autumn Statement which included what he described as an increase in spending on the NHS of £2.7 billion. The announcement was an attempt to defend the reputation of the Conservative Party on the issue of health following Labour charges of privatisation. Lamont argued that:
These latest increases will bring the total real increases in NHS spending since 1978-79 to well over 50%. When tough decisions have been necessary across the range of public expenditure programmes, we could not have made our commitment to the NHS more clear. [Financial Times, 7.11.91]
The Health Secretary William Waldegrave also argued that the new money would illustrate the falsity of Labour claims of privatisation and demonstrate that the NHS is 'safe in our hands': 'This demonstrates yet again in the clearest and most emphatic way our commitment to invest in the future of the health service.' [Financial Times, 7.11.91] But there was criticism from the BMA which said the money was 'disappointing' and from the RCN which called it an 'elastoplast approach to a complex problem of underfunding'. [Daily Telegraph, 7.11.91].
The majority of the nineteen stories on trust hospitals focussed on the success or failure of particular trust hospitals. The most heavily featured hospital was Guys in South London (13 items) which was used by the government as its flagship for the success of the reforms. Twelve of the thirteen reports suggested that Guys was a success. The Sun, for example, ran an editorial titled 'Magic Cure', which referred to Guys as 'treating 3,500 more patients. Nearly all out-patients are seen within half an hour. Hours for junior doctors are going down, pay for low paid staff is going up by £6 a week. While Socialists merely talk, Guys has found a magic cure for Health Service ills'. [16.11.91] Only one of the thirteen items was critical of Guys. The Daily Mirror featured the case of a woman who died after being wrongly diagnosed at 'the governments show piece Trust hospital'. The headline read 'You can't trust these guys - dying woman is turned away as bosses toast NHS 'reforms''. [22.11.91]
The 18 items on public opinion resulted from the publication of three opinion polls. There were 7 items on the first poll by Gallup for the Daily Telegraph which reported the latest state of voting intentions as well as opinion specifically on the Health Service. Significantly the increased labour lead in this period is mainly attributed to the Health debate by the press. The eighth annual report of the British Social Attitudes Survey accounted for a further seven items and found that public 'devotion to state provision of welfare especially the NHS survives undiminished.' [Guardian, 20.11.91] The third poll, which was reported four times in, respectively, the Sun, Daily Express, Times and Daily Telegraph, was conducted by the National Association of Health Authorities and Trusts and the Health Service Journal. It was interpreted as far more comforting for the Government and it led the front page of the Daily Express:
Thousands of patients have given the NHS and overwhelming vote of confidence... Nearly nine out of ten declared they received 'excellent' treatment while they were being cared for... The poll... was hailed by jubilant Government ministers as proof that health reforms are at last filtering through to patients. [14.11.91]
The impending General Election provided part of the context for the increased prominence of the Health Service in February. A total of 290 press and television news items were recorded, the highest monthly total of the year. The largest stories were Labour's alternative proposals for the NHS (57), the Patients Charter and waiting lists/times (42), NHS staff pay and conditions (38), cuts and funding (34), the reforms (31), prescription charges (25) and GP fundholding (25). Appendix III shows how the stories were distributed over the month.
In February the waiting lists themselves had reemerged as an issue substantially separate from the Patients Charter. The government had promised to reduce two year waiting lists so that no patient in this category remained untreated by April 1st. William Waldegrave announced record quarterly falls in Waiting lists in February, while Labour attempted to shift the agenda by claiming that the figures had been fiddled. They alleged that the government had overseen the removal of thousands of names from waiting lists without the patients being treated. Other critics highlighted the dilemma for doctors in choosing between achieving targets to avoid financial penalties and proper clinical judgement. The debate about privatisation continued with the opposition arguing that patients were being forced to seek private treatment because of the length of waiting lists.
Labour proposals for the NHS
Labour's alternative proposals were the subject of fifty one separate items, the largest number on any one debate for the month. More than half (27) of these appeared on February 21st, following the launch of the proposals,entitled 'Your Good Health' which recommended abolishing the internal market, self governing trusts and GP fundholding. However, the Financial Times suggested that Labour's plans were not as radical as they seemed:
While Labour want to free the NHS from 'commercial pressures,' they do not reject the purchaser-provider split entirely and would use service agreements between health authorities and hospitals. The health authorities would provide incentives for good performance hospitals without, Labour are having to compete in order to succeed. [Financial Times 21.2.92]
Some of the press welcomed the strategy. For example:
'Labour's care before cash' [Daily Mirror 21.2.92]
'Taking the sickness out of health' [Guardian 21.2.92]
Others focussed on the problems that further changes would bring. The Times suggested that with these plans 'competition' was being replaced with 'collaboration' [21.2.92] and the Financial Times saw them as one way 'to make a mix of care and cash healthy.' [21.2.92]. The government criticised the plans and William Waldegrave argued that Labour would:
throw away everything and go back to a 1948 style, top-down pyramid NHS, turning upside down all the good work that has been done. [Daily Mail 21.2.92]
The main criticism though appeared to centre on the fear that efficiency incentives, proposed to replace the internal market, would simply not provide the same stimulus. This was highlighted byThe Times, which argued that 'Labour has striven to distance itself from the governments health service reforms so as to present voters with a clear choice between a service in which competition provides the stimulus for change and one in which that incentive comes from the promise of extra funds.' [The Times 21.2.92]
There were a total of 36 items on waiting lists in February. The patients charter, which was to come into effect on lst April 1992, stated that no-one should wait longer than two years for an operation. A debate on how the government intended to fulfil this promise and the question of exactly how many people were still over the limit dominated coverage. The Daily Mail claimed that the government were already well on the road to success:
Long term delays for treatment have already fallen dramatically following the Government's recent health service reforms. In the last quarter of l99l, the number of patients waiting more than two years for an operation fell by l3,8224. [Daily Mail 11.2.92]
This was not a universally held view. The Guardian [11.2.92] suggested that the 'zero target ' could not possibly be reached because there had still been 29,385 two year waits in December 1991. The government announced that £39 million was to be given exclusively to improving long-term waiting lists. [The Star 11.2.92] But problems with the governments plans became apparent. There were a plethora of stories regarding the use of private treatment to cut long term waiting lists. The headlines read:
'Bid to beat Tory deadline, NHS hospital spends 100,000 on private ops '
[Daily Mirror 18.2.92]
'NHS pay £1 million on private ops' [Daily Mirror 20.2.92]
'Rush to beat deadline' [The Times 20.2.92]
'£1 million to cut sick list' [Daily Express 20.2.92]
The Guardian went further and reported that surgeons were being paid up to £1,000 a morning to treat long term patients.[Guardian 21.2.92] The impression of frantic NHS activity on waiting lists continued in The Guardian [22.2.92] and the Daily Telegraph. [22.2.92] However, the Sunday Express suggested that the government might have to accept defeat:
despite a frantic 'money-no-object' campaign by Health Secretary William Waldegrave's department to clear the 20,000 backlog of patients in the next six weeks, ministers are admitting privately that the chances of meeting Mr. Major's patients charter pledge in full are fading. [Sunday Express 23.2.92]
To counterbalance this a number of success stories appeared. The Daily Mail carried a feature on a 'labour supporter' whose operation was carried out in ll months.[24.2.92] Success stories from some of the regional health authorities were also highlighted. In particular the cases of health authorities which had cut waiting lists by more than 60% and one which had completely cleared its two year backlog.
There were a total of thirty four items dealing with questions of NHS staffing, much of it concerned with the announcement of the NHS Annual Pay Review Awards. The resulting controversy around dentists pay accounted for seventeen items alone. On February 11 it was reported that an 8.5% increase was to be awarded to NHS dentists. The Department of Health issued a statement claiming that 'much of the 8.5 per cent pay rise had already been given 'through a 'substantial' overpayment last year' [Times 11.2.92] which led to dentists' leaders threatening to refuse to treat NHS patients in protest. The BDA commented:
The government came to us with it's contract and we have made it a success- now they are turning a pay rise into a pay cut. [Daily Telegraph 19.2.92]
The Independent claimed that because of this threat the government 'beat a hasty retreat' [21.2.92] over the issue, but some questions were raised as to why the government had given in. One suggestion was brought up in the Independent on Sunday which quoted a dentist who viewed the back-track with cynicism:
The government has simply pushed the issue back until after the election. I suspect that if the Tories win they will bring it back and push it through again. [23.2.92]
The remaining l7 items were all directly or indirectly prompted by the Pay Review Awards for junior doctors, GP's, the ambulance service and nurses. Of these there were six items on the pay increase for nurses. While it was reported that their rise was above the inflation rate, there was a great deal of disappointment at the 'below average increase', with COHSE claiming that it 'would do nothing to halt the exodus of nurses from the NHS.' [Independent 11.2.92]
Funding and Cuts in Funding
Issues around the funding and cost of the Health Service accounted for 34 items in February. The largest peak of coverage came on February 20 with six papers reporting a Kings Fund research survey on London hospitals. The Times headlined its report: 'High costs put London hospitals "at disadvantage"'.
Remarks by Virginia Bottomley sparked controversy earlier in the Month when comments made to the North London Conservative Association were reported in the Guardian. Speaking on the subject of numbers of NHS beds she said: 'We can't afford to have people lingering around for a recuperative holiday. We are not catering for people who do not have a home or who have nowhere else to go. Now people have telephones, central heating, GP services and remarkable drugs. The whole structure of health care has changed and beds are not what we want. We want the minimum necessary. We still probably have got more than we need.' [10.2.92] These comments were seized on by Harriet Harman who commented that 'many people in hospital would object to the idea that they were lingering, while many people who were not in hospital but needed to be... would be appalled at the suggestion that there were too many beds.' For the Daily Mirror Bottomley's speech was a 'sick joke' [10.2.92]
These reports came on the same day that the Independent previewed a 'World in Action' report on the NHS. According to the programme in intensive care 'the bed shortage is so bad that very sick patients are regularly transferred from one hospital to another and, as a result, some die'.
The Mirror, the Independent and Today [on the 11th, 17th and 19th respectively] reported Doctors leaving the NHS because of inadequate funding. There was a clear theme during February suggesting that cuts in funding and services were resulting in preventable deaths. A total of twelve items reported specific deaths as a result of cuts. Seven of these related to the death of Carly Reavill, aged six. All of the reports except two were in the Daily Mirror. The story appeared on the front page of the Mirror on February 20 under the headline 'Carly - Killed by the NHS cuts'. The death was raised in the Commons, where the Prime Minister and the Health Secretary denied that Carly had died because of cuts. The Mirror carried the denial the next day under the headline 'Desperate men, Desperate Lies'. Only the Daily Star headlined the government position and even then Major's statement was in quotation marks in a single column: 'Cuts not to blame for death' [21.2.92]. Of the eight remaining items two were about bed shortages in hospital and three were on deteriorating standards in hospitals. An additional three dealt with general funding issues.
There were twenty nine items on the success or failure of the NHS in practice on February. The biggest story related to Labour's leaking of a memo from the NHS Management Executive to illustrate the difficulties faced by the NHS. Robin Cook accused the government of covering up the truth about a 'financial crisis' in the health service and claimed that hospitals were being forced to 'slam the brakes on patient care'. He also said the document made it clear that the priority of civil servants had been to keep the truth about hospitals out of the news. The document referred to the need to 'minimise noise' about the deficit at one particular hospital:
This private report tells the truth. It is the same picture of underfunding with which we have become familiar under the Conservatives. The priorities in this document are a disgrace to Ministers. Patients are not even mentioned [Independent 6.2.92]
The debate about whether the new-style health service was becoming too bureaucratic continued. Figures released by Virginia Bottomley showed that 'the number of National Health Service Managers has soared by l,800 per cent, but the number of nurses has fallen for the first time on record.' [Guardian 10.2.92] This resulted in a number of articles discussing the bureaucratisation of health care as a direct result of NHS reforms. The Daily Mirror headline read:
'Health warning: Nurses lose out to pen pushers'. [Daily Mirror 11.2.92]
The item claimed that these figures were proof that the government were being 'forced to boost bureaucracy in the run-up to Health Secretary William 'Wally' Waldgrave's cash-before-care NHS shake up'. The Guardian published a particularly scathing letter from one NHS consultant who claimed that what the reforms had created was:
an organisation overwhelmed by tasks which divert it from its main purpose. Skilled clinicians now devote inordinate amounts of time to bureaucratic activity. Money is being spent on unnecessary information processing. Wards are closed and operating theatres lie idle, while accounts departments are burgeoning with staff . [Guardian 18.2.92]
William Waldegrave, however, assured NHS managers that everything was going 'remarkably well' and that 'only the most blinkered and prejudiced of commentators can now deny or dismiss the benefits that are coming from the reforms.' [Independent 25.2.92] More support came from the News of the World who warned it's readers of how the system would work under a Labour Government. This, it claimed, would mean a return to the 'bad old ways,' which apparently meant the 'overstaffing of ancillary services, abolition of hospitals' rights to get such things as laundry and cleaning done cheaper from outside, return of total bureaucratic control by those ignorant of how hospitals should work. A phenomenal waste of money at the tax-payers expense'. [News of the World 23.2.92]
On April 1st Prescription charges increased by 35p to £3.75. There were 22 items reporting the increase. The Independent was one of the few papers to put the increase in the context of overall changes in the financing of the NHS. It reported that according to Department of Health figures 'The Government has virtually doubled the share of NHS spending which comes from private patient, prescription and dental charges'. The significance of this was that the 'fall in total NHS spending that comes from tax over the past twelve years, and the increase in income from charges and land sales is likely to be used by Labour as further evidence of 'creeping privatisation' in the NHS' [13.2.92]
The Daily Telegraph emphasised the government explanation that there was a 'safety net' of exemption from charges for the those on low incomes. Virginia Bottomey claimed that 'No child, no pensioner and no person on income support is affected by the increase' [Times 14.2.92]. Over the next ten days there were seven stories and letters to the papers which contested this account, emphasising the gaps in the safety net.
The nineteen items on GP contracts focussed on the question of the success of this part of the government reforms. Research from the Kings Fund entitled 'A Foothold for Fundholding' was reported in three papers. 'Doctors' fundholding 'still to prove itself'' was how the Independent saw it, emphasising the argument that 'it is still too early to judge whether the scheme should become universal'. The Independent also reported one of the reasons for caution given in the report; 'Only the best organised and most highly-motivated practices were selected by the Government as the fundholding pioneers. Those under the greatest pressure, in inner city areas were less likely to apply, partly because of inadequate accommodation and uncertainty over future funding.' [11.2.92]
On the other hand the Times reported the story as indicating that '"Patients benefit" from GP budgets' and that a two tier system had not resulted from the changes. This approach was echoed in the Guardian which reported that 'Ministers receive a boost today for their National Health Service changes with a report arguing that the innovation of GPs running their own budgets has been introduced successfully'.[11.2.92]
There were three items following the announcement of Labour Party policy on fundholding which featured reaction from William Waldegrave and fundholding doctors. On February 20th Waldegrave announced that the range of services fundholders are allowed to purchase would be extended. The Times saw this as 'an attempt to steal Labour's thunder as it launches its plans to scrap the government's market based reforms of the NHS'. It also reported clashes in the Commons between Mr Waldegrave and Mr Cook over fundholding and a two-tier system.
The Sun ran a full page feature on what it called 'Cure Genius - docs opt out to help patients cut the red tape'. It detailed how fundholding has dramatically reduced bureaucracy and increased patient care. Other items included three letters on fundholding and its impact and three items on GP successes in reaching both Cervical smear and Immunization targets under their new contracts.
Labour Leak row
Following the leaking of an internal Department of Health document which revealed financial difficulties in 86 hospitals, there were a further 15 items which dealt with the controversy about the identity of the 'mole' and the role of the Labour Party in encouraging leaks. The story broke in the Express and the Mirror on the 13th. The Express reported 'Labour's NHS mole trapped' and described the official concerned as having sent 'stolen government papers' to Mr Cook. The Mirror on the other hand headlined 'Tories boot out NHS mole', describing him as 'an official who helped expose bogus Tory claims about the NHS'. The leak was seen by the Independent as 'politically damaging since the government says that the NHS will balance its books this year'. For some papers the 'leak' story was one of the few opportunities they got to attack the Labour Party over Health. The Daily Mail assessed the story in terms of its implications for the coming election: 'The British people will be eager to know Mr Cook's answers. They should help many to decide whether he and his party are fit to govern' [14.2.92]. Robin Cook gave little comment on the controversy until a week later. He repeated the Labour pledge to introduce a Freedom of Information Act, saying that 'I don't accept any of the criticism aimed at me, which springs from the assumption that the government has the right to keep from the public that which they have a right to, suppressing information for the convenience of the party in government' [Daily Telegraph]
The issue of television and news bias was again commented on by some of the papers. There were eight items in this area, five of which appeared in the Daily Express either berating 'Labour Lies' or BBC coverage of the NHS. We will discuss this issue in greater depth below.
Of the seven items on Community Care, four were in the Guardian, two in the Independent and one in the Financial Times. This issue was ignored in the other broadsheets and by all the tabloids. The coverage focussed on the difficulties of providing long term social care within existing resources. A Guardian editorial argued that:
there is an urgent need for the government to define much more clearly the respective roles of health and social service authorities. By refusing to clarify these responsibilities Ministers are only extending to NHS clients the 'game of geographical chance'. [1.2.92]
Inadequate funding was a recurring theme in the coverage with a further three items (two of them letters). A Consultant Psychiatrist wrote to the Guardian explaining problems in these terms [21.2.92]. Counterposed to this was a report in the Financial Times which reported William Waldegrave's announcement that competition may be extended to Community Care.
Liberal Democrat Proposals
There were five items on the Liberal Democrats alternative proposals for the NHS 'Restoring the Nations Health', the main theme of which was 'sustained increases' in NHS funding.
In May 1992 there were a total of 127 stories on the Health Service ( Press: 118, TV News: 8, Documentary: 1 ) covering nine areas of interest. 60% of the total number of stories can be placed into only two categories which are:
Health Service Staff ( 31%)
Health Service Reforms ( 29%)
The remaining 40% of coverage in this period dealt with a variety of topics which included the debate over the introduction of new Government policies on Community Care for April 1993 ( 12 items), the Waiting List issue ( 9 items), GP Fundholding ( 9 items), the funding of NHS Reforms ( 9 items), and, growth in the Private Health Care Sector ( 9 items). There were two further stories, one on the Labour party and how they see the future with the Reforms now firmly in place [Observer 10.5.92] and one on the Press Complaints Commission ruling on the Bennett case [Financial Times 5.5.92]. Appendix IV shows the distribution of news items.
This category was the largest of the whole month and was dominated by two particular issues. The announcement by the government of a reduction in the number of hours worked by junior doctors (April 10) took up 14 of the total of 39 items .The announcement was seen by the majority of newspapers as a positive move forward with headlines such as:
'Aid for tired doctors' [Daily Express 11.5.92]
'Virginia comes out fighting for doctors' [Today 11.5.92]
'Bottomley orders cut in junior doctors' hours' [Independent 11.5.92]
But while Mrs. Bottomley was being congratulated for tackling one of the health service's 'greatest scandals' [Today 11.5.92], it was made clear in much of the coverage that 'the government's aim of a maximum 72 hours by 1995 was still a long way from being achieved.' [Times 11.5.92]
Another major story in this category concerned a conference attended by dentists from all over Britain. The debate centred on whether there was any future for dental treatment on the NHS if the Government went ahead with a proposed cut in their fees postponed just before the election. The problem was put very clearly by the Daily Mirror:
Angry dentists are set to sink their teeth into the Government. They're threatening to pull out of the NHS over plans to slash fees. [Daily Mirror 19.5.92]
Most of the coverage described the bleak future for NHS dentistry with the Dental unions' promise to urge its members to avoid NHS work and treat only private patients if the fee cutting went ahead. [eg. Independent 22.5.92, Guardian 19.5.92, Daily Mirror 19.5.92, Daily Telegraph 19.5.92] Some of the newspapers went as far as to offer advice on the pros and cons of some of the private dental plans currently on the market. [Daily Mail 20.5.92, Daily Telegraph 20.5.92, Independent on Sunday 24.5.92]
There were also 5 stories which looked at the investigation into the case of a medical scientist who was sacked from an NHS trust hospital 'after exposing cases of financial irregularity and scientific fraud.' [Guardian, 6.5.92]. The remainder looked at pay levels for different NHS staff.
Of a total of 37 stories on the effects of the health service reforms 12 dealt with the General Medical Councils move to introduce a new system for dealing with doctors who 'perform badly.' [Times, 15.5.92]. The Daily Telegraph claimed that it was concern about the standard of private doctors which 'has been a key factor in pushing the GMC into the biggest overhaul of disciplinary procedures for almost 150 years.' [Daily Telegraph, 19.5.92] Other newspapers reported that it was the whole profession that would be under scrutiny and that the purpose of the new procedures was to 'restore the standards of medical practice by a doctor to the level when he or she was registered.' [Independent, 20.5.92].
There were 8 items on the most recent announcements of those applying for trust status. Health Minister Brian Mawhinney claimed that another 129 hospitals and NHS units had applied and suggested that 'almost two in every three hospitals could be self-governing within a year.' [Today, 21.5.92]. The Guardian [21.5.92] reported that Dr Mawhinney's speech was 'largely well received' by NHS managers and health authority directors but went on to comment that:
the minister prompted disbelieving laughter when he asserted that it was not compulsory for hospitals and other health care units to opt-out. [Guardian, 21.5.92]
The debate over the contentious issue of the 'rationing' of health care, whether it means the 'denial' of treatments or the 'elimination' of unnecessary ones, was covered in 7 stories. The majority of this coverage was in the form of letters to the Guardian following an article they had published on this subject on April 29. The future of the new style NHS was looked at in the Daily Telegraph who reported on a BMA statement which 'signalled their acceptance of the health reforms' [14.5.92]. In what the Telegraph called a 'significant shift of stance' they reported BMA chairman, Dr Jeremy Lee-Potter as saying:
It is clear to us as doctors that we must work with Government. Now the election spotlight is off the NHS, it is time for the Government and the BMA to look ahead. [Daily Telegraph, 14.5.92]
This issue was first introduced on May 2 with the publication of a BMA and Association of Directors of Social Services report which called for improvements to the Governments plans for Community Care from April 1993. The headlines from the three stories stress what the BMA feels is missing from the proposals for the future of the service:
'Doctors demand a Minister for Community Care' [Independent, 2.5.92]
'BMA calls for cash to help elderly' [Daily Telegraph 2.5.92]
'Social workers and BMA warn on policy of caring for old' [Guardian 2.5.92]
The Government proposals will mean a complete re-organisation of the Community Care system with funding moving from the Department of Social Security to local authority control. The three items on May 2 reported the BMA and ADSS argument that more money was needed to fund the changes and their warning that 'ministers would be making a fatal error if they saw Community Care as a cheap option for caring for the elderly and disabled.' [Guardian, 2.5.92]
The Independent on Sunday described the planned changes as 'an innovative way of dealing with a long-standing problem' but added a word of caution :
the new system must be viewed as a positive way of providing a better form of care to more people rather than just unburdening itself of responsibilities and cutting spending. [Independent on Sunday, 3.5.92]
The remaining stories in this area continued the debate on how the new Community Care system will function and whether the Government will channel in enough resources 'to back up it's good intentions.' [Guardian , 12.5.92] . The Daily Telegraph looked at the problems for what it called the 'silent army' of people who look after the sick and elderly at home. They suggest that more public recognition and funds should be made available for their time and services because it 'would cost £24 Billion a year - more than two-thirds of the NHS budget - to replace the free care they provide.' [Daily Telegraph, 12.5.92].
The main focus of this coverage is whether Community Care will be funded properly. While it may be seen as a good idea in theory, questions about implementation and funding dominate.
The controversy over waiting lists which has been one of the biggest issues over the last year had all but disappeared by May 1992 with a total of only 9 items. Seven of these stories appeared on May 13 and dealt with the release of Government statistics on waiting lists. Interestingly, six out of the seven stories chose to focus on the positive aspects of the Governments figures with headlines such as:
'Hospital waiting lists cut' [Independent 13.5.92]
'Patient drop' [Times 13.5.92]
'NHS 'should be proud of waiting list cuts' ' [Daily Telegraph 13.5.92]
'Hospital queues shorter' [Daily Express 13.5.92]
'A good year for hospital queues' [Daily Mail 13.5.92]
'Record drop in hospital waiting lists' [The Sun 13.5.92]
While these reports stressed that the number of patients waiting more than a year 'fell by a third to 79,000' [Daily Mail] and the numbers waiting more than two years had 'been slashed by a record 97 per cent' [The Sun], most either ignored [Times, Daily Express, Daily Mail] or very briefly mentioned [Independent, Sun] that the fall in numbers could be counterbalanced by the simultaneous rise of the numbers waiting for up to a year for treatment. This was addressed by the Guardian which reported:
The number of people waiting up to a year for hospital treatment rose by more than 7 per cent..... the growth in the queue, representing 9 out of 10 people on hospital waiting lists, occurred as health authorities scrambled to meet the Governments promise that nobody should wait more than two years for treatment. [Guardian 13.5.92]
The Kings Fund's view appeared in the Daily Telegraph when Deputy Director, Ray Robinson was quoted criticising the 're-ordering' of waiting lists because of Government targets and also addressed another potential problem. He said:
The drive to reduce those waiting over an arbitrary time limit must raise questions about whether clinically more important cases are being put back.[Daily Telegraph 13.5.92]
The Independent also focussed on this idea with the publication of a letter from John Chawner of the BMA in which he describes the Governments action on waiting lists as 'simplistic' and claims that managerial and Government objectives have led to 'worrying distortions in clinical priorities' [19.5.92]
The 9 stories on GP fundholding included 3 reports in the Daily Telegraph [5.5.92], Today [6.5.92] and the Independent [6.5.92] about two GP's who are boosting their income by 'making large numbers of night visits' [Daily Telegraph 5.5.92]. It seemed that the two Doctors were earning quite a lot of extra money from this venture , but no-one seemed to know the exact sum:
'boosted their income by an estimated £40 000 ' [Daily Telegraph, 5.5.92]
'raking in up to £50 000 a year in fees for night visits' [Today, 6.5.92]
'were making an extra £60 000 annually' [Independent, 6.5.92]
While the Independent mentioned that the Department of Health had 'expressed concern' [6.5.92] over the potential increase in claims for night visits, the Doctors themselves were reported as claiming they were simply promoting their services in line with the 'spirit' of the new legislation:
We are just responding to consumer demand. People expect to be able to go to Tesco until eight in the evening, and they expect doctors to be available for longer hours.[Daily Telegraph 5.5.92]
The Daily Telegraph ran a story on a 'new style of 24-hour telephone surgery' [5.5.92] which would, for £50 a year, offer advice to people who could not decide whether to go to their doctor. The Independent covered the problems for GP's of the growing 'pressure' from the Government to reduce drug bills by remaining within the 'indicative prescribing amount' [20.5.92] and questioned this play-safe concept by asking if it means that in some cases 'patients are being denied unique drugs that would improve their quality of life, in favour of cheaper, weaker, older preparations.' [20.5.92] The Times [26.5.92] reacted to the GMC ethics ruling on family doctors who negotiate with Health Authorities to secure priority treatment for their patients.
Cuts and Funding
Of the nine stories in this category, 3 looked at how Charing Cross hospital in London was attempting to make more money by offering 'cut-price operations by junior staff for patients who have either been refused free health service treatment or are on long waiting lists.' [Sunday Times 24.5.92]
While the Daily Express called it 'a pioneering scheme' [25.5.92] both the Sunday Times and Today reported opposition to the move with Labour Health spokeswoman Harriet Harman attacking it as 'blatant privatisation' [Sunday Times 24.5.92] and suggesting that the quality of care given under these circumstances would not be adequate: 'With cut-price operations you get the least experienced surgeons and that should not happen.' [Today 25.5.92]
Other issues included the growing cost of compensation to patients, made available under the citizen's charter, for cancelled operations [Daily Telegraph 18.5.92], mistakes made by doctors [Today 18.5.92], and the removal of free fertility treatment at Kings College hospital Assisted Conception Unit because of lack of funds. [Sunday Telegraph 3.5.92] The People [17.5.92] made their views on the effects of NHS under-funding very clear in a story about one particular GP who found his job 'impossible' after the introduction of the health reforms. The People claimed that he was not alone:
He joins the nearly 400 GP's who resigned last year in frustration at NHS under-funding. For that the Tories should be ashamed of themselves. We thought John Major's aim was to create a classless society. NOT A SICK ONE. [The People 17.5.92]
Private Health Care
The Financial Times and the Daily Telegraph were the only newspapers to deal with the private health care issue. The focus of these stories was on the 'restructuring' of the sector in order to exploit 'a rapidly expanding market in health-care' [Daily Telegraph 20.5.92] made possible by the health service reforms.
Television news is particularly important in supplying people with information about the world. It is consistently cited as the major source of information about the world in Opinion surveys. In 1989 television was cited by 58% followed by the press which was cited by 25% [IBA, 1990:16].
The Events in the Soviet Union also affected the television coverage of the health service in August. There were a total of seven items on the health service. Channel Four News carried an item on GP contracts on August 1, all four programmes reported the government announcement of the applications for the second wave of opt-outs on August 5 and Channel Four and News at Ten ran short round up pieces on the launch of Labour's proposals for the Health service on August 28.
In November there were ten TV news reports mostly concentrated around the beginning of the month and originating mainly from government announcements or made in connection with by-elections. The only story covered on all four news programmes in one day was the funding of the NHS which was prompted by the Chancellor's Autumn statement [BBC1 1800, C4 1900, BBC1 2100, ITN, 2200, 6.11.91]. The next day in the context of the Langbaurgh by- election, both Newsnight and News at Ten reported on the impact of the NHS reforms on voting intentions. The same issue was reported in Newsnight in relation to the Kincardine By-election. On November 8, prompted by the announcement of the Patients Charter, Newsnight examined operation rates. On November 13 BBC1 reported on the effect of the reforms at Guy's hospital, the governments flagship. Finally Channel Four News had a special report on the state of collapse of the American health service towards the end of the month. [28.11.91]
In the months between our two sample period of August and November the health reforms became a very substantial political story. There were strong clashes in the House of Commons over whether the government intended to privatise the NHS and the length of waiting lists. Finally the government announcement of the second wave of hospital opt-outs was extensively covered.
There were a total of thirty television news items on the NHS in nineteen news programmes in February plus a total of two documentaries. The news items echoed the concerns of the press concentrating on Labour's proposals for the Health service (6 items), waiting lists/times (6) and GP fundholding (6). Television also covered the NHS pay review awards (4), prescription charge rises (3), Lib Dem proposals (3) and the reforms in general (2). Current Affairs coverage consisted of one edition of 'World in Action' and a 'Viewpoint '92' programme 'My Life in Whose Hands?'
World in Action ( ITV 10.2.92 )
Focussing on the area of intensive care, this programme questions whether the reforms have properly considered the specific needs of this particular service. Treatment in an Intensive Care Unit differs both in time and cost for each individual case The programme argues that the medical profession feels that the reforms have not 'earmarked' any special resources to cover the sometimes huge variations in cost of intensive care which has led to a critical shortage of beds and patients being turned away. The report suggests that financial considerations are now dominating the running of the NHS. The result of this is that doctors are now acting as 'debt-collectors' rather than carers because of the need to ensure a guarantee of payment before treatment is given.What this could lead to is serious delays in treatment in an area where instant decisions are essential and cost effectiveness should never be a priority.
Viewpoint '92 : 'My life in whose hands?' ( ITV 11.2.92 )
Journalist Geoffrey Lean wrote and produced this programme which is the story of how he became aware of the health service debate. Having spent over five months in hospital, a great deal of it in intensive care, Lean questions the introduction of the NHS reforms looks at how they are already affecting the running of the health service, and may transform it in the future. He concludes:
The reforms worry me. However busily ministers are now sandpapering the jagged edges of Mrs.Thatchers private plans, the changes are at odds with the tradition of service implicit in the NHS. Like so many measures over the last decade they seem to have called money almost a divine power. I fear the result will be to put looking after pounds and pence before looking after people.
Health service news was almost non-existent in May 1992 with a total of only 8 items. There was also one current affairs programme 'Blind Data' broadcast in the Dispatches slot. The cut in junior doctors' working hours was covered on ITN [2140, 10.5.92] and BBC1 [2205, 10.5.92]. Both programmes included Virginia Bottomley's announcement, and representatives from the junior doctors' campaign who claimed that there was 'still have a long way to go to meet the publics demands of junior doctors working less than 72 hours in the future.' [BBC 1 2205 10.5.92]. This announcement was also the only time any politician was seen on television news discussing the health service in the whole month. There were three reports on the dentists' dispute [C4 News 1900, BBC2 1915 BBC1 2300, 9.5.92]. Both BBC items were identical and focussed on the dentists' warning that there would be a fall in the standard of dental care if more money was not provided. As one of the two dentists interviewed pointed out:
Currently, under present conditions, the future of NHS treatment is bleak. We have never been better set up to deliver high quality dentistry and it has never been more difficult to fund our practices.[BBC1 2100, 9.5.92]
Channel 4 News reported on a survey in the dentists' magazine The Probe which claimed that since the new contract there had been a 61% rise in the extraction of teeth that could have been saved which 'is being linked to a lack of funds to cover cases needing a lot of work.' [8.5.92].
Of the remaining three TV News stories one dealt with the government's plans for community care in 1993 [BBC1 2100, 21.5.92], one with the 'mounting cost of public health care' and whether 'health rationing' is inevitable [ITN 2200, 6.5.92] and one on whether the citizen's charter was having a real effect for patients. [BBC1 2100, 6.5.92]
We can see from this that covering the health service in this period was closely tied to the routines of the parliamentary cycle and particularly to announcements from the Government. The only two stories to be covered by all four programmes in August and November were sparked by Government announcements. With the election over, health became much less of a political issue with no major government or opposition announcements.
Those interviewed on television news were predominantly politicians. Government and opposition spokespersons accounted for 16 out of 32 interviews in August, for example. The most often interviewed in August were Stephen Dorrell, junior Minister of Health (8 times), Harriet Harman, Shadow spokesperson (5 times), Robin Cook, Shadow spokesperson (2 times) and Liberal Democrat Charles Kennedy (2 times). In February politicians accounted for 45 out of 85 interviewed. Robin Cook was on most often (13 times) followed by William Waldegrave and Charles Kennedy (9 each), then Virginia Bottomley (4), Harriet Harman and Stephen Dorrell (3 each) and finally Neil Kinnock and Nicholas Winterton (2 each)
Dispatches : 'Blind Data' ( C4 6.5.92 )
This programme looked at the causes and cost of the use of computer systems within the National Health Service:
Since the demise of the red army, Britain's national health service is now the largest organisation in Europe. Information technology was seen by managers and politicians as the key to controlling such a giant.
But far from controlling the 'giant', the £200- £400 million spent a year over the last ten years on computer systems may have been a waste of money. While the idea was to improve the quality of information, statistics, and management of the NHS, the reality suggests that much of the money has been wasted on systems that either do not work, are incompatible with other computers, and ultimately do not suit the needs of the service. This raised the issue of how accurate the information collected is, information which is used to draw up business plans and put forward trust applications. The programme suggests that the information base is quite poor and the information coming out of it inaccurate and asks,'if we can't trust the statistics how can we trust the government's reforms.'
Reporting the Health Service
Unlike television, the press is not legally bound to be objective, balanced or impartial. Accordingly the stories which papers report are influenced by the political line of the paper and its assumptions about its own audience. These can shape the stories which are covered, the angle which is taken, the sources of information which are used and the way that information is presented.
We can illustrate this point by examining some differences in the stories which are covered. The Mirror and the Sun are quite clear on the political line that they pursue on the Health Service and this often means ignoring inconvenient stories or not reporting them prominently. For example, the Sun reported the announcement in the Chancellors Autumn statement of more funds for the NHS, under the headline 'Hospital cash joy for Tories', and stated that:
Tory MPs dubbed the NHS the national wealth service last night after the £ 2.7 billion increase. [7.11.91]
By contrast the Daily Mirror did not carry a main item on the Autumn statement and the NHS. Conversely the Mirror published ten separate stories in November on the controversy around the 'opt-out leak'. This was twice as many as any other paper (The Guardian, the Independent and the Financial Times all had five) and contrasts with the Sun, Mail and Express who did not report the story at all. Television news too studiously ignored the issue. As the Mirror argued in an editorial:
There has been a real political scandal this week which other news has buried, in some papers deliberately so. [11.11.91]
The Mirror ran regular stories on the Health Service, a total of 28 in November in contrast to the other (more conservative) tabloids which ran far fewer. The Sun for example had only 8 stories in November. The Mirror also renamed the Health Secretary William Waldegrave as 'Wally' Waldegrave and by early November they could use the name 'Wally' in headlines by itself, on the assumption that it had been used so much that it was familiar to the readers. Headlines included ''Jobs for the Wives' Wally Sparks Storm' [4.11.91], 'Crisis for Wally over Tory Dirty Tricks Plot' [8.11.91], 'Just not good enough, Wally' [11.11.91] 'Wally's 'leaky' aide in trouble' [11.11.91], 'You've no place to hide, Wally' [14.11.91] and 'Pressure on Wally to resign' [22.11.91]
The political complexions of the papers also influence who is quoted in news stories. Appendix V gives figures for the number of people interviewed or quoted in the press for the months of August and November respectively.
Overall the four most commonly quoted people were the representatives of the government and the opposition, although with the emphasis firmly towards the government. In the press in August, for example, William Waldegrave was quoted a total of 17 times and Junior Minister of Health, Stephen Dorrell a total of 22 times. In contrast Robin Cook was quoted 10 times and his deputy Harriet Harman a total of 7 times.
Analysis and Discussion
In the aftermath of the Monmouth by election press reports claimed that the Conservatives were being adversely affected by their policies on Health. This left the government with two options. Either to try and remove health from the political agenda or to challenge Labour on what was seen as their strongest area. The Independent on Sunday reported the forthcoming announcement of the second wave of hospital trusts in early August, pointing up this dilemma for the government:
The move on health is a high-risk strategy, with some Conservatives arguing that it will move the political agenda back to Labour's strongest area. The Tories' opinion poll set back after the Monmouth by election was widely seen as being linked to the political row over health which dominated campaigning. Some Tory strategists believe that with health now lower on the public's list of concerns, Mr Waldegrave is ill-advised to raise the trust issue again. [Independent on Sunday, 4.8.91]
The problem for the Government was that they could hardly push ahead with their reforms of the Health service and expect to keep them off the political agenda. In the event the Government went ahead with its announcement on August 4. In the days before this announcement William Waldegrave made it clear that there was no question of the Government delaying the implementation of an internal market in the NHS. The claim at this stage seemed to be that the changes were no more than an exercise in efficiency, which by devolving power and responsibility for health away from health authorities and down to managers, doctors, nurses and consultants would allow the development of the best care programme for patients. As Waldegrave commented:
We are challenging Labour's arrogant and utterly false assumption that only they can be trusted with the public services. [Daily Telegraph, 4.8.91]
The row over waiting lists blew up again in September with the announcement by Waldegrave that waiting times and the size of waiting lists had decreased. Immediately following this announcement at a news conference at the Department of Health, Robin Cook met reporters on the pavement outside with what he said were more recent figures showing that waiting lists were going up. Cook also claimed that the waiting list figures were being massaged by the government. This story was reported on all television news bulletins, some of them commenting that this clash showed that health is regarded as an important election issue. As an ITN reporter concluded:
Clearly, election talk has put the health issue firmly on the political agenda. [ITN 2200, 19.9.91]
November saw fresh outbreaks in the debate over the 'privatisation' of the NHS. In his speech to the party conference Waldegrave replied by attacking what they called 'false scare stories' saying the NHS would be privatised [BBC1 2100, 10.10.91] and launching the 'Patients Charter'. It was this bulletin on BBC1 which prompted John Major and Party Chairman Chris Patten to complain to the BBC about bias. Later in October the Government announced the names of the hospitals which were to be granted trust status in the second wave of opt- outs. Again this story was covered on all TV news bulletins and allowed TV reporters to investigate the effects of the reforms on the first wave of trusts.
The effect of launching the patients charter was to shift focus from the length of waiting lists or waiting times to a focus on the effect of the charter on waiting times. One of the central claims of the charter is that no-one should have to wait for more than two years for an operation. This target was then to be applauded if or when it was reached. Yet it was only at the beginning of August that the House of Commons Public Accounts Committee had condemned the 'appalling' delays of up to 18 months which faced some patients. Thus the shift in focus from lengths of wait to the Patients Charter had in just three months turned a bad reality into a target to be aimed for. There was little comment on this in the press.
There was a further attempt to shift the focus on waiting lists in November from concerns about the length of lists or waiting times to arguments about why they were so long. Following a letter in the Times [7.11.91], both the Express and the Mail ran stories arguing that the reason the waiting lists were so long was that patients were failing to turn up for appointments. The Express reported:
A leading surgeon believes he has exploded the myths about long hospital waiting lists. Consultant General Surgeon David Crosby discovered that fewer than half of the patients on his waiting list were genuinely in the queue for an operation. The rest included patients who no longer wanted surgery and others who did not bother to turn up for appointments with doctors. [12.11.91]
The Mail called its report a 'special investigation on the millions who are thoughtlessly holding up the drive to create a healthier NHS.' Headlined 'Painful problem of the stayaway patients' it reported:
One in every eight patients fails to turn up for specialist appointments without bothering to give a reason. [27.11.91]
This shift of focus, seemingly initiated by the papers themselves, was clearly intended to boost the Government. However by early the next year waiting lists themselves had re-emerged as an issue on their own and were to remain so all the way to the election.
Evidence that the reforms are popular with at least some Health service staff has been promoted by the Department of Health and by some of the newly formed trusts, sometimes on the basis of questionable research. Nevertheless some Health Service staff are in favour of the changes. There are also claims that the reforms are reducing waiting lists, treating patients faster and running more efficiently. Views such as these have been widely reported in the press, particularly the papers which are most noted for their sympathy for the Conservative party [the Daily Telegraph, the Daily Mail, the Daily Express and the Sun]. They have also been present on television news.
It was partially on the back of the Health debate that Labour pushed ahead in the polls in late 1991. To some in the media the Labour Party began to look increasingly likely to win the next general election. This has led to speculation that some proprietors and editors had begun to think about the political position of their papers in the light of increased support for the Labour Party and the potential knock on effect on sales. Rupert Murdoch's Today newspaper was rumoured as a possibility to change to supporting Labour and as we have already seen some elements of their health service coverage have been quite hostile to the government. Indeed, according to one report, the Political Correspondent of Today was berated by Conservative politicians at the Party conference and Today was referred to as a 'Labour paper' [Today, 14.10.91]. The Sun has also taken the extraordinary decision to employ Ken Livingstone as a columnist. The editor of the Daily Telegraph, satirised as the Torygraph in Private Eye was reported as sending a memo to senior staff worrying that the paper might still be thought of as the 'poor old Torygraph' and saying that headlines sometimes 'reflect a clear bias' against Labour. He continued:
The election result is by no means predetermined and while our comment pages will continue to heap scorn on the Opposition, our news pages should on no account give any impression that Labour is unelectable, because it is not [Independent, 29.10.91]
The evolution of the debates over the course of the year represented in part the progress of the information battle around the NHS. The promotion of some issues, the downplaying of others and the struggle for public opinion were the motor forces of news coverage for much of the year. With the election over, the coverage in May included the lowest number of stories on health in our whole sample period. The most routine way of influencing the content of the media is through public relations. The next section examines some of the strategies used by the government and the opposition to influence the media.
Using the media
The media provide an arena in which the various political parties, pressure groups and others vie for space. In this contest the government has many more (institutional and cultural, as well as financial) resources available to it than do its competitors. For example, it is only the government which is able as a matter of course to compile and release large amounts of statistical information on the NHS on a routine basis. While such resources give the government an in-built advantage, they do not mean that government views always dominate the media. The case of the Health Service is perhaps one of the best example of this. Nevertheless large amounts of resources were ploughed into the government's campaign to sell the Health Service reforms to what, on the face of it, appeared to be a reluctant public.
In order to convince the public that the NHS reforms were 'working' the government concentrated on two questions - the size of waiting lists and the amount of 'activity' in the NHS. Their pledge to reduce two year waits to zero by April 1st 1992 and claim that the NHS was treating more patients more efficiently were the subject of much debate. This battle of statistics was fought out right up to the election on April 9. In general the debate was centred around routine allegations that the figures had been fiddled or in some way manipulated. There was less concern with the reliability of the statistics coming from individual hospitals. In one exception an edition of Dispatches [6.5.92] examined the installation of Information Technology in hospitals and concluded that the statistical information being gathered by both parties may be fundamentally flawed. Additionally there was very little discussion of whether activity levels, for example, are the most useful barometer of progress on public health [See Barker, 1992].
The figures produced on waiting lists and times were challenged on a number of grounds. As were the governments motives and tactics in getting them reduced. There was heavy pressure on Health Service Managers to abolish two year waits, backed up by a £39 million fund to pay for operations before April 1. As the Guardian reported:
Health Service managers have been told that money is no object in the frantic race to fulfil the promise by April 1... This follows health ministers summoning Regional Health Chairmen to instruct them to reduce the lists at any cost. [21.2.92]
The main criticism of this approach was that it was not a sustainable long term strategy but an electoral gimmick with harmful consequences. For example, people who had been waiting two years were being taken in preference to those who had waited less, some of whose were clinically more urgent. The College of Health has suggested that some operations were being rationed. The director, Marianne Rigge, told the Observer that 'some orthopaedic surgeons are using age as a rationing criterion, avoiding operations on patients over 80 because the demand for surgery is so high'.[25.8.91] The Independent reported the closure of waiting lists at a Kent hospital and the existence of a pending list on which patients wait until they can be admitted to the waiting list itself. [6.11.91] Some patients have apparently been given inflated waiting times, the result of which was to pressure them into going private. Finally, some waiting lists for operations like varicose veins have simply been abolished. A parliamentary answer revealed that the number of people removed from waiting lists after treatment had risen by 7% over three years whereas the number of people removed without treatment had risen 82%. [Times, 13.2.92] Robin Cook argued that this showed that 'almost half of all the increase in patients taken off the waiting list comes from culling the waiting list rather than increasing the treatment'.
The Financial Times [l3.2.92) reported Stephen Dorrell as saying that 'those removed from the lists were among 836,000 patients judged by doctors as no longer requiring treatment'. Earlier in February a letter in the Daily Mail [3.2.92] argued that waiting list numbers are inflated - 'About a third do not show up'. On the other hand, it is also the case that since 1987 a new category - the 'self deferred' - is excluded from the overall totals. These patients are still waiting [Radical Statistics Health Group, 1992a, 1992b].
Department of Health statistics contain no measure of how many people are waiting for their first out patient appointment in England and it has been suggested that such appointments may be being delayed until treatment will be available, thus minimising longer waiting times. It is also possible that the change to finished consultant episodes may speed the throughput of patients who may then need to be readmitted, but will not be classed as having been on the list for very long.
As it became clear that the government was not going to fulfil its promise to clear 2 year waits by April 1 the Daily Express reported that 'plans are already being drawn up to hail such a significant reduction as a triumph for the newly-reformed NHS' [23.2.92] Turning a failure into a success is a standard public relations tactic, but the more remarkable achievement is the attribution of the waiting list cuts to the reformed NHS. The designated budget to cut two year waits bears no relation to the NHS reforms.
After the election the health issue slid down the political agenda. The question of waiting lists and times was no longer such a hot issue and the Department of Health were no longer launching the latest figures from high profile press conferences. Figures for April were not even given to journalists via a press release, but were instead published as a written answer in the Commons. As a result none of the television news programmes covered the figures and they received low profile coverage in the press. The Guardian was one of the few papers to report the figures which showed that 'Waiting lists went up just after [the] election'. [11.6.92]
While Labour and health unions have emphasised beds closed, the government insists that this is the wrong way to look at the issue. Instead of beds they prefer to count finished consultant episodes. The increase in beds closed is explained as an increase in efficiency. According to Stephen Dorrell 'Every body knew that modern health care involved shorter hospital stays... We are spending less money on beds and more on patients, and more patients are benefiting' [Guardian, 28.2.92]
At the beginning of March figures for hospital activity were released. For the Telegraph this was a sign that 'The government is preparing to make the National Health Service reforms one of the central issued of the General Election campaign by publishing figures tomorrow showing an 'impressive' increase in hospital activity' [4.3.92]
There are two main ways in which government claims are misleading. Firstly, the method for measuring hospital activity changed in 1989 from 'discharges and deaths' to 'finished consultant episodes'. This has the effect of counting patients every time they move department inside a hospital. It has also been alleged that the pressure on hospitals to collect money from health authorities has led to some patients being discharged too quickly in order to finish a 'consultant episode'. However, the patient may then have to be readmitted through the 'revolving door' and consequently be counted again.
Secondly, increases in hospital in-patient and out-patient activity are part of a longer term trend. The figures published by the government in January 1992 include estimates for growth between the years 1990-91 - 1991-92 which are actually lower than increases in previous years. [See Radical Statistics Health Group, 1992b, 1992c]
As well as the question of manipulating statistics there are other means to get over the preferred message. Timing and selective use of information can be valuable tools for the information manager.
The Conservative strategy was to announce the second wave of opt outs on a Sunday (a quiet news day) to get maximum coverage during what Channel Four News claimed was the 'relative peace of the parliamentary recess' [5.8.91], while Today asked why 'when the government's plans hold out the promise of an infinitely improved health service should it be so reluctant to shout about it' [Today, 5.8.91]
Today was also suspicious of the timing of the Government announcement on the raising of Prescription charges, claiming that 'increases usually take place around March... Labour MP's claim the Government wants to do it now in the hope it will be forgotten by the election' [13.2.92] The Mirror added that it suspected that the release of the figures on the same day as the rising unemployment figures showed that Waldegrave was 'hoping it will be buried in yet another row over appalling jobless figures' [13.2.92]. To their credit both Channel Four News and News at Ten made a point of mentioning the motives of the government as they reported the rises in prescription charges. The government strategy had some success with the unemployment figures knocking the rise in prescription charges of the top spot on all four main evening news bulletins. Newsnight spent most of the programme on the unemployment figures and the prescription charges were relegated to the news summary towards the end of the programme. Viewers were left with only two sentences on the price rises.
Prescription charges are to rise by 35 pence from April to £3.75. That's an increase of over 10%, more than twice the rate of inflation. [BBC2 Newsnight, 13.2.92]
Timing can also be important to shift the agenda one way or another or simply as a spoiling operation. This involves scheduling press conferences or announcements at the same time or on the same day as your opponent. When Labour called a press conference at 10.30am on August 28 the Department of Health responded with a press conference at noon to present new evidence of patient satisfaction with the NHS.[Guardian, 29.8.91].
Unforseen world events can also hamper information managers in their bid for news space. A press conference called by Robin Cook in early February 1992 which he expected to return health to the top of the election agenda was relegated in the news by revelations about Paddy Ashdown's extra marital affair [Guardian, 13.2.92].
It seems that the implementation of the reforms at least temporarily shifted the focus of much debate away from cancelled operations and deaths caused by cuts to the back and forth debate about the progress of the reforms and whether they were working. The appearance that the government was doing something about the Health Service, meant that discussion focussed on the outcome of the reforms. New evidence and information about waiting lists or wards closed were introduced not as issues in themselves but in the context of the 'success' or 'failure' of the reforms.
Another less subtle way of influencing the media is through political pressure and intimidation. Again it is the government which has most of the cards in this game, although the thought that the opposition may soon be the government undoubtedly lends it some credibility. The government, after all, sets the licence fee which funds the BBC and is preparing to renegotiate the BBC Charter in 1996. This latter fact is never far from the surface in debates on the role of broadcasting as we shall see.
The Months leading up to the election were a period of intense political lobbying. The apparent unpopularity of the government in the opinion polls led to jitters in the Tory camp, some of which were expressed in the pages of the Conservative press. Of particular concern was the role the Health Service was perceived to be playing in the Labour lead in the polls. As one headline had it 'NHS and Europe give Labour 8 point lead' [Daily Telegraph, 8.11.91]. During the Conservative Party conference the television coverage - specifically BBC coverage - of William Waldegraves speech was attacked by the Party Chair and by the Prime Minister. Chris Patten urged Conservatives to complain to the broadcasters when they were angry about bias. 'Phone them, write to them, above all phone them on the spot - if necessary, jam the switchboards.' [Conservative Party News Release, 616.91, 11 October 1991]
Broadcasters and the Government
Attacks on television are not a new phenomenon of political life but have a history as long as that of television itself . However relations between broadcasters and the government have been particularly stormy under the last three Conservative governments [See Cockerell, 1988]. There have been many confrontations over the coverage of government actions in, for example, the Falklands, the bombing of Libya, and intelligence activities, as well as coverage of opponents of government policy, most notably in Northern Ireland. Such confrontations have occurred in tandem with a re-evaluation of policy on broadcasting which has seen television licences being auctioned off to the highest bidder and the shadow of dismemberment cast over the BBC. In the disputes between the government and the broadcasters it is the BBC which tends to be singled out for criticism, even when there is no clear distinction between their coverage and that of Independent Television. This was the case with Norman Tebbitt's attack following the US raids on Libya in 1986 and when both BBC and ITN initially refused to hand over tape of the attack on two Army Corporals at a West Belfast funeral in 1988. The BBC is expected by many in government to live up to its name as the British Broadcasting Corporation and therefore to exert some partiality in the 'national interest'. With their complaint about coverage of the NHS, the government were following a long precedent in confining their attention to the BBC.
Conservative allegations and BBC response
It was against this background that Chris Patten issued his appeal to Conservative supporters to jam the BBC's switchboard. This followed the BBC coverage of William Waldegraves speech to conference the previous day, October 10th. The Sun broke the story in a front page exclusive 'Major in BBC rage' on October 12. It reported John Major as having 'hit the roof' after watching the bulletin and included comments from a Downing Street 'aide' and a 'Government source' respectively:
The premier's temper has been rising for months over alleged Leftie bias at the BBC. He wants Director General John Birt to 'stop his staff pumping out Labour propaganda'
'Their coverage of the two party conferences was totally biased. They are dominated by news editors with anti-Conservative views and it shows' [17.2.92]
The complaint focussed on the latter part of the Nine O'Clock News report on Waldegraves speech in which there were a number of critical comments. Apparently the Prime Ministers political secretary then phoned the BBC newsroom to convey the Prime Minister's 'deep personal displeasure'. According to Phillips  ' Senior editorial figures then decided that although the item was not biased it did fall short of the professional standards required' and the editor of the Nine O'Clock News phoned the Prime Ministers Press Secretary the next morning to acknowledge the slip. 'As far as the BBC was concerned, therefore, it had conceded a lapse that regrettably sometimes occurs.' However Chris Pattens speech urging angry Tories to jam the switchboards at the BBC was released that same morning and Downing Street sources were briefing some of the press (notably the Murdoch owned Sun and the Sunday Times) about Major's reaction to the news item and about Ministers 'rising' temper with BBC coverage [Sun, 12.10.91]. According to the Daily Express [12.10.91], William Waldegrave also joined the attack, alleging 'the bias has been astounding. In the health sector they have been totally out of control. The BBC is behaving very disreputably'. The BBC was apparently 'dismayed' that the issue had changed 'from a complaint about standards to an allegation of institutional bias' [Phillips, 1992]. The Tories kept the pressure up on the following Monday by revealing to the Express that the BBC had apologised to Employment Secretary Michael Howard over the way appearances on TV and radio had been handled.
The BBC stated that it had not had a formal letter of complaint about its coverage of the NHS. Tony Hall, director of News and Current Affairs wrote an article in the Times defending the BBC's coverage [Hall, 1992] and according to Conservative Director of Communications Shaun Woodward this prompted Chris Patten to write a formal letter of complaint eight days after the offending newscast [See the Daily Express, 19.10.91] A letter from John Birt appeared in the Sunday Times the next day replying to a story the previous week and strongly defending the BBC from political pressure. He wrote:
We are not in the business of publishing handouts. The next general election will be tightly and toughly contested. In the build up passions will run high. The BBC will continue to listen to complaints and to consider them seriously. But we will not be bullied by any party. [20.10.91]
Two days later Michael Howard, the Employment Secretary made a formal complaint to the BBC after he withdrew from an edition of the BBC's On the Record. He complained that he had not been allowed to see in advance a filmed report which would precede his interview.
According to the Daily Telegraph [24.10.91], Birt then replied to Patten but 'Tory sources' said the reply ''skirted round the central issues' and contained no apology although one had been sought formally by Mr Patten. Now Mr Patten has written to Mr Birt saying the reply was "unacceptable"'. Both Labour and Tory parties also announced that they were setting up units to monitor political bias on television. Birt then replied again and refused for a second time to apologise. The Observer reported that 'John Birt's response this week to Mr Patten will make clear that the Tories should look at the overall BBC coverage of the NHS debate over the past months.' [27.10.91] Finally, Birt and Patten met on November 4 to thrash out their differences. The price for the settlement though was that the honour of both sides was satisfied. The BBC would appear to publicly climb down by admitting that a mistake had been made and allowing Patten to claim a victory. They would not however formally apologise as Patten had demanded. Their admission was in fact nothing more than the one made three weeks previously to the No. 10 Press Secretary. Nevertheless, as planned the press reported the agreed version. For example, 'Birt admits error over Tory report' [Daily Telegraph, 5.11.91], 'Birt backs down in BBC bias row' [Daily Express, 5.11.91], 'Tories claim BBC victory' [The Times, 5.11.91] and 'We blundered over NHS say Beeb' [Sun, 5.11.91]. The public humiliation of the BBC was thus the price for a temporary cessation of hostilities with the government.
The government seemed undecided about the precise nature of their complaints. For some it was the old problem that the BBC is 'the willing handmaiden of the Left' [Sun, 12.10.91], or as Paul Johnson put it 'The BBC is not so much anti-Conservative as anti-authority... The BBC is in fact a nest of self important radicals who believe it is their moral duty to challenge the doings of the powers-that-be in every sphere.' [Daily Mail, 21.10.91]. For others it was the 'arrogance' of the Corporation in defending itself with such vigour: 'We will not be bullied' said Birt. There also seemed to be differences over what the party was complaining about. Downing St sources viewed the Nine O'Clock News item as the last straw in a succession of BBC 'blunders'. Others singled out the Nine O'Clock News and Radio Four's Today for special criticism. 'Sources close to Chris Patten' tried to dampen the attack by emphasising that his speech 'was not meant as a generalised attack on the corporation but on the way that certain programmes had handled the news'. According to a 'senior Tory source': 'Nobody has any complaint about Newsnight or John Cole [the BBC's political editor]. We know we will face tough interviews from Jeremy Paxman or Peter Snow. So will Labour. That is fair. The problem for us as a party comes when we are not subjected to the same treatment as the other side' [The Times, 14.10.91].
Perhaps the clearest indication of the uncertainty in the Tory camp was that there was even some division over whether the poor showing the Tories were getting in the opinion polls was due to the BBC or their own failings. The Sun reported that some Ministers were putting the blame on the Conservative head of Communications, Shaun Woodward. One Minister reportedly said: ''You can't put all the blame on BBC Lefties. Shaun Woodward should know how to deal with them. He is not doing his job properly'. Some Ministers say Woodward should be replaced. But this is unlikely, as he is a friend of Tory Chairman Chris Patten.' [14.10.91] The fact that such tensions and rivalries surfaced at that time is an indication of just how seriously the government took the Labour lead in the opinion polls.
But what of all the allegations of bias at the BBC? Was the BBC running consistently or even occasionally biased news items about the Conservatives in general or the NHS in particular? Is BBC reporting markedly different or 'worse' than that of ITN? The next section analyses the offending BBC bulletin and compares it with the four months television news coverage on both BBC and ITN which were analysed for this report. We also include some analysis of television bulletins of the two other major Health stories from September and October 1991, which fell outside our sample, namely the publication of the latest waiting list figures [19.9.91] and the announcement of the second wave of opt-out hospitals [16.10.91].
The BBC report
The specific Conservative complaint focussed on the reaction to William Waldegrave's speech which, according to John Major 'questioned what Mr Waldegrave said without an adequate counter view' [Guardian, 12.10.91] . According to Waldegrave himself: 'They had a short report of my speech in which I laid the Labour lie that we plan to privatise the NHS. Then they tagged on at the end a lot of scam [scare?] stories' [Daily Express, 12.10.91] Major's press secretary, Gus O'Donnell said 'A procession of people were wheeled on to say Mr Waldegrave was nasty and wasn't telling the truth' [Sun, 12.10.91]. What all these accounts and many others fail to mention is that as well as showing several extracts of Waldegraves speech to conference and a total of 38 seconds summarising his speech, the report featured four Tory delegates, two speaking to Conference and two reacting to Waldegraves speech. The first of these delegates says to Conference 'These reforms are about modernisation, not privatisation' It is not therefore true to say that Conservative views were not given space or that there was nothing to counter the criticism. Indeed this part of the report including the headlines lasted over three minutes. The total time allotted for comment from others was just over two and a half minutes. It is interesting to note that this is the only example we can find of such views being given air time by non party representatives on either channel in the sample period we looked at. Certainly at no point did we find any television reporter endorsing such a view. Yet such views are hardly a rarity in contemporary Britain. It is interesting that the BBC should regard it as 'unprofessional' to feature such views on the news. On the other hand we did find a number of examples where journalists endorsed the government view on the health service on television.
Conservative complaints were based on what they saw as a series of biased items. They did not consider the routine coverage of the NHS broadcast by the BBC or by ITN. This meant that reports that did not fit their analysis could be ignored. Our research has considered four separate four weekly periods over the course of a year and has in addition looked at three major stories outside our sample period, including on the day that William Waldegrave addressed the Tory Conference.
We found no evidence that the BBC was biased against the government. Both BBC and ITN appeared to be scrupulously trying to maintain 'balanced' coverage. If anything our evidence points towards a heightened caution in BBC news bulletins as compared with ITN. For example, in neglecting to point out the motives behind the announcement of prescription charge increases on the same day as the latest unemployment statistics. We also found a small number of examples where BBC news slightly favoured government views of the Health Service.
When reporting one of the earlier skirmishes in the waiting list saga the BBC reported the government figures as if they were facts, only later did they go on to feature the Labour view that the figures had been 'fiddled'. The headlines on the BBC's early and main evening news bulletins were as follows:
Hospital waiting lists are down, but there are fears of a growing cash crisis in the Health Service. [BBC1 1800, 19.9.91]
The number of people waiting for hospital treatment has fallen, according to figures from the Department of Health. Overall waiting list numbers are down by one per cent to a little over 900,000. But the number of patients waiting over two years for treatment is down by nearly forty per cent. [BBC1 2100 19.9.91]
At 1800 the BBC are unequivocal - the waiting lists are down. By 2100 the figures are attributed to the Dept of Health but then stated as if they were a fact. There is no mention of the Labour allegation that the figures are misleading or out of date. Compare this with ITN's more even-handed presentation:
And waiting lists are shorter say the Tories. No, longer, say Labour.
The government's published figures showing that the number of people on hospital waiting lists has fallen. Labour says the opposite is true. Who's right? A report coming next. [ITN 2200 ,19.9.91]
Channel Four News was even more non committal, delivering a critique of both parties:
The emotive electoral issue of hospital waiting lists. The government proves they're shorter. Labour proves they're longer. [C4 News, 19.9.91]
Channel Four was the only bulletin to attempt to make some kind of sense of the debate over the size of the lists by doing more than reporting the opposing views of the government and opposition and pressure groups. They had done their own investigations and were willing to state that at least some patients were being forced off waiting lists:
Much of the row centres on how the government arrives at its figures for waiting lists. Some family doctors concede list sizes have been cut at a number of hospitals, but only at those hospitals refusing to take on patients if the waiting time is over a certain limit, often a year. This can mean patients having to go privately if they want their operation done at all. Last week Channel Four news reported on how one health district - mid Essex - had shortened its waiting list by simply dropping certain types of treatment unless very urgent, such as hospital surgery for varicose veins and wisdom teeth. The move followed a letter from the Regional headquarters which advised districts that 'regional officers are presently preparing a list of procedures which unless there is an overriding clinical need may be deemed inappropriate to place on waiting lists in the future'. But the Health Secretary today denied that patients were being deprived. [C4 News, 19.9.91]
There were other occasional BBC reports which indicated that the reforms were going well and that at least some NHS staff supported them. The following item, for example, was clearly supportive of the reforms:
Epsom Health Care was one of the first 57 hospitals to become NHS trusts six months ago. Here they say they have already treated more patients, cut their waiting lists by a quarter, hired more Doctors and opened two new wards. All this without running into debt or getting extra money. It's all been done, they claim, by managing their resources better than the Health Authority. [Our emphasis]
A manager of the trust is then interviewed and comments on the change from 'bureaucratic' decision making to managing their own budgets. The reporter then, remarkably, concludes that:
There appears to be absolutely no dissent in the hospital. Even the unions could find no-one to oppose the trust. [BBC1 2100, 16.10.91]
It is interesting to compare this report with the coverage of William Waldegrave's speech to conference the previous month. In that report there were two excerpts from Waldegrave's speech and the comments of a total of four Tory delegates. Following this there are clips of a Doctors representative and a Health Authority Manager and then finally three comments from staff in a London Hospital. In the case of the Waldegrave speech there are a total of five speakers putting the governments case and five against. In the report from Epsom as the journalist concludes there was 'no-one to oppose the trust'.
Consider a BBC report on the day Labour launched their NHS proposals. The journalist reports the Labour view and then there are sound bites from Labour, the Liberal Democrats and from two Doctors - one in favour and one against the reforms. Before going on to interview William Waldegrave the journalist sums up the Labour position and contrasts it with that of the Tories:
Labour claims the NHS is underfunded but gives no figure. They pledge to restore the missing money over a Parliament, paying for it as and when growth in the economy allows. Meanwhile the Health Secretary indicated his confidence in the present system by telling budget holding GPs that they'll now get more power. He attacked Labour plans. [BBC1 2100, 20.2.92]
This type of reporting can be compared to that on ITN the same evening. News at Ten simply reported the contending views of the two parties:
The Tories believe they've neutralised the Health Service as an election issue; that few people will want to see another round of upheavals in the NHS. But Labour is convinced it's an Achilles Heel for the Conservatives that may well cost them a decisive number of votes. [ITN 2200, 20.2.92]
Channel Four news was critical of both parties with the reporter arguing:
Labour has been at pains to remove anything that smacks of buying and selling health care, no matter how it is managed... Not surprisingly the Health Secretary William Waldegrave was quick to attack Labour's plans... In the end according to Health Policy analyst Chris Ham, the approach of the two main parties reflects their ideologies. [C4 News 1900, 20.2.92]
Much of the news featured a 'balance' between the contending party views on the NHS. There was little on the main evening programmes [2100 and 2200] which was critical of either party. Roger Bolton, Controller of Factual Programmes at Thames TV, argues that this is the type of reporting which results from constant pressure from politicians. Reporting the real world gives way to what he has called a 'balance of propaganda' [cited in Phillips, 1992]. Such sanitised coverage is unlikely to look for, or broadcast, simply factual reports about the Health Service since these are likely to annoy the major political parties. The reluctance to offend the government in the run up to the election was illustrated again when an edition of Panorama was pulled from the schedules. Officially this was for editorial reasons, but when the press got hold of the script this explanation seemed unlikely. As one journalist put it:
The effect of the programme is to make [ex Chancellor] Lawson seem like a bad gambler who had what he thought, wrongly, was a lucky streak. The Government appears to be made up of people with no economic nous at all. [Leith, 1992:4]
A further reason for the careful balancing act evident in much coverage is that in the debate on the health service the major political parties are associated with quite distinct policies and views. Dissent from the governmental view is not considered to be dangerous or in any way misguided. It is perfectly 'respectable' to oppose current government policy on the NHS. Indeed, it is widely recognised that the NHS is one of the oppositions strongest suits with the public. In other controversial areas, such as defence, Northern Ireland, industrial relations and in terms of the General Election, the economy and public spending, this is not so clearly the case and the boundaries of the 'consensus' are more tightly drawn. This makes it easier for the broadcasters to represent opposing views on the Health Service than on other sensitive topics. Nevertheless this does not mean that they will always be critical, simply that there are more opportunities for critical coverage.
The string of Conservative attacks on television have their own rationales and triggers, but they also reflect a Conservative agenda which favours breaking up and selling off the BBC and moving away from a public service tradition towards a more market based system. Such motives were evident in the press coverage of the Health row. As the Sun put it when breaking the story :
The BBC must realise it is not a perpetual monopoly. The charter by which it exists is given by Parliament in the people's name. It can just as easily be taken away. And the licence revenue can be stopped as simply as turning off a tap. The BBC has the chance to mend its ways. If it does not, its privileged existence may have to cease. [12.10.91]
On this occasion the row over the reporting of the Health Service reflected jittery nerves in the Tory party abour their chances of winning the election, which at that point had still not been announced. With Labour ahead in the polls apparently because of the NHS the temptation to blame the media was strong.
Tory jitters over the impact of media coverage of the NHS debate, and more widely, coverage of the Election campaign, assume that the media has a large impact on public opinion, belief and understanding and possibly on voting intentions. The main barometers of public opinion on the NHS are public opinion polls produced regularly for newspapers and television programmes. However opinion polls are not straightforward reflections of public thinking. There are a number of issues which affect the data collected and how it is presented and interpreted. In our previous work we highlighted some of the factors affecting data collection, such as the effect of the wording of questions as well as their context and order on public responses [Judge et al, 1992]. The next section tries to clarify a number of issues around the interpretation and presentation of data and then moves on to consider the possible role of the media in influencing public beliefs and understandings of the Health Service.
Interpreting public opinion
It seems reasonable to suppose that the relatively low overall level of dissatisfaction with the NHS found in the OPCS and other surveys may be partly related to an uncertainty in peoples minds about whether the question refers to the running of the NHS or the concept. If we compare the levels of dissatisfaction with some of the other poll evidence the difference is marked. The BSA and NAHAT surveys show dissatisfaction at 47% and 12% respectively. Similar questions in an ICM survey for the Daily Express in May 1991 showed '88% of patients were 'satisfied' with the general efficiency with which their case was handled by the NHS' [Daily Express, 22.5.91]. This is not very different from the NAHAT survey and seems to be related as does the NAHAT data to the phrasing of the question in cueing people in to talk of their 'personal' experience. However, in the same survey, the results of which were carried on the inside pages of the Express (in contrast to the '88% happy with NHS' front page headline) it was revealed that 58% disagreed that hospitals were inefficiently run, 84% thought that nurses were overworked and 83% disagreed that doctors 'don't work hard enough'. Huge majorities of people were also very satisfied or quite satisfied with the standards of care from nursing staff and doctors (91% and 89% respectively). The overwhelming support for the staff of the NHS and the way it is run are instructive. This translates disproportionately into support for the Labour Party. 42% in this poll thought Labour would 'best protect the NHS' compared with 20% for the Conservatives. Although there was a large degree of support for the services supplied by the NHS, there was also a large majority of people (83%) who thought that NHS hospitals needed 'more money to run efficiently'.
More recently both Gallup and MORI conducted polls in the last quarter of 1991. MORI asked 'Do you think that the Conservative Party has plans to privatise the NHS if they win the next election, or not?' A majority answered yes in all cases but there was some decline in the numbers. (Oct 3-4 62%, Oct 18-21 50%, Nov 22-25 56%).
Consistent majorities of the population seem to have negative views on government policy on the NHS. This is found in tandem with high 'satisfaction' ratings for the standard of care within the NHS. These latter results are consistently interpreted by some newspapers as positive news for the government. Thus the Daily Express front page 'We Love the NHS, Say Patients' which reported the NAHAT survey published in November 1991. As the Express put it 'The poll... was hailed by jubilant government Ministers as proof that health reforms are at last filtering through to the patients.' [14.11.91] Similarly, just before the election, the Express reportedthe appearance of the poll results from OPCS as a boost to the government. According to the Express: 'The poll is a powerful blow to Labour claims that the NHS is on its knees' [3.4.92]
The clear implication of reports like this is to suggest that the high ratings of satisfaction with the Health Service indicate that the reforms are working or that Opposition predictions of chaos have come to nothing. However this ignores the fact that a key part of the argument against the reforms emphasises the heroic qualities of NHS staff and the benefits of NHS treatment. Thus we find the Daily Mirror arguing:
Mr Waldegrave is the only one out of step. He is a limping liability. He should ask the patients if they are satisfied. NOT those who have their hospital treatment, which is usually wonderful. But the thousands upon thousands who have to wait week after week, month after month, in discomfort or downright pain, for operations. [Daily Mirror, 15.1.92]
It seems reasonable to suppose that the 'wonderful' treatment available in the NHS might lead to respondents being 'satisfied' with the NHS and yet still bitterly opposed to the government reforms.
Impact of the Media
It is clear that most of the daily press is hostile to the Labour Party and to their policies on Health. The Sun, Mail, Express, Times, Telegraph and their Sunday equivalents were all supportive of the reforms, the Mirror stood out as the most critical of the government, with many articles in the Guardian and the Independent giving alternative views.
Yet as journalists repeatedly pointed out, the Health Service is not a strong area for the Conservatives and public opinion polls consistently showed that opinion was against them, even though the polls could be interpreted in differing ways. ITN election analyst David Cowling gave this explanation for Government unpopularity:
The government has to face the problem that for many, many years now, even when Labour was on its knees, in the 1980's, people trusted Labour more with the NHS than it did the conservatives. I've seen no evidence that that's any different now and therefore I think the Government has a forlorn hope if it thinks it can seize the issue and make it its own and take the advantage away from Labour. [Channel 4 News, 5.8.91]
One way in which the government was trying to change perceptions was by fostering the impression that the Major government was quite different from the previous years under Thatcher. Yet some government allies saw this as a problem. The Express was worried:
Ministers and Central Office mandarins are at such pains to avoid referring to Mrs Thatcher, save in the most ritualistic terms, that they cannot extol the Government's record with the unbuttoned enthusiasm it warrants... This uncertainty is reflected in an inability to spot good news and beat the drum about it. A good example is the way the Government made so little of this week's survey showing overwhelming satisfaction with the NHS - a story given its proper due only in the Daily Express. [16.11.91]
The problem for the Conservatives in winning the debate in the media is the relative weakness of the arguments that they use on health. The main Conservative arguments have centred around convincing the public that the NHS is safe in their hands, that it is not being privatised and that the reforms will improve efficiency and cut waiting lists. Labour's contention is that none of these are true. The Government approach largely accepted and indeed promoted the idea that the success of the reforms can be measured by the size of waiting lists or other measures of efficiency. This way of measuring success neglects the role of other factors such as demographic change and the increasing expense of 'High-tech' (and high cost) medical advances which might put a ceiling on the amount of GNP that any society can spend on health. In the periods which we studied such arguments were not strongly emphasised by either the government or the opposition. Indeed it was very hard to find either of these arguments anywhere on television or in the press. In August and November we could find only two references to such arguments and there were no more than a handful more in February and May. In November there was an oblique reference in the Daily Mail which appeared as a fragment in the midst of other information about the rise in costs of private health care:
Major Technological advances in medicine and the range and complexity of treatment now on offer, have also added to costs. [26.11.91]
The other reference in a Daily Telegraph editorial put the argument into the context of the debate about privatisation of the health service:
The fact is that the advances of medical science offer a range of treatments previously unimagined, and with that new range come even more unimaginably increased costs. This is a problem for the whole Western World, not one provoked by the parsimony in the NHS. Demand cannot be fully satisfied by the tax-payer. It would help if the representatives of the medical profession made this clear to patients, instead of pretending, as they too often do, that it is only mean spirited politicians who are preventing perfect health treatment for all. [12.11.91]
Given the lack of discussion of these perspectives in the media it is hardly surprising that the public does not believe the government when it says that it has increased spending on the Health service in real terms. Indeed some supporters of the government in the press have pointed to wider reasons why the government was losing the health debate. These relate both to public experience of the Health Service and to the working practices of the media.
The problem is that the intricacies of these reforms are dull, they are too recently introduced for their good effects to be visible, and the public are not in the mood to listen to the arguments. [Daily Telegraph, 12.11.91]
On the one hand it is argued that the benefits of the reforms cannot be seen either by patients or journalists and on the other the reforms themselves are too dull to trumpet in the newspapers or to interest or convince the public. This is a tacit acknowledgement that the opposition case which emphasises wards closed and operations cancelled is much more to the taste of both the public and the press.
Evidence that the reforms are working or are good in principle doesn't filter through because of the powerful images of people (especially children) being refused treatment, of wards closed and beds lying empty. In the period between August and the end of November, the Daily Mirror printed many front page and double page stories on the Health service vilifying the government over its health policy. If these are compared with front page stories in the other tabloids the power of these images is clear. The Daily Mirror dubbed the NHS the 'No Hope Service' [29.8.91], reported the story of a young boy who could not get free treatment under the heading 'SICK! Why Chris shames you, Prime Minister' [19.9.91] It also revealed that the intervention of the Mirror itself had led to a woman's cancelled operation going ahead under the heading 'YOU'RE MY HEART THROB' with sub headings: 'Wife savages Premier over cancelled operation - Nothing Happens. She complains to her local newspaper - Nothing happens. She writes to the Daily Mirror. Operation completed in 24 hours - YEAH!' [14.11.91]. And finally, claimed 'WALLY'S PORKIES, Patients' Charter is a sham' [11.10.91]. In contrast the only front page banner headline in the other tabloids in August and November was in the Daily Express which reported an opinion poll as indicating that nearly 9 out of 10 people had received 'excellent' treatment as in-patients, under the headline 'WE LOVE NHS, SAY PATIENTS' [14.11.91]. The lack of positive news about the NHS also worried the Sun. They ran a small news item appealing to their readers to ring the Sun with good news stories about the NHS. 'Did the NHS treat you well?... Knockers are forever moaning about service and complaining treatment is poor. But the Sun wants to hear the other side of the coin. Perhaps your life has been saved or you have another reason to be thankful. Call us with your NHS good news today... We'll ring straight back.' [27.2.92]
The plight of children such as Carly Reavill, Georgina Norris or Jennifer Bennet are much more likely to be remembered than the latest figures on activity in hospitals or waiting times. The saga of Jennifer's ear during the election campaign may have moved the debate away from the Labour agenda of the effects of Tory cuts, but it did little to encourage Conservative arguments on the success of the reforms.
A crucial element of this research is to examine the relative impact of different areas of coverage. Claims about efficiency and service are clearly not as powerful at carrying meaning as stories about the death of children because of inadequate care. This is recognised by politicians and by some in the media. We have also to understand that news information is understood and interpreted by members of the public in relation to their own practical experience and knowledge of the Health Service. In further examinations of opinion poll data it is important to investigate links between social class, experience of Health Service provision and opinions on the NHS when attempting to evaluate the possible influence of the media. The media can influence apparent levels of public concern by highlighting specific issues such as the quality of care or by focussing on other areas such as the 'efficient' use of resources.
We have shown that the relationship between the media and public beliefs on the Health Service is complex. But we should not underestimate the power of the media to influence public agendas and to provide key elements of popular understanding in this very controversial area.
Barker, Walter, 1992, 'Measurement of NHS service provision: activity levels or outcomes?', Radical Statistics, Number 51, Summer:21-29
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Mohan, John, 1991, 'Privatisation in the British health sector: a challenge to the NHS?', in Gabe, Jonathon, Calnan, Michael and Bury, Michael (Eds), The Sociology of the Health Service, London:Routledge
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Appendix V The sources of newspaper stories
Who gets quoted in the Daily and Sunday Press - August 1991
In support Against the reforms
of the reforms
Star 2 2
Sun 3 1
Mirror 2 3
Express 2 1
Today 0 1
Times 13 13
Telegraph 16 11
Independent 10 25
Guardian 6 12
Financial Times 4 2
News of the World - -
People - -
Sunday Mirror 1 2
Mail on Sunday - -
Sunday Express 8 4
Sunday Times 8 1
Sunday Telegraph 3 1
Independent on Sunday 1 0
Observer 0 2
Who gets quoted in the Daily and Sunday Press - November 1991
In support Against the reforms
of the reforms
Star 2 2
Sun 7 2
Mirror 11 33
Mail 14 9
Express 15 5
Today 1 4
Times 15 23
Telegraph 26 17
Independent 17 21
Guardian 12 60
Financial Times 15 3
News of the World 1 2
People 2 3
Sunday Mirror - 2
Mail on Sunday - -
Sunday Express 1 1
Sunday Times 3 2
Sunday Telegraph 3 1
Independent on Sunday - 2
Observer - 2