There are bad times just around the corner,
There are dark clouds hurtling through the sky
And it’s no good whining
About a silver lining
For we know from experience that they won’t roll by . . .
– Noel Coward
WE ARE told endlessly that the NHS is irredeemably broken and that the whole edifice needs to be scrapped. Waiting lists are off the scale, it seems impossible to see a GP and the A&E four-hour target is a distant dream. Hospital beds continue to be taken up by those fit for discharge but with nowhere to go since social care is also in disarray.
Nurses, paramedics and physiotherapists have all been on strike although the Royal College of Nursing has suspended action pending talks with the government. The British Medical Association has announced that junior doctors have voted overwhelmingly for a three-day strike next month. The only ones not contemplating striking, it would seem, are the managers and the consultants (someone has to do the work). All in all, a pretty dismal picture which I find increasingly worrying as I move from being a provider of health care to a consumer.
Three years ago many (excluding me) were clapping and banging pots to celebrate the NHS, and who does not cringe at the memory of the 2012 Olympic Games opening ceremony which included dancing bedpans and nurses or whatever? However, amidst the clamour of ‘something must be done’ there is a dearth of original ideas as to what actually could or should be done.
Let me say from the outset that I am profoundly pessimistic that anything fundamental will change for two main reasons: the politicians and the doctors.
The NHS is an institutional behemoth and radical restructuring would prove a major task. So does anyone believe that the numpties who purport to govern us, given their record on almost everything, are capable of coming up with a coherent plan, let alone having the political will and the skills to deliver it? Answers on the back of a postage stamp please.
‘The NHS must reform or die,’ says Sir Keir Starmer. When politicians talk of reforming the NHS, what they mean is not reformation (making changes to improve it), but reorganisation (changing the way it is organised).
The historical precedents are endless. Following its inception in 1948 the first 26 years of the NHS were relatively stable. Since then there have been multiple reorganisations, minor and major. In no particular order we have had Regional Health Authorities, Area and District Health Authorities; the Griffiths report under Mrs Thatcher created CEOs and middle management. Tony Blair’s contribution was The New NHS: Modern and Dependable. We have had the internal market, Payment by Results (the biggest misnomer ever), GP Fundholders, Purchasers and Providers, Hospital Trusts, PFI, The Patients’ Charter, Care in the Community, Clinical Commissioning Groups and competitive tendering. More recently Integrated Care Systems and, of course, involvement of the private sector to varying degrees. I could go on, but by now you might have lost the will to live.
Each reorganisation has resulted in chaos, burgeoning bureaucracy and management with associated costs. Have there been any serious attempts to evaluate these changes, particularly in terms of improved healthcare? None that I am aware of. The health of the nation seems worse than ever. This is understandable since the main object of all the changes is to limit expenditure and control the doctors.
I am reminded of the quotation by Charlton Ogburn (often incorrectly attributed to Gaius Arbiter): ‘I was to learn later in life that we tend to meet any new situation by reorganizing; and what a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralization.’
So where is the big political idea for reformation rather than reorganisation? Sir Keir Starmer wants to nationalise the GP service. Wow, what a great plan; that should solve everything (sigh). So don’t expect anything sensible soon from the politicians.
The doctors, by which I mean the BMA (of which I was never a member), are no better. The BMA was opposed to the setting up of the NHS until Bevan famously had to ‘stuff their mouths with gold’. Not much has changed, and I have seen no evidence that they have any solutions for the NHS other than to ask for more money.
Sadly, judging by experience, any significant reform of the NHS is just a pipe dream, and we have no alternative but to try to build something better on the existing foundations, however shaky, although I am not hopeful. So here are a few of my ideas, other than the bleedin’ obvious of getting a proper workforce strategy and reinstating the care home workers sacked for refusing the jab.
First, renegotiate many of the private finance initiative (PFI) contracts which were ludicrously overgenerous to the PFI companies who will rake in billions of our money over the course of the contracts. When the contracts for my own hospital were signed, there were three hospital representatives and hordes of commercial lawyers present. Before the ink was dry they were popping champagne corks, and little wonder. Cash released from these contracts could be used to better pay nurses and paramedics, but this would involve a huge legal battle and I doubt if the Conservatives are up for it since they may need well-paid corporate jobs after the next election. Labour might have the balls for it: we may see.
Secondly, the divide between primary and secondary care causes unhelpful friction and does not necessarily smooth the patient pathway, so I would abolish it. This does not mean abolishing the role of the GP; there are many excellent GP practices and it would be wrong to scrap these. However they tend to be in prosperous areas while in poor inner cities or remote country areas they struggle to recruit. In this situation the hospital trusts should incorporate failing practices, and closer involvement with hospital clinicians would be more attractive to GPs. Indeed this already happens to some extent with some GPs working in specialist roles in hospitals.
Thirdly I would link pay progression for doctors (and nurses) with performance. Most doctors put in a good day’s work, but not all. Some do the bare minimum. Pay progression depends on seniority, not output or quality, which is largely true throughout the public sector. I accept that this would need careful management since the output of differing specialities may be hard to evaluate but it should be possible. But this will never happen because the BMA would fight it tooth and nail, and I doubt that any government would take them on.
On a more positive note I would encourage local improvement initiatives rather than top-down edicts. I know from experience that these may be very effective in increasing efficiency and in improving the patient pathway since a local team will understand the issues far better than any politician. To give one example, in my own department we reduced a frustrating two-hour patient pathway to 20 minutes by eliminating steps which added no value.
However this requires a paradigm change in corporate thinking and considerable management buy-in to maintain it. It also requires time and often financial input to make savings down the line. Unfortunately most NHS managers spend their time trying to reduce costs and stay in budget and the daily pressures militate against out-of-the-box thinking.
Finally I would scrap all top-down imposition of targets with associated punitive measures if they are breached. They never worked, and indeed most have been quietly dropped anyway. Instead I would encourage realistic goals determined by local agreement which would motivate staff far better than externally imposed ones.
These are just a few of my thoughts; what are the chances of any of these ideas being accepted? Virtually nil, I suspect. Inertia is built into the system too deeply for meaningful change.
A close relative has a very painful condition which limits almost all of life’s activities. An expert in pain relief suggested a procedure which could be done by the end of last summer. It has now been cancelled twice and, in view of the strikes, will likely be cancelled again. So the pain, and the frustration continues, as it does for many thousands.