THE NHS is seldom out of the news these days. Previously we were banging pots and pans to celebrate it (not me) and staying at home to ‘protect it’ (not me – perhaps I should get a £50 fine). But now the reality is coming into focus and discontent is growing.
I have been reading the ‘NHS 2022/23 Priorities and Operational Planning Guidance’ (version 3, February 2022), a document sent to all NHS authorities with ‘best wishes’ from Amanda Pritchard, NHS Chief Executive. The background is that assuming Covid continues to become more endemic and less of a threat (was it ever?) how we are to rescue the NHS from the appalling self-inflicted damage of the last two years.
I wouldn’t bother reading it. I have been reviewing similarly produced documents for years although against different backgrounds. Much of the aspirational text could have been simply cut and pasted. My eye was caught by the phrase in an early paragraph, ‘Building on the excellent progress seen during 2021/22’, which gives you a flavour of the whole thing.
Also: ‘To support the restoration and recovery of services we need more people, working differently in a compassionate and inclusive culture where leaders at all levels inspire, empower and enable them to deliver high quality care in the most effective and efficient way.’
To quote Eliza Doolittle, ‘Words, words, words: I’m so sick of words.’
As a retired diagnostic radiologist, let me focus on one small area to demonstrate how badly the NHS keeps getting it wrong. Addressing the issue of the backlog of cancer patients, estimated at 36,000, the paper states, ‘Recovery of the highest possible diagnostic activity volumes is critical to providing responsive, high quality services and supporting elective recovery and early cancer diagnosis.’ And ‘to invest in CT capacity’. So down to detail.
A CT scanner is an X-ray tube using exactly the same physics as the original images discovered accidentally by Wilhelm Roentgen in 1895, but with radiation detectors rather than photographic plates. These are connected to a complex computer which generates the images.
All politicians want to see improved productivity, (a worthy aim), but the factor controlling throughput in a modern scanner is not the scan itself. A modern machine can scan from nipples to knees in one breath hold and generate thousands of images in seconds. The limiting factor is the patients. They need to be greeted, prepared, changed, cannulated IV, consented, checked for allergies, accurately placed on the scanner table and connected to an IV infusion. This is easy if they are fit, but harder in the frail, sick and elderly. Then obviously after the scan they need to be disconnected, got off the table and observed for 15 minutes. This account is for routine scans: emergency work is much more complicated and is often kept separate.
Scanners are highly complex and are staffed by specialist radiographers. For a scanner to work efficiently and productively without break over an eight-hour shift will require a team of at least four individuals (remember they will need time off for loo and lunch breaks and for sixteen weeks a year one or other will be on annual leave). And of course there will need to be time out for compulsory ‘equality and diversity training’ and suchlike.
Extending the working day from eight to twelve hours will increase the staffing requirement, and if full seven-day working is demanded again this will significantly boost the numbers needed (you cannot expect the same staff simply to work longer and longer). So what is the problem?
It started in the 90s when we had forty-two schools of radiography producing a steady supply of radiographers, which was a good training and career for those who did not want to be too academic. But to keep up with nursing training these schools were closed, and in their place were opened eleven university-based degree courses. And the result? You’ve guessed it. We had the biggest recruitment crisis ever. We could not get radiographers for love nor money. In desperation my department sent a team to the Philippines where we managed to recruit some first-class staff (most of whom are still with us). But the problem of a shortage of radiographers persists and there are simply not enough to cope with the accelerating demand.
The second problem is that while politicians love to bestow additional scanners they generally provide only the capital costs, not the revenue consequences which have to be found elsewhere within the budget. I am a bit out of touch with the current costs, but it probably costs between £500K and £1million a year to run a CT scanner, with all the additional costs which I have not mentioned.
The next elephant in the room is huge. Most politicians think that the end result of a scan is a picture. It is not! The end result is a carefully constructed report on the images by an experienced radiologist. These are doctors who have gone through full medical training, usually followed by several of years of clinical work at the coal face, and who have then undergone at least five years of specialist training to gain a Fellowship of the Royal College of Radiologists. This is often followed by further training.
A consultant CT reporting session will last about 3.5 hours and depending on the complexity of the scans there will be a finite number that s/he may safely report in that time. (Note that airport security staff screening baggage by X-ray do it for only 20 minutes at a time: any longer and concentration and perception diminish.)
The brutal truth is that modern scanners will churn out far more images than there is capacity to report. And demand continues to rise. Note also that I have not mentioned MRI, ultrasound and nuclear medicine scans.
In April 2019 the Royal College of Radiologists issued a sobering report headed ‘The NHS does not have enough radiologists to keep patients safe, say three in four hospital imaging bosses’. Of course the images, being in digital form, may be outsourced. There are many excellent radiologists in India, for example. So in 2018 NHS hospitals spent £165million on outsourcing, locums and overtime pay, £49million more than in 2017 and three times what was spent in 2014. These staggering amounts continue to rise and could easily pay for the training of adequate numbers of radiologists in the UK.
It gets even more bizarre. Before the world fell apart in 2020 the NHS had a target (how I love targets) that any patient suspected of cancer must have the definitive scan within 28 days of referral. This generated an army of administrators with clipboards checking up on every patient because if there was a breach the trust would be in trouble. So if Mrs Jones was set to breach, Mr Smith (not a cancer suspect) would be bumped to allow her in. But the images might sit in a digital queue for weeks waiting to be reported since there was no target for reporting.
All this merely highlights the simple fact that long-term workforce planning in the NHS is non-existent and affects every area of the service. It is estimated that there are currently more than 100,000 vacancies in all staffing groups. Pictures of smiling local MPs in the newspaper cutting the ribbon to open the new CT scanner, or policy papers on priorities and planning are fine, but they will not address the issue of chronic understaffing of essential services.
We are in for a bumpy ride.