With the same monotonous regularity as the wrong sort of leaves on the line or Gazza coming off the vodka in rehab, the annual winter beating of our breasts and tearing of our hair over the state of the NHS is upon us. The loaded trolleys waiting in A&E corridors have reached crisis levels as they somehow always do when it’s cold outside.
But nothing ever really gets done and the system creaks on as it yet again approaches ‘breaking point.’ We’ve long argued here that the NHS, ‘our’ NHS as so many still insist on calling it in blind, super-saccharine fashion, is not fit for purpose. It’s a sacred cow that nobody dare, if not put out of its misery, at least re-design into a beautiful butterfly or even a race horse.
The way the debate has degenerated into a binary fight between the government and the doctors over funding is very unhelpful. Both have a strong vested interest in holding their ground and neither is to be trusted with the unpalatable truth. The inevitable tensions between clinicians and managers have been there almost since the start back in 1949.
The answer to fixing the NHS is not to throw more money at it. It is in sore need of major structural reform. Its outcomes are often unimpressive when compared with similar systems in the developed world. And it is, after all, outcomes - the state of the nation’s health - that matter. Well-meaning, ‘heroic’ doctors and ‘angelic’ nurses don’t make patients better on their own. Clinical and management strategies are at least as important - our survival rates from cancer, for example, remain woeful.
The BBC has been going gangbusters on the NHS’s woes this week. Every day has been calamity piled upon calamity. Today it’s set out a list of Ten Charts ‘that show why the NHS is in trouble'. Let’s have a look at them one by one.
1) We spend more on the NHS than ever before. Yes this is true: £140 billion was the bill last year, which is more than ten times the figure 60 years ago. But to what end? The important measures in the NHS should not be inputs but outcomes and there’s much evidence that the system is highly inefficient. Any organisation that boasts of the fact that it has 1.7 million staff should accept that like the Indian railways or the Red Army in China such ludicrous size is fundamentally unmanageable. You pull at the controls but very little happens to change direction. Nobody dare hit the brake. The NHS’s bloated bulk has become its own worst enemy - it frequently gets none of the advantages such as the purchasing power such heft should bring but does have to grapple with the disadvantages.
2) A bigger proportion of public spending goes on health. Yes but health has also come to include social care. The NHS is being forced to take up the slack for poor levels of funding for elder care for example. If in doubt send them to A&E which is the safety net for all manner of woes from loneliness to mental health problems. Then once these individuals are in hospital you frequently cannot get them out to be cared for by more appropriate agencies. A&E cannot say no. Or go away. This problem will get worse and worse.
3) Key A&E targets are being missed. This is a long way from being a vital issue. Such targets were Captain Clipboard’s frisson, a random measure of efficiency and performance anyway. (They are also gamed by those involved to a huge extent.) It’s horrible lying on a trolley in a corridor if you’re sick, however many should not be in A&E in the first place but being looked after by GPs and primary carers. But as most GPs shut up shop at 6pm and do not do their own on-call any more this option is no longer open to the unwell.
4) The UK’s population is ageing. You don’t say! Who knew? The number of people over 70 in the UK is doubling every 20 years. Many older people with health problems do not belong in expensive hospitals but in the community. The chronic diseases of ageing - diabetes, heart disease and dementia - cost a fortune to treat. But the first two are to an extent preventable. Far more should be spent on stopping disease in the first place. And those who don’t listen to advice should not expect instant remedies. Incidentally, if we insist on barring entry to EU nationals and others post-Brexit that average age will go up faster. Migrants are young and often perfectly healthy.
5) Care for older people costs more. The average 65 year old does indeed cost twice what a 30 year old costs the NHS - and over 80s cost wildly more - but see above. Prevention is better than cure and we are going to have to accept that working people pay into a fund to help care for them when they grow old. This should be on top on income tax and NI. The only problem with this approach would be that no cash-strapped government would ever be able to resist stealing from the pot.
6) Increases in NHS spending have slowed. Indeed they have and for good reason. Our national finances are in a very poor state. Our debt remains shocking. In the long run patients will have to pay for certain services. They already pay for specs and dentistry. Other services will follow.
7) The UK spends a lower proportion on health than other EU countries. Yes but other countries put more into the pot. They tax harder and expect contributions for GP appointments, for example.
8) Demand for A&E is rising. See 3) above. GPs must be forced to take more of the burden. But they are self-employed SMEs and don’t do what they are told as if they were NHS employees.
9) Fewer old people get help with social care - see 5) above.
10) Much more is spent on front line care than social care. Telly producers make ‘Casualty’ and ‘ER’ not ‘Geriatric Clinic!’ Looking after old, frail people isn’t sexy. It hasn’t won many votes or junior doctors wanting to make it their mission. This is a scandal. The way we treat elderly people in this country is little short of disgraceful.
So here are some modest proposals:
Break the NHS down into proper autonomous units to make it more manageable.
Manage demand far more strictly and not just by a crude queuing system.
Use technology far better. The NHS’s excursions into data and tech thus far have been costly and disastrous. But a new attempt to turn the NHS higher-tech is vital.
To a greater or lesser extent we all have to rely on our own subjective, often strongly-felt experience with the NHS. Those who are still alive when they could be pushing up the daisies are usually eternally grateful for its care. Those with chronic conditions are sometimes less positive. Here, for what it’s worth is my latest encounter. A few weeks back I strained my Achilles whilst out running with my nine year old son. I went along to my GP, whom I like and respect, who quickly and with the minimum of fuss referred me for physiotherapy at my local London teaching hospital.
In the meantime I did what many patients do these days and Googled the various exercises I should be doing to heal the problem - the Achilles is a tendon, not a muscle, and therefore slightly trickier when it comes to healing.
I phoned the hospital after a couple of days - as I’d been told to do - and was eventually told that my GP’s letter would be considered after about ten days. ‘Take your place in the queue, sonny,’ was the message. I then received an extremely complex letter from the NHS e-referral service. This told me to book my appointment myself for which I required a password.
Password? Where did I get that from? I rang the GP. It was on the referral letter. Could they email it? No. I would have to come to the surgery to get the password. I went to the surgery again. Got the password. Filled in the online form on the system. And guess what? The referral appointment did not require I attend because they would just be considering my GP’s application for treatment. Maybe I should Skype in, shove my ankle in front of the laptop camera and moan loudly. This all struck me as deeply weird and inefficient especially when I got another reminder letter from said e-referral service saying I hadn’t done anything.
However, in the meantime - surprise surprise - the Achilles is slowly getting better. So the socialized medical system has worked on me like a Stalinist bread queue when the loaves run out. It has taught me the values of natural healing and stoicism. In the US I’d probably have been sent for a fabulously expensive MRI scan by now.
I’ve made way, I hope, for someone in greater need than me. And anyway I can afford a sports physio, if needs must. Stopping people getting instant free treatment is sometimes the way to go. But, in the long run, the NHS will need someone with courage and vast political will to shake it up until it's unrecognisable. But better.
Image credit: Gamerscore Blog/Flickr