NHS reform or die

What will happen?

I spent 18 years in the NHS 2001-2019 and have returned back in April of this year, I cover all wards between two county hospitals.

I’m not expert, but the only thing I can see which keeps it going is the staff who are amazing, from the cleaners, the Health Care Assistants, Matrons, Consultants, they are all working so tirelessly in such a difficult working environment.
Those same staff who got a hero’s clapping during COVID whilst endlessly wearing full PPE, who are leaving in droves, burnt out, and whom we thankfully rely on recruited overseas nurses to fill the gaps, and who so often receive so little financial reward.

Budgets slashed beyond function.
Staff working conditions are poor.
Support services can’t support people from hospital back into the community, or from being there in the first place.
GPs stretched to beyond capacity.
Ambulance services have all resources stuck at hospital leaving nil for the next 999 call.
Not a single NHS dentist in the county accepting new patients.
Mental Health services vastly overwhelmed and over subscribed, and no ease of access.
Children are presenting with more need: neuro diversity, eating disorders, mental health issues.
Homelessness increasing and resourcing. slashed.
Substance misuse increasing and resourcing slashed.
There will be so many, many more areas painting the same picture.

Forget blaming conservatives VS labour, as the damage has been done over many decades, and needs a different no blame approach.

Are we ready to close the NHS and embrace private healthcare?

And the work volume is only ever increasing…

Are we ready to close the NHS and embrace private healthcare?

Can the UK afford private healthcare?

The evidence from the United States is that private healthcare provisions are considerably more expensive and the United States spends a far greater portion of its GDP on healthcare than other countries.

There is a lot of money to be made from private healthcare though, people will spend a lot of money on their own healthcare if they have it, so that obviously makes it very attractive for a lot of people.

When people don’t have to pay for the thing, they don’t value the thing.

When people don’t have to pay for the thing, they don’t value the thing.

Any evidence that people don’t value the NHS because they don’t pay for it directly?

Talking to the patients who screech at me about their entitlement, I see the evidence of it daily. Or perhaps I’m just cynical after [yet again] one of my receptionist was bought to tears already today by people who seem to be unable to behave like adults.

“The health service makes more people proud to be British than our history, our culture, our system of democracy or the royal family”

https://www.health.org.uk/news-and-comment/charts-and-infographics/how-the-public-views-the-nhs-at-75

But the public see “NHS” as a single branded company which makes them proud, this is propaganda as the reality is very much a different story.

It may say “NHS” on the shop front, but once your inside it’s a private bazaar.

“Last year nearly 15% of NHS staff had physical violence from patients, their relatives or the public.

A BMA survey in January 2020 found:

 – 43% of 602 doctors were concerned about physical violence and verbal abuse from patients at work

 – 32% of 602 doctors believed that incidents of violence or verbal abuse had increased in the past year

– 43% of 644 doctors saw physical violence or verbal abuse towards staff

 – issues thought to be factors in the incident(s) of physical violence or verbal abuse included discontent with the service provided (60%), health related or personal problems (54%), and being drunk (30%).”

https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/creating-a-healthy-workplace/preventing-and-reducing-violence-towards-staff

As a non expert, it seems to me a lot of the investment needed needs to go to “non-hospital” areas to free up hospitals to do their bit more effectively – support to discharge patients back home or into convalescent homes, GPs to deal with less serious stuff, social care to keep people out of hospital.

More work on prevention, exercise, better diet, rehab – would reduce longer term NHS costs, increase tax paying employment.

We also are going to have to face the cold harsh fact that we can’t afford to keep everyone alive. We are not designed to be immortal. We die. We should be able to have some say in how that happens at a time and with the dignity of our own choosing.

(If you can get tickets, I recommend seeing Ben Eltons current stand up tour, he does on amazing long running gag about how assisted dying might work, Granny’s final meal)

Can the UK afford private healthcare?

Wages would need to increase.
More Companies would have to start including healthcare insurance.
In the US, even if you have insurance the deductible can be in the thousands.

Speaking from personal experience (here not the US), get sick, can’t work, on SSP.

Would be unable to pay for medical treatment to return to work.

Sure £400 for a scan would be doable, but an operation? No way.

When people don’t have to pay for the thing, they don’t value the thing.

But we do have to pay (at least us PAYE plebs not dodging our taxes), and I think most people do value the NHS, hence most are up in arms when it’s decline is increasingly obvious.

Two decades of politically engineered decline with a RW press trying to coax us towards a national consent for destroying a key national resource still hasn’t quite done it.

Coordinated NHS reform along with joined up social care and broader investment is very much needed. It’s not just about money.

Most fundamentally (beyond the NHS in fact) the national discourse needs to get away from focussing on financial costs, but looking at consequences. Every time the question back seems to be “how much will it cost?” rather than journalists, politicians and the public asking “what are the consequences of not doing this?” 

The Neo-Libs have had their go (Someone does need to tell Reeve and SKS though) anyone still believing that Austerity works needs to be challenged and asked what they think ‘Success’ actually looks like.

Can the UK afford private healthcare?

Ask the Germans or the French. They both have a tightly regulated private insurance schemes backed by the govt. They both seem to have better healthcare outcomes on more or less the same overall % GPD spend. (Germany 12.7, France 11.9 UK 11.3) Not every private healthcare model = the US version.

backed by the govt

Do you class GP services as “private healthcare” then? If so the question has been answered – we already have private healthcare provisions.

The NHS will always be a victim of it’s own success. Save a life?, the person comes back again and again for more treatment as they age and decline. Let them die first time round?, no more patient to drain future resources. <sarcasm> Simples!

Except it isnt simple at all. My octogenarian parents attend many more out patient and GP appointments than my children. They no longer contribute financially to society but did so for decades. They’ve earned their treatment from cradle to grave. One of the weans will become a net contributor to society, the other won’t, both will need the NHS. Who chooses?

What type of treatment does the NHS withhold and from whom? Liver transplant for an alcoholic? Heart and lung transplant for a heavy smoker? Orthopaedic treatment for a mountain biker? All self inflicted, so sod ’em all?

It’s an impossible situation in a humane society but keeping Tories, US insurance companies and shareholders as far away from the NHS as possible would be a great start.

I work in a completely different part of the public sector that has many of the same problems.

The answer isn’t just reformation, the primary answer is more tax, mainly for the rich.

I’m a staunch believer in socialised healthcare, free at the point of use but the NHS is, by and large, an absolute shit show. Individual parts of it can work well but integration is severely lacking and if your health needs span several different disciplines then ime you’ve really got to be on the ball to improve your chances of a good outcome.

And it’s a controversial view I know, but NHS employees at all levels are not a team of uniquely dedicated saints, they’re mainly well intentioned ordinary people working for a wage like ordinary people do. Some of them are exceptional, and equally some are absolutely useless, just like in any large workforce.

I agree that the whole system is in need of reform, not least by integrating social and healthcare. It’s a hugely complex “organisation” and I wouldn’t have a clue where to start.

All I can add is, having been taken to an A&E well away from my home town not long ago with a serious condition, alone, tbh scared with a real fear of what it was all going to reveal, the NHS staff and service can be fast, efficient and a good experience, full of the best of humanity. It’s had me thinking about where the NHS is a lot recently. That the staff are paid what they are is a travesty and we need to value them more than just performative clapping.

I have zero faith in privatisation, water and rail tell us all we need to know there and regulation is ineffective when money and big companies are involved. Ultimately the things we need most in life like heat, water, health are the things that we can be gouged the most for and the gouging is done by wealthy people who have private cover. I don’t have an answer of course but if funding is the issue and increasing private business in the NHS is the answer, I suspect the frameworks that prevent beyond-reasonable profiteering need to be thought about. Is there anything like that in pharmaceuticals?

Do you class GP services as “private healthcare” then?

Depends on your definition of private healthcare I guess. To me, most of the NHS provision outside of Trusts – and anything that is a profit generating enterprise is [by definition] private healthcare. So that’s GPs, Dentists, Opticians, Pharmacists To my mind, it’s the “free at the point of care” for some healthcare that’s the issue though not necessarily how it’s provided. Some folks could (and perhaps should) pay for their care so that others who can’t afford to do so, don’t have to.

Most fundamentally (beyond the NHS in fact) the national discourse needs to get away from focussing on financial costs, but looking at consequences. Every time the question back seems to be “how much will it cost?” rather than journalists, politicians and the public asking “what are the consequences of not doing this?

This. Because this:

I work in a completely different part of the public sector that has many of the same problems.

Ask the Germans or the French. They both have a tightly regulated private insurance schemes backed by the govt. They both seem to have better healthcare outcomes on more or less the same overall % GPD spend. (Germany 12.7, France 11.9 UK 11.3) Not every private healthcare model = the US version.

Percentage of gdp isn’t really a good way of measuring, if you look instead at the figures spent per person, then France outspends the UK by about 20% and Germany by nearly 60%.  If the health outcomes are nearly the same, then that would indicate that their systems are less efficient, which given how the NHS has been targeted by the Tories over the past 10 or so years is quite incredible that the NHS is still delivering such outcomes, and actually speaks to the efficiency of the system that they have been able to deliver under such poor political management and undermining.

Figure from 2022

United States $12,555
Switzerland $8,049
Germany $8,011
Norway $7,898
Netherlands $7,358
Austria $7,275
Belgium $6,600
Australia $6,597
France $6,517
Sweden $6,438
Luxembourg $6,436
Canada $6,319
Denmark $6,28
New Zealand $6,061
Ireland $6,047
Finland $5,676
United Kingdom $5,493
Iceland $5,314

but keeping Tories, US insurance companies and shareholders as far away from the NHS as possible would be a great start.

I worked briefly for a company that in turn was owned by one of the largest US heath insurance firms. Every representative I met (and some of those were senior executives) were pretty adamant that inflicting the US style healthcare on the UK would be a disaster that they’d not want to go anywhere near, despite what the likes of Farage and the Tories may say.

It’s indicative I think of us that we look at how the US has evolved its private healthcare rather than at most European countries who are nearly all a mix of mandatory personal private insurance and govt backed schemes

water and rail tell us all we need to know there and regulation is ineffective when money and big companies are involved.

This.

Speaking to an ambulance driver the other week.
Serious RTA had them on scene for approximately 2 hours using 2 vehicles to both treat people and act as blue light road blocks to ensure safety of themselves and others on site.
Because the traffic police are also parred right back to the absolute minimum cover all it takes is multiple incidents and they can’t be in 2 places at the same time.
I do feel we will end up with a pay to use system for NHS treatment, where you pay a percentage of the cost of treatment via savings, 3rd party insurance or a government funded loan scheme.
The costs are enormous though, and the cost of making it better is huge. Probably be the same as a high capacity railway line to Birmingham.

It is so complex, so huge and so challenging that I wouldn’t dare suggest how to fix it. But a decent start would be to whack huge tax in unhealthy stuff, and use that to heavily subsidise healthy stuff. Make it cheaper to be healthy than unhealthy.

I’d also suggest trying to establish a cross party approach, similar to a war cabinet, and remove the NHS from party politics.

I feel an essay coming on…

Some quick bullet points:

• I don’t think the characterization of NHS staff as “heroic” is helpful in any shape or form.
• It’s not so much the way that things are funded, as what is funded that makes the difference.
• Historically, increases in funding have been associated with better outcomes in the NHS, and funding has fallen in real terms since 2010.
• There’s no doubt in my mind that secondary care (hospitals and specialist services) have become less productive in the past decade, including community based specialist services such as mental health, despite receiving increased funding.
• GP services have become more productive in the same time frame, but that’s come at the cost of retention of GPs which is a tragedy on many levels.
• Despite those past two points, there is a continued push to try and make GP surgeries work more like miniature hospitals, rather than make hospitals and community services work more like GPs.
• The focus on access is counterproductive and IMO self-defeating because of induced/uncovered demand.
• Despite our productivity, GPs are no substitute for well-conceived and executed public health policies.

Great to have input from people actually involved on topics like this – at the risk of @Kramer neglecting his professional duties to write an essay (wink emoji) could you give us some bullet points on how you think reform should look and/or where investment needs to be targeted?

Anybody who is obese, a smoker or a drug addict should simply have their right to free healthcare withdrawn.

Junk food needs to be taxed heavily, to the point where real food is cheaper.

GP appointments and basic treatments should be paid for by the individual.

Anybody who is obese, a smoker or a drug addict should simply have their right to free healthcare withdrawn.

You do not understand addiction.

In my limited experience we seem to waste an awful lot of NHS resources on giving people an entirely undignified death.

I have no clue how to fix it, so many things seem broken and it’s such a vast organisation that it will take years and £billions to affect any noticeable (to Joe Public) change. I hope they do though and I’d gladly pay more income tax for it.

What happens when its a recurring condition or try getting a holiday insurance company to pay up when you have a medical emergency due to an underlying condition.

“The computer says no”

It’s an impossible situation in a humane society but keeping Tories, US insurance companies and shareholders as far away from the NHS as possible would be a great start.

This, most definitely this.

In my limited experience we seem to waste an awful lot of NHS resources on giving people an entirely undignified death.

This would require a grown up conversation which, in general in this country, we are not capable of.

Starmer on NHS reform here

“Let me be clear from the outset what reform does not mean first – it does not mean abandoning those founding ideas of a public service, publicly funded, free at the point of use, the basic principle of dignity, inspired, of course, by Bevan that when you fall ill, you should never have to worry about the bill”.

Good god.

The tenents of failed capitalism are alive with this thread.

You want to improve things then stop with this idea that the private sector does things like this better.

Same pool of labour and same skills are available to government. At no cost to the public.

The private sector adds a layer of inefficiency called profit.

It’s a terrible path. Fund it and fix with the state. Labour are certainly convincing people they’ve got a bridge to sell for sure.

Just about everything privatised is shit. Why more? It’s ridiculous.

The tenents of failed capitalism are alive with this thread.

Actually, the majority of posters clearly don’t think that. Have you thought about going to Specsavers for a (private) eye test?

Talking to the patients who screech at me about their entitlement, I see the evidence of it daily. Or perhaps I’m just cynical after [yet again] one of my receptionist was bought to tears already today by people who seem to be unable to behave like adults.

Without wanting to diminish the problems that your staff have, this isn’t dissimilar to the stories that my daughters tell me about their workplace. The incredibly rude customers, people who shout about the most trivial issues and reduce the staff, mainly teenage girls, to tears. They work in an ice-cream parlour!

The issue is with how people treat each other these days. I’ll bet that your staff (or a significant number of them) treat other ‘workers’ just as poorly as they get treated themselves.

@IdleJohn

They work in an ice-cream parlour

Before I became a doctor, my summer job was as an ice-cream man. Twas ever thus…

Although I do think it’s become more commonplace.

I’d also suggest trying to establish a cross party approach, similar to a war cabinet, and remove the NHS from party politics.

100% agree with this.
The NHS shouldn’t be a political football which “needs”reform every time a new government is elected.

@MoreCashThanDash

could you give us some bullet points on how you think reform should look and/or where investment needs to be targeted?

• We need to cut funding to hospitals and secondary care and give it to Primary Care to retain and recruit doctors.
• Primary Care needs to be a GP (doctor) lead service supported by other professions, not replaced by them.
• Secondary care and community services need to support GPs, not the other way round as currently happens.
• In all areas of the NHS we need to stop trying to save money by replacing doctors with other professions, it’s not working and IMV it’s a root cause of the drop in productivity in secondary care.
• We need to look at the training of doctors, it’s gone wrong and we are starting to see a generation of doctors who can only follow protocols and have little practical experience of  clinical decision making and leadership.
• We need to stop trying to get GPs on the cheap and start investing in getting our best and brightest doctors into the position where they can do the greatest good – primary care.
• We need to understand that patient satisfaction is a terrible measure of outcomes, it has little to no correlation with mortality and by prioritising it we inevitably deprioritise patient safety and effectiveness of treatment which are far more important – as shown in the Berwick Report.
• In all areas of the NHS we need to stop focusing on resource efficiency (costs) and start focusing on flow efficiency (outcomes).
• We need to realise that GPs add value through our clinical acumen, continuity of care and ability to effectively gate keep, and that to empower these qualities means compromising in areas such as accountability and resource useage.
• The complaints system needs to be streamlined so that spurious complaints can be dealt with quickly and GPs don’t need to put up with serial complainers, who take up a disproportionate amount of time and resources.
• Now that we’ve separated negligence from compensation, IMV the “prudent patient” standard needs to be replaced.
• Medical leadership at Whitehall and various other agencies needs to come mostly from frontline GPs who are currently both under-represented as a specialty, and over-represented by academics in the few roles that are nominally occupied by GPs.

@Dickyboy

In my limited experience we seem to waste an awful lot of NHS resources on giving people an entirely undignified death.

We do, and it’s one of the areas where well-resourced GPs who have a long-standing relationship with patients can both improve outcomes, patient satisfaction and save loads money to boot.