NHS reform or die

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?

Ultimately I think this is a big part of the problem, not just for NHS but all public services – people are living too long, and whilst they did contribute financially whilst working they don’t pay National Insurance once they are over pension age – many now living longer than their life expectancy at birth because of the benefits of the NHS.  There’s people on pensions far above the average salary who whilst they will be paying tax on it are some of the most comfortably off in the country now contributing disproportionately less but using more…  removing the upper age limit on NI would unlock significant cash; it wouldn’t affect the poorest pensioners; it would restore the link between contributing and using the service!  Having seen the furore about winter fuel payments I’m quite sure this would go down like a lead balloon but ultimately pensioners have had the most protected income for decades with the tripple lock – if they keep that something else has to give.

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

This.  And not just the death itself – last week I was at the funeral of a 98 yr old.  Her final few weeks were actually probably exactly as you might hope. But pretty much the whole of the last decade has been grim, zero quality of life, alzheimers ridden rarely leaving her own bedroom and never leaving the home except for hospital trips – each of which her and her family thought would probably be the final one.

Anybody who is obese, a smoker or a drug addict should simply have their right to free healthcare withdrawn.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

Ah the words of the lucky!  Smoking and other addictions are a byproduct of society.  Obesity may well fall into that umbrella too – once a sign of prosperity and wealth its now much more likely to be associated with poverty.  Nobody really agrees what “real food” v “junk food” means or how you’d define that without just providing manufacturers with a new marketing opportunity to exploit people.  It is almost certainly less financially efficient to charge for GP appointments than to encourage people to seek help early.  A small infection from someone who doesn’t have £20 this week becomes sepsis next week and costs thousands.  A patient with a lump waits till after payday to seek the appointment they were dreading anyway – making a “caught quickly” problem a much worse one.  The person with addiction issues never seeks help as every penny feeds their habit.  The asthmatic kid with poor living conditions faces another barrier to life.  The 16 yr old who wants to go on the pill can’t afford to see the doctor and becomes a new teenage mum.  Meanwhile I can afford to go and waste my GPs time discussing my varroucca and by god will NickC’s life get worse if “I’m paying for my appointment so I expect better service”, not to mention that “businesses” which were never set up to take customer’s money will suddenly find themselves having to hire admin staff rather than clinicians:

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.

The law already allows NHS to recover treatment costs from insurers for RTAs.  My understanding is this is rarely used because we just aren’t set up with the admin and procedures for tracking it.  In countries where it’s the norm – they count every plaster, every needle, every minute.  That encourages “over treatment” because an insurer is being billed.   I’ve done some work with those healthcare systems – the IT providers are not asked “how can we improve patient care / experience / outcome” its “how can we track the billables better”!

Starmer:

The NHS must “reform or die” but this doesn’t mean more money

10-year plan

https://www.bbc.co.uk/news/live/c0qejx03zjnt

Politicians should not be in charge of this, it’s just another flavour of the same shite that they’ll spoon feed us whilst blaming their predecessors.

What goods an unprotected 10 year plan when your stay in power is only protected for 4 years?

ambulance driver

The 70’s called, and wants it’s phrases back #laughingemoji

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.

I’m intrigued by this – which professionals in secondary care do you think are the problem for inefficiently soaking up all the cash?  Physios, Pharmacists, Nurse Practitioners, Dieticians – I’ve had contact with all of them in secondary care and couldn’t imagine a hospital doctor doing that bit of the care anywhere near as well?  The system seems really keen to have people self-refer to those sort of services in primary care too – and I generally think that greater public respect/understanding for those professions would actually help.

Perhaps you are alluding to PA’s?  There’s a lot of hostility to PA’s from medics.  Some of it might be merited, some is definitely because the government bodged its creation and there’s no proper regulatory/professional framework BUT the concept that some parts of doctors work are either so simple (admin) that they don’t need a doctor, or could be just as well performed by someone who hasn’t learned about every other part of the body and disease etc but is really experienced in this one specialist area actually doesn’t seem too mental to me.

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.

Last night I met a friend who’s daughter is an FY2.  She’s considering going to GP rather than hospital after this because the work life balance is much more realistic for someone who one day will want to become a mother.  I do think there’s an issue there – where the reason people want to be a GP is for a bit more home life rather than because of the medicine or impact they can have!  I’d say that’s got to be as big an issue in surgery or other disciplines as for primary care – if your best* (female) doctors are opting out of some fields because 8 yrs of hell to maybe make it to a level where you can start to negotiate your hours isn’t a great position.

*I’ve no idea if she is any good at doctoring or not;

Speaking to an ambulance driver the other week.

No such thing.

The NHS is a mess, it needs reformed it will cost billions and take decades. PFI needs scrapped, purchasing should be on an open market and they need to save costs by wastage prescriptions amongst meany other things.

I’m very glad to be out if it and hope it does improve.

Can the UK afford private healthcare?

Wages would need to increase.

A move to a full insurance model would see a significant reduction in income tax. Just checked my last available tax summary and over £5k of my income tax was spent on health. That’s significantly more than my private health insurance premium

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

US system is completely unique. It simply cannot be used as a barometer of example of how private health insurance works. In short it’s a basket case of a system. Typical deductible in the UK (and most other countries) is £100-£200 but often zero

(Source: me, who’s spent their entire career pricing private health insurance)

Having spent way too much time in hospitals and GP surgeries recently, I think one thing that would make a massive difference would be if every single person dealing with a patient’s care had immediate access to every single piece of information about the patient, their history, and their medications in one place. The amount of times I’ve been asked to provide an NHS person with some piece of information or re-tell a history or tell them what drugs someone is taking is phenomenal. It’s an incredible waste of time, and has led to serious things being missed.

One system. One record. All information. No ability for a patient to ‘opt out’.

Oh, and put in place some sort of mechanism for a patient to be able to send medics information that doesn’t required booking another appointment. I can understand not publishing email addresses or direct phone numbers, but there should be an easy way you can add information you find out to your record so it can be viewed by treating medics without having to book an appointment.

Get rid of the layers and layers of managers who contribute nothing  but cost large amounts of money.

Get rid of the layers and layers of managers who contribute nothing but cost large amounts of money.

And make clinical staff treat patients and do all the management stuff too?

One system. One record. All information.

There are many projects underway to get things linked together better. But you would not believe (you probably would actually) the number of systems that need joining up. It’s a total mess.

I’ve been involved in a local project to replace a particular system which hit major problems due to a constrictive time frame and a poor chosen product. The project should’ve started years and years ago and had a three year or so time frame, but the over arching trusts screwed the procurement and obfuscated time and again and we ended up trying to spanner it in in a year.

NHS England tried to prevent us going back to a different (better) supplier as an emergency recovery plan because they want to see competition in the market and don’t want this particular company to have the greater market share.

The whole debacle has wasted a few million, should never have happened like this.

In the meantime, I went to work last weekend and had to work in a room that was 31 degrees all day because the air con unit has been broken for about 3 months. They wouldn’t replace it because there’s no money (it had actually been done this week finally, although it’s not “plugged in” yet because we need a different contractor to come and sort the wiring.)

 which professionals in secondary care do you think are the problem for inefficiently soaking up all the cash?  Physios, Pharmacists, Nurse Practitioners, Dieticians – I’ve had contact with all of them in secondary care and couldn’t imagine a hospital doctor doing that bit of the care anywhere near as well?

All of them are great in their specific roles. They also tend to get good patient satisfaction, but see also my comments about patient satisfaction being an unreliable indicator of quality.

However when they replace doctor lead clinics in extended roles our experience in General Practice is that they tend to be less productive because they are limited in what they can practice, and anything that is outside their remit they need to refer on which is costly and unproductive. Unfortunately we are starting to see the same thing in specialist hospital doctors too.

More and more we’re seeing patients being bounced back and forward between various specialist clinics in secondary care, without anyone taking clinical ownership of the patient, which is both unproductive and disastrous for the patients.

BUT the concept that some parts of doctors work are either so simple (admin) that they don’t need a doctor, or could be just as well performed by someone who hasn’t learned about every other part of the body and disease etc but is really experienced in this one specialist area actually doesn’t seem too mental to me.

Please see my comments about the ways that GPs add value being through continuity of care (good evidence base), and clinical acumen (anecdotal from my own experience, some evidence to support).

The idea that you can somehow hive off the simpler parts of being a GP, is, I think, one of the biggest mistakes that we are making.

You may argue that I would say that, wouldn’t I, but as far as I’m aware there is good evidence that reasonable access to well resourced primary care doctors is expensive but overall very good value for the system for the above reasons.

@bensales what you’re actually talking about there is continuity of care.

Yes I agree that it’s important, see my previous answers. However I don’t think that the one healthcare record is the answer, already GP records are starting to become so unwieldy that they are bordering on unusable. Better design may solve that, but you still have the problem of categorising the information that is put in there, and who is clinically responsible for acting on it.

Again I suspect that it probably would be cheaper and more effective to have a well resourced GP who knows you well who could write a relevant referral letter for other sevices.

Get rid of the layers and layers of managers who contribute nothing  but cost large amounts of money.

I believe that the evidence is that, if anything, the NHS overall is undermanaged, not overmanaged.

Again I suspect that the reason that GPs are/were so cost effective was that a small to medium sized GP surgery is a very efficient and agile unit of organisation, at least until we started to be micromanaged.

my one contribution is to fund studying medicine free, or heavily subsidised.  Studying medicine is ruinously expensive, and therefore junior doctors expect a large salary

provide the opportunity to many more to study medicine, rather than just those who are from money or willing to take on a huge debt.  Increasing the number qualifying will reduce pressure in the system

more qualified doctors makes the skillset less unique, and with less debt the pressure to pay more is reduced.

stop paying doctors ever more money whilst keeping the system shit.  All it does is enable them to retire earlier or go part time.  You need to sort out the conditions so it isn’t shit, before you pay more money.  Increasing the number of junior doctors is one of the pieces in the puzzle

* I seriously considered studying medicine, I had the grades, I didn’t because I was a self funding student and I couldn’t / wouldn’t take on that level of debt, so I went into IT…..

Just checked my last available tax summary and over £5k of my income tax was spent on health.

As I don’t pay £5k in tax, thank you for paying for the care that keeps me able to work, rather than forcing me to break into your garage and nick your bikes to feed my family.

Consequences, not cost, as someone said on the first page.

A move to a full insurance model would see a significant reduction in income tax. Just checked my last available tax summary and over £5k of my income tax was spent on health. That’s significantly more than my private health insurance premium

Does your premium cover all aspects of healthcare, with nothing taken up by the NHS? Is there an A&E department etc? Genuine question.

Also how would you go about getting cover with pre existing medical issues, say cancer or a heart condition?

I’ve used French private healthcare a couple of times and was surprised how reasonable the costs were.

Get rid of the layers and layers of managers who contribute nothing  but cost large amounts of money.

Much as I admire my clinical colleagues, many of them make for terrible managers of both people and money. They haven’t trained for it, and don’t really want to do it, often don’t understand it, and it takes them away from the job they’re really good at.

Again I suspect that the reason that GPs are/were so cost effective was that a small to medium sized GP surgery is a very efficient and agile unit of organisation, at least until we started to be micromanaged.

Interesting. When I first started attending my GP practice some 40 odd years go there was two full time GPs with no other staff whatsoever. If the phone rang during a consultation one would answer it and if it was an issue which required his partner to deal with he would bang on the partition wall for the other one to pick up.

Now I have lost count how many part-time GPs there are at my practice and it would appear an even greater number of receptionists, plus nurses and physiotherapists.

Mind you we never had the multitude of blood tests, urine tests, scans, etc. and of course we were expected to die younger. Kids today, eh? ……they don’t know they were born.

What goods an unprotected 10 year plan when your stay in power is only protected for 4 years?

Well if the electorate perceive you are doing a decent job you can get multiple terms. Look how long that last shower of shite got.

Buy yes, it is an issue. There is a lack of long term planning in UK politics.

Does your premium cover all aspects of healthcare, with nothing taken up by the NHS? Is there an A&E department etc? Genuine question.

Not on a typical UK PMI plan. That doesn’t cover chronic, routine maternity and some other key benefits. If it did, it would still be significantly less than my tax contribution

Also how would you go about getting cover with pre existing medical issues, say cancer or a heart condition?

Pre-existing conditions won’t be covered under an individual policy. They typically are on a group policy unless it’s a very small group. For a definition of “group” think about employers buying health insurance for their employees.

However in simple terms, you can’t  directly compare the existing UK private health insurance market with what a move to an insured setup would look like in the UK.

However as has been mentioned previously, other countries that aren’t the US run perfectly adequate private insurance systems instead of state funded healthcare. The costs are regulated and controlled by the state. The poorest in society still have access to free care For the record, I would not advocate the UK scrapping the NHS and moving to an insured model. Mainly because I have no faith we wouldn’t go down the US route.

I would also highlight that there’s considerable confusion over what the term “private” means and I’ve seen it crop up a few times already in this thread

A) there’s private health insurance

B) there’s private providers of healthcare services, either frontline clinical stuff or behind the scenes management, logistics etc

B is the one you all need to be worried about

@ernielynch I think organisations that get above a size where everyone in the organisation knows the name of everyone else become inherently more complicated to manage.

The problem with the US system of healthcare is that inordinate amounts of ineffective work is done.

Which is the way we seem to be going in the UK.

They haven’t trained for it, and don’t really want to do it, often don’t understand it, and it takes them away from the job they’re really good at.

I went through numerous training courses for management the posts I held, including regular refresher courses. My experience and clinical knowledge meant I fully understood the roles of staff and what they were expected to do as I had done the job. Those that were management from outside others areas didn’t always understand or took a long time to learn.

@Kramer – thanks for answering about where you see the innefficiencies.  I know a consultant onchology pharmacists who would probably argue those issues are better now than before he lead clinics… but actually thats probably because hes a stubborn arse who works “around” the system than following it… he’s also very heavily networked within the hospital with people who’s ass he’s saved from errors or drugs shortages at 4am – one issue may be that people who haven’t had that “circulation” don’t know how/where to get stuff done.  Like ernie – I remember when your GP not only knew you but knew the whole familty and you did get continuity of care.   That’s long gone now.  its funny the forms you get from the school etc – still expect you to put the name of your doctor in – I’ve never seen the same person twice (not that I am a regular attendee but it turned out I’d been putting in a name for my Daughter’s GP who retired before she was born!).

I believe that the evidence is that, if anything, the NHS overall is undermanaged, not overmanaged.

100% – if you believe we have layers of beaurocracy and admin then look at any other country’s healthcare system it will be worse.  It might be more efficient because of it, but there will be managers and paper pushers.

Again I suspect that the reason that GPs are/were so cost effective was that a small to medium sized GP surgery is a very efficient and agile unit of organisation, at least until we started to be micromanaged.

And probably because GPs of old were doing a lot of shit out of the goodness of their hearts!   My Uncle was a GP and his wife was expected to be at home when he was on call to answer the phone to patients whilst he was out visiting others – can you imagine that now!

my one contribution is to fund studying medicine free, or heavily subsidised.  Studying medicine is ruinously expensive, and therefore junior doctors expect a large salary

It amazes me that we don’t have bursaries for all the jobs society needs and underpays – not just Dr’s but nurses, teachers etc.  Or a scheme where whilst working essentially for the govt your student debt is paid off for you (effectively that is a pay rise but wrapped up in a particular way)

Increasing the number qualifying will reduce pressure in the system

Not a great idea to train more doctors than we have jobs for.   They’ll just leave the country.

more qualified doctors makes the skillset less unique, and with less debt the pressure to pay more is reduced.

that assumes training to be a Dr is just a spell at uni – its probably about 10 yrs from leaving school before you are doing anything useful!

stop paying doctors ever more money whilst keeping the system shit.  All it does is enable them to retire earlier or go part time.  You need to sort out the conditions so it isn’t shit, before you pay more money.

Mmm… says someone who went into IT for better rewards!

The problem with the US system of healthcare is that inordinate amounts of ineffective work is done.

Which is the way we seem to be going in the UK

One of many problems with the US system, but the issue you’re referring to is the tendency to over prescribe treatments, tests, medications etc in the US.

2 main reasons for that

1) US medical providers are terrified of being sued, so will go way over the top to avoid accusations of misdiagnosis, mis treatment etc

2) Those providers are  typically working in for profit hospitals, clinics etc (see point B in my previous post) and are tasked with maximising their employers profits

For all the US insurers get vilified, they’re the only ones keeping the medical providers and pharma companies in line. If they didn’t, the US  healthcare costs would be even higher than they already are

As Jeremy Hunt himself said, the problem isn’t getting enough doctors becoming GPs, it’s retaining them. At the same time we’re losing some to retirement, but an awful lot of them don’t even become established GPs. Money is an issue, especially when you’re competing for highly intelligent, highly motivated people who are likely to become doctors.

From my point of a view of as a GP, we’ve had ~ 15years of money being taken away from us to give to hospitals and secondary care, they’re doing less and less, we’re doing more and more, including their workload for them, and they’ve just been given a 20% payrise vs my 6%, which, despite Mr Streeting’s protestations, I’ve yet to see a penny of.

I had a rather large crash in Spain last year, went to A and E and saw a doctor then a consultant then a scan then back to the doctor all in 4 hours. I was advised to have a follow up back in UK and had to wait 5/6 weeks for a scan here.

Is that Spain charging the NHS so going all out on treatment or just more efficient?  I only had to show my EU healthcard.

I have lost count how many part-time GPs there are at my practice

I’m part time. I’d love for it to be viable to be full time, because I genuinely love my job. I’m passionate about it (as people can probably tell) and it’s generally a lot of fun and very rewarding.

But it’s not viable to do more than four days a week, and even that’s pushing it, because the workload is so intense.

20 years” frontline” NHS service tells me that whilst there are highly qualified and motivated staff in the NHS there are also a large number that are over promoted, under trained and  under resourced

Today I have witnessed Physicians associates running entire CWT clinics with no direct medical cover which led to deffered invesgations and repeat visits. The root cause being poor admin and booking of clinics as a result of insufficient admin cover and lack of medical time to triage.

It is these domino effects that are so prevalent in secondary care that lead to huge inefficiency and waste.

Delayed investigations or inappropriate falsely reassuring tests because of lack of access to high value diagnostics and expertise is a daily frustration meaning patients languish on wards adding to the spiral of cancellations and delays.

The problem with the US system of healthcare is that inordinate amounts of ineffective work is done.

That’s what my (recently retired) GP would say about the German model. Many years ago he explained to me that low blood was generally not seen as a condition which needed to receive treatment in the UK.

Apparently treatment for low BP was seen as an unnecessary and simply an extra cost to the NHS. However he explained that in Germany low BP was treated because the treatment generated profit for someone within the German model.

I know absolutely nothing nothing at all about how healthcare is provided in Germany, nor whether this discrepancy in low BP treatment still exists, but I did trust my GP. I was gutted when he retired about three months ago.

the problem isn’t getting enough doctors becoming GPs, it’s retaining them. At the same time we’re losing some to retirement, but an awful lot of them don’t even become established GPs. Money is an issue, especially when you’re competing for highly intelligent, highly motivated people who are likely to become doctors.

where do they go?  I don’t think I’ve ever come across an “ex GP” in the outside world.

Some of them are exceptional, and equally some are absolutely useless

Are you a spy in my dept?

We are taking in lots of work from private clinics, presumably to “sort out the NHS waiting list for treatment” but ironically those specimens just end up in the backlog with the NHS specimens.

The backlog in my lab is caused by lack of staff, out of 30 people we have 7 vacancies, 2 off long term sick and 3 new starters, training takes up to 12 months to be up to speed.

Management have delayed recruitment to save on the wages a new starter would receive!

Staff retention is chronically poor as the career progression is so poor. The last 3 people we’ve trained have left for private sector as soon as the qualified

where do they go?  I don’t think I’ve ever come across an “ex GP” in the outside world

Abroad, retrain in other professions, consultancy, reduction in hours, private sector etc.

And why would they tell you, do you get the full CV of everyone you interact with?

On the news they’re currently talking about how people could help themselves by eating more healthily, exercising and the like.

.

So on that note they should be leading from the front.

A look at Parliaments members dining room menus and it doesnt look that super healthy to me. So it should be out with the steak and chips, and in with fish and salads.

Their extensive wine list could be replaced with water and a selection of fruit juices

On the news they’re currently talking about how people could help themselves by eating more healthily, exercising and the like.

Ah yes, the old personal responsibility bull$hit.

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

I get what you mean but seeing as obesity will be one of the biggest drains in the near future one could look at the US and wonder why anyone is obese considering they pay for health care.

Of course if they weren’t obese the health care industry wouldn’t get paid. How do you privatise an industry and it still be in the interests of the general population when their profits come from treatment not prevention?

A move to a full insurance model would see a significant reduction in income tax.

Really?

Ah yes, the old personal responsibility bull$hit.

We do eat badly in this country. Drink alot. Don’t exercise enough etc etc

Really?

Yes, but offset by whatever premiums people had to now pay.

Of course, the unknown is whether or not the government actually would reduce everyone’s tax by the amount currently allocated to health costs, but if they did then yes everyone’s tax should reduce.

My instincts tell me any UK government would palm the NHS off to the private sector and not reduce the tax take…

Ah yes, the old personal responsibility bull$hit.

How on earth is it bullshit?