How are we to solve the problems in the NHS? Some thoughts…

One cannot pick up a newspaper or access the news media these days (and particularly during the winter months) without reading another NHS scarestory, in particular concerning the ever lengthening waiting times for accessing either your GP or seeing a Consultant in your local Hospital.

After 13 years as an NHS Consultant ENT Surgeon, with experience of both the NHS and private sector, I continue to be exasperated by the lack of clear thinking moving forwards!

The truth of the matter on the front line in the NHS is to me a simple one. There is exponentially rising demand for existing services, with new and potentially exciting new developments coming on stream in a system that is just about managing to maintain it’s existing funding allocation, let alone increase it to match these changes. Politicians and NHS managers pay lip service to the fact that changes in both funding and personnel are taking place to match this demand, but it is my view that as long as the present NHS delivery system continues as it is there will never be enough capacity or funding to match demand. Year on year ‘efficiency savings’ are being forced on services already cut to the bone. That generally means cuts to existing services if the truth was known.

In addition to this, the medical workforce has changed enormously since when I came through Medical School. More than half of all medical graduates are now women, and while this is an excellent development, it does mean that at least half of your future medical workforce will usually want to have children at some stage and if and when they return to the workplace may want to work part-time.

Junior Doctors have grown up in a training system where their hours are closely adhered to and they are used to having a life ‘outside medicine’ as opposed to the silly hours and constant in-hospital presence required when I was a junior. When they are appointed as a Consultant or GP they will want to continue within this pattern of working, and this has had an effect on the amount of time a Doctor is physically at work. The constant pressure on these junior doctors and recent unhelpful Contract dispute with the Government (i.e paycut to you and me) has left a bitter taste in their mouths and many have voted with their feet and left the UK altogether to work abroad or moved into more lucrative areas in business. These are, after all, the intellectual elite of our young people, and the NHS discards them at it’s peril.

In recent years being able to access ‘healthcare’ within the NHS within a certain timeframe has become gospel and is now even written into the NHS Constitution. It is worth remembering, however, that these timeframes were introduced not from well researched and investigated methodology, but for political ends by Tony Blair’s Government. At that time, as I remember, the average waiting time from referral to surgery was 18 months, and he set out to reduce it to 18 weeks as a great political soundbite. Admittedly, he did arrange for an increasing percentage of GDP to be assigned to the NHS, but neither Medicine or the UK population stands still, and the funding in place 10 years or so no longer matches the demographic of our population or the treatment costs.

Mature and non-political debate has to take place as to how the NHS in the 21^st Century evolves. As long as there is a ‘Health Secretary’ and the NHS continues to be a political football to be kicked about and argued about on ideological grounds then the cracks will continue to be papered over, fire fighting will continue to be the norm and we will continue to stumble from one winter crisis to the next. Healthcare needs to be taken out of the political debate, cross-party representation established (with extensive clinical input) and any decisions made on realistic clinical and business grounds without Politicians fearing being voted out of office if they instigate change brought about by this consensus view.

I believe the NHS has to change radically in both thinking and thus delivery to continue to offer high-quality healthcare moving forwards. The general public needs to understand what the service can offer (and more importantly what it cannot), and realise that it cannot pay for everything as it does not have a bottomless pit of money. Above all people need to realise that it is not ‘free at the point of delivery’ (a particularly unhelpful slogan) but ‘very expensive, but funded by general taxation at the point of access’!

Cooperation between the private sector and the NHS has to become the norm in the next few years I believe, and the sooner ideological differences to this are forgotten the better. The private sector is the only real place where there is meaningful capacity to offer the NHS and as soon as agreement is reached on tariffs that will allow both parties to be satisfied then the sooner this can commence. Of course private hospitals are businesses and will need to be allowed to have a margin to make a small profit, but I believe the numbers of patients that could be transferred into this sector and the efficiency inherent in the DNA of the private sector hospitals will allow both parties to be satisfied, and most important of all a great outcome to be achieved for Patients. Such systems work perfectly well in countries such as Australia, and there is no reason why we cannot research and potentially improve upon these systems from their experience.

There are, of course caveats to this. Private hospitals can never offer the breadth of care and multidisciplinary nature of all the teams immediately available in the NHS. The problem this presents as things stand is that the tariff a hospital receives for the straightforward patient with no long term illnesses or problems and who sails through Hospital as a day case without complications is the same as those with many intercurrent medical problems and whose care is complex. These patients may require inputs from several different clinical teams, and involve a prolonged hospital stay, and therefore be considerably more expensive to treat.. It is obvious who then is the ideal patient for private providers, as the former group of patients cost the least, and thus give the greatest scope for profit. It is these patients who private providers have ‘cherry picked’ within the healthcare system up to now.

This is understandable and has to be acknowledged if we are to move forwards without rancour between involved parties keen for improvement and those with more deep seated ideological objections to such change who will continue to cry foul.

What does the NHS do best? Cancer, Trauma and Emergency care, Paediatrics, Obstetrics, Intensive Care and Long Term Conditions (and Medical conditions in general) would be top of my list, and these are the areas that the NHS should be allowed to concentrate on and be excellent at. In the real world we exist in at the moment (and which is increasingly becoming the ‘norm’ for an increasing amount of the year rather than just the winter months) this is what the NHS understandably concentrates on in times of high demand in any case. The rest of services are stopped as there is no capacity, beds or otherwise, for the hospitals to carry out more elective work during these periods of heaviest demand., and this happens predictably year after year!

The situation in Primary Care (i.e your General Practitioner (GP)) is even more stark. A GP is paid £146 per patient per year, regardless of the potential complexity of their medical problems. If a patient is completely well and never goes to the GP, the GP is paid the same as a patient who is in the Practice weekly with multiple problems costing a huge amount to finance.

It is my view that the care of the more ‘challenging’ group of patients is what the NHS SHOULD be concentrating, and which it does so well. It should be remunerated accordingly for it. If the more straightforward patients are moved to the private hospitals, where their care can be streamlined and delivered with maximum efficiency and with optimal outcomes then everybody wins.

The problem is with the funding arrangements as things stand is that the more complex patient’s increased costs are subsidised by the more straightforward group’s ability to make profit for the provider, NHS or otherwise.

Speaking from an entirely clinical perspective, if I have patients (or friends and relatives) with intercurrent illnesses and potentially complicated surgery I would generally advise them to have it done in the NHS. Therefore, for the best outcome for patients (which, after all, is the goal all of us Doctors are trying to achieve) a balance must be reached in the financing of patient care so that enough funding is given to care for more complex patients, while allowing the more straightforward patients to be outsourced to an ‘alternative provider’ without threatening the future viability of either.

With the principle of state funded healthcare being maintained if this principle of plurality of healthcare provider was sanctioned and accepted, I fail to see why both politicians and the general public throw up their arms and refuse to implement it purely on idealogical grounds!?

As an adjunct to this, I feel people should be encouraged to take out Private Health Insurance (PHI) if they have the means to do so. Tax breaks should encourage this (as they used to when I was growing up.) If more people took out PHI, it would become cheaper for more people to use it, and this would have the additional bonus of freeing up more space in the NHS for those who cannot. A no-brainer in my view.

How to introduce these more deep seated and fundamental changes to the way healthcare is delivered in the UK (whilst maintaining the principle of state funding at the point of access when required in appropriate circumstances) is the kind of mature non-political debate we should be having. At the moment, any changes of this sort promotes outcry of ‘privatisation’ from those with idealogical disagreements to the private sector in all walks of life. No politician is going to commit political suicide by pushing this agenda forward when there is such widespread ideological opposition to change of this nature. As long as this blinkered approach continues, the ever-widening cracks in the NHS will continue to be papered over and it will continue to wither on the vine.

The NHS really is not any longer ‘the envy of the world’, but I believe it could be so in the future if such radical steps are taken to modernise, improve and thus protect the way it’s care is delivered.

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