The NHS at 60: It’s great…BUT

It’s the 60th anniversary of the great institution we both love to love and love to hate. Dr Rant couldn’t resist a birthday card to the dear old NHS. So here it is:

The NHS is great because it provides care free at the point of need, to the whole population of the country. All health systems have to be paid for somehow, and paying tax is as good or bad as paying an insurance premium.

The NHS is great because it takes monetary considerations away from the immediacy of the doctor-patient consultation…but this is bad as it simply makes rationing covert.

But once we have stated the good in the NHS we need to acknowledge the significant downsides of the NHS.



1. The NHS is such a good system that no other advanced industrial economy has one.

In the old days we were taught to see the irony in “They’re all out of step except my little Johnnie!” It seems we have a blind spot about the merits of American and European systems. Must be the great education we all get under Commissar Balls-Up.


2. The NHS has no co-payments. It just prefers people to die!


3. The NHS results in terms of successful treatment of serious illnesses are less good than those of our European neighbours.
Somehow our system isn’t getting the sickest patients the best treatment. Somehow the Europeans and Americans have got things better organised than we have. We still have much mortality amenable to healthcare.


4. Despite the NHS, health inequalities in the UK are worse than in past generations.

This is not a failing of the NHS itself- Medical treatment only patches up the casualties of the battle, it doesn’t stop the battle going on. In this battle health is more or less an outcome of education and wealth, and ill health a consequence of poor education, poor housing, and lack of money. The failure of Government policies to do anything about this is well illustrated by the health statistics from Glasgow East. The role of the NHS in keeping unemployment down by classifying everyone as incapacitated is also well shown there.


5. The NHS treats everyone…eventually

The NHS works as a sausage machine production line. We treat everyone, but the service to patients is far from great. Consultations are rushed, and we regularly order tests to get people out of the door. The NHS is becoming ever more efficient at throughput measurement, but is steadily destroying the therapeutic alliance (a relationship of respect, listening and trust going both ways) between doctor and patient. The NHS prattles a good deal about “ patient centeredness” but this is simply becoming a term of rampant consumerism. “ I pay my taxes, and you Dr are my servant and must do what I say” Most of the people who praise patient centeredness see very few patients. We see the idiocy that those people, who can actually do the work and see patients, are accused of not being patient centred…by twaterati who will do anything else other than see patients!


6. Access and convenience

These are far from great. People like NIKU would have you believe that doctors make patients wait for the fun of it. Actually we don’t. We’d actually prefer to run to time. When doctors are running late it’s actually not because we are having a cosy chat with our favourite nurse over coffee whilst leaving 40 patients fuming in the waiting room. The NHS has never been run to the convenience of doctors.

Doctors in primary and secondary care are usually attempting to do too many things too quickly, as routine. Then extras are added in.

And the NHS superstructure is so efficient that getting patient, doctor, notes, and results together in one place is far from guaranteed. So more delays, and more waiting, and time wasting for both doctor and patient. Fortunately most patients are tolerant…and sometimes I have been grateful to patients for reducing my frustration. They have maybe done more for me than I can for them some days.

And patients often want and need more than the allotted time. So we overrun, and get delayed, and so frustrated. Forgive us that we get rushed, frustrated, fed up, and sometimes this shows. We sometimes use arrogance to shut people up. It’s not actually that we are uncaring. It’s that we are using our defence mechanisms to prevent ourselves from being overwhelmed. Ultimately there are more symptoms in the world than we can ever hope to properly deal with.

The NHS arrangements for bringing doctors and patients together are time poor, awkward and militate against good medicine. They prevent the development of relationships, and of mutual understanding and learning between doctor and patient. The fact doctors still get on well with most patients despite the handicaps the NHS generates is a tribute to resilience and good sense of doctors and patients.

Even so the obvious problems here are:

• Poor communication
• Poor understanding
• Poor compliance or concordance with treatment plans
• Risk of complaints and litigation over “failure to explain risks fully”
• Excessive testing
• Loss of follow up
• Patients not knowing whether they are coming or going
• Important results going unacted upon
• Collusion of anonymity- the buck is passed between several people but never actually stops anywhere.
• Much rushing, too little listening.

These can be observed any day in primary and secondary care settings. They cost the NHS a lot of money, and they show the system not making care of the patient its first concern.


Managers only care about throughput figures (18 week target etc) The Darzi report on raising quality may help a bit…but it still does not get into the basic clinic or surgery environment and look at what needs to improve to enable better doctor-patient communication. It’s sad, as improving this would significantly reduce the need for tests and investigations, whilst increasing patient satisfaction. But tests are cheap, and doctors are clearly obstructive, overpaid skivers as any fule such as Ben “Fotherington Thomas” Bradshaw kno.


7. Comprehensive coverage

The NHS provides great comprehensive coverage unless:-

• It’s a dental problem.
• It’s dementia: your needs are social and not medical you see, and be a good taxpayer and sell your house to fund your nursing home bill.
• Fertility- we’ll pay for contraception and abortion…but we don’t to create new babies.
• It’s a new cancer drug.
• You need rehab rather than curative treatments.
• You need adaptations to your house.
• You don’t want to wait.
• You have a mental health problem.
• You want a permanent and recognisable psychiatrist.

Yes the NHS is a very comprehensive service…that over time has comprehensively and covertly reclassified problems so that they are not medical any more but social…and so come out of a different budget.


8. High quality service

Except that:-

• It ignores foreign comparisons.
• It actively manages against its staff achieving this.
• It sets targets for quantity not quality, and refuses to admit that there is a trade off to be made here.
• The criteria for high quality are poorly defined.
• Pretends that “excellence comes as standard” which, as any fule (except Alan Johnson, Ed Balls, Darzi, Bradshaw and Donaldson) kno, is an oxymoron.
• Pretends that guideline implementation and measurement and compliance is an assurance of quality.
• Dreams that a computer (or nurse drone) could replace a thinking human being.
• Believes that rationing is merely a technical issue rather than a moral issue.
• NHS direct still exists (see below).
  

NHS Direct: A bit shit and not cheap

9 A cheaper pooled service

“The NHS used to be underfunded and inefficient. Now it is only one of these”

Nigel Hawkes' succinct summary captures this well.

The NHS is now expensive, ineffective and inefficient. It has squandered a fortune on a useless computer system, botched management reorganisations, increase internal transaction costs, management, and management consultants.

Yes the whole of the NHS funding increase has pretty well been wasted entirely. Gordon Brown had no idea what he was buying from the NHS and it shows.

Clinics and surgeries are in poor state, new builds are PFI or LIFT on the never, never and the barbarians of private profiteers are at the gate. The CBI is frothing at the mouth, and Sir Richard may drop by as well…as long as he only treats the young and healthy patients that is. He doesn’t want any of those old so and so with multiple problems- not worth the capitation fee you know. Not a viable business proposition to anyone.

So there we have it. We love our NHS but it is failing to deliver on:-

• Finance
• Cost control
• Clinical effectiveness
• Accessibility
• Computing and record keeping
• Quality
• Comprehensive coverage
• Relationship based care to patients
• Staff satisfaction

It is delivering on:-

• Corporate bullshit
• Redisorganisations
• Meaningless waffle
• Meaningless meetings
• Visions into vapour
• Squandering money
• Laying up future debts under PFI
• Paying more heed to management consultants than medical consultants
• Staff disengagement
• Bureaucratic processes
• Increasing negligence bills

Happy Sixtieth Birthday NHS!