It cannot have escaped your notice that all is not well with the NHS. I would go further and say that it is in a period of deterioration that could lead to collapse and calls for it to be abandoned and replaced by some other funding model.
Many have used the term
crisis to describe this situation. The word is a Latin one, used first in medieval times in Britain to describe a turning point in a disease, originally derived from the Greek for decision. My mother, a nurse in the days before antibiotics, told me of her role looking after patients with pneumonia. She watched the temperature rise and she cooled the patients by tepid sponging, until after several days they reached crisis; they either died or the temperature fell and they started to feel well again. This was the original use of the word – the pneumonic crisis – and it persisted until penicillin enabled cure.
Over the 76 years of the NHS, there have been three critical developments. First, the population has grown, its average age has risen, and with it the burden of chronic degenerative illness and disability, obesity and diabetes has increased. Second, relatively recently a large underclass characterised by poverty, often poor education and diet, and a temptation to adopt unhealthy habits, has developed. Third, medical and surgical practice and our ability to manage and prevent previously fatal and disabling conditions have improved dramatically.
In order to achieve this, expensive diagnostic and therapeutic methods have been added to the repertoire of the medical and surgical teams. Think of the multi-million-pound scanners and the expensive cardiac interventions and anti-cancer regimens now commonly deployed, and of the numbers of doctors and other staff required to operate them. Hence, an ever-increasing workload on staff and increased costs. The standard medical staffing of a hospital of a few general physicians, surgeons, paediatricians and anaesthetists has been replaced by specialists in every organ of the body. As medical knowledge and capability expand, so does this requirement for more staff, to the potential benefit of us patients.
Last week, I pointed to the obvious causes of the current crisis in the NHS, the bottlenecks that prevent us getting the care we need at the times we need it. All are related to deliberate political avoidance of adequate funding and false economies in the name of efficiency since 2010. This is true of all four countries despite the variety of political regimes. I concluded that staffing was at the core of it and that a systematic approach was needed to address the long-term problems. Those problems start at both general practice, once the keepers of the gate into hospital, and also at social care, a function that has always been the poor relation but now is at crisis point, obstructing the gate out of hospital.
The consequence is overload of the acute hospital sector, especially accident and emergency, which is there to deal with seriously ill or injured people who cannot be looked after at home, and to provide efficient diagnostic and treatment advice to general practitioners. The acute sector in times of crisis requires more staff to work more hours.
Pay rises
I do not believe that pay is the most important long-term issue, though it is related to the most important: workplace stress. Most NHS staff are paid at rates that compare well with those of other workers in the public sector, though these rates at the lower end now barely allow for the current inflated housing and energy costs and certainly need improving.
To use workplace stress as an argument for higher pay is a step in the wrong direction as it diverts attention from the need to reduce the stress. It is analogous to the danger money that was at one time widely paid to manual labourers to avoid necessary expenditure on safety. But public service pay must be sufficient to retain the enthusiastic services of the workers in their vocations, and management should ensure that their efforts are seen to be directed at ensuring a contented and productive workforce. Efficiency relates to this – it drops off both with too much and too little stress; the key for managers is to strike the right balance.
As I have pointed out previously, pay settlements on a percentage basis related to GDP or inflation make the worst off even poorer in relation to cost of living. Lump sum increases across the whole workforce are an intelligent alternative, reducing the income gap. As a junior doctor on £650 per annum, a £130 increase would have made a huge difference to me in 1962 but would have been pocket money for consultants on £5,000.
With inflation at the time around 20%, a percentage rise across the board would have been unaffordable and unnecessary. Unions always stress the need of the poorest, rightly, but sometimes seem to miss this point. Inflation hits the poorest hardest.
Solutions from within
One thing that has impressed me in the NHS is the way in which solutions arise from the frontline staff themselves rather than from managers; often bureaucratic obstructions are put in the way of innovative suggestions. I can give many examples of this, including some small personal initiatives such as setting up a regional asthma service that allowed patients quick access to hospital advice and treatment.
Over the same period, much minor surgery and major investigation has been moved from in-patient to out-patient, saving waits for hospital beds, but the most impressive recent example has been the response to the Covid-19 emergency, which owed everything to the quick actions of doctors in the frontline, while politicians and managers panicked. The discovery of effective Covid-19 treatment and management was another successful initiative by medical staff.
From their vocation, doctors and nurses want to do as much as possible for their patients, and this includes improving service provision. This role of medical and other staff is I think under-appreciated but the public may be assured that staff see improvement of services as central to their role. Some initiatives are worth mentioning – the introduction of services across Scotland to give complex antibiotic treatments to patients in their homes or in out-patient departments rather than keeping them in hospital for weeks, community support for patients with chronic heart and lung disease otherwise requiring hospitalisation for treatment, and 'hospital at home', where complex care, particularly for older patients, is carried out in people's homes by special hospital teams supported by remote monitoring.
The general practice bottleneck
Many of you will agree with me that something is seriously wrong with general practice. For much of my career, a GP was available, like hospitals, at all hours and every day. Practices had rotas for nights and weekends or arranged these with other local practices. House calls were commonplace and GPs knew their patients, so avoiding many unnecessary admissions to hospital. GPs also sometimes carried out minor surgical procedures. As hospital junior doctors, when we were on call, GPs would ring and seek advice on or admission of their patients directly or via an admission service.
All this has gone and so, I suspect, has much of the satisfaction of the job. Now, telephone and video consultations are becoming more frequent and with them the loss of personal observation that is so important a part of the clinical consultation. Of course, medicine has got more complex, and more work is done by GPs in long-term care of chronic disease. This is exacerbated by long waiting lists to get necessary investigations and advice from hospital, causing a vicious circle of delay.
For the future NHS, a critical review of the role of GPs will be essential – the job must be attractive to newly qualified doctors and to those who need to combine it with bringing up their children. But its role as a gatekeeper, ensuring that only those who really need it go to hospital or the emergency department, has largely disappeared and the pressure point has moved to the hospital. A critical review might start by asking, what is now the purpose of general practice? Its functions seems to have changed, it is still overloaded, but GPs do not seem to be any happier than they were 40 years ago.
The social care bottleneck
Social care evolved from the Victorian Poor Law and Workhouses, the recognition of the need to look after the poor and disabled of society. It has always been partly separated from the NHS, less so under socialist than conservative governments, but has never attracted as much public or political sympathy as the NHS.
However, an increasing and ageing population is bringing its weaknesses into clear focus. At the low-pay end, it has relied (as did the NHS for many years) on immigrant labour and many of us are profoundly grateful for the care given to our parents and other family by so many kind underpaid people. In times of low unemployment, as currently, such people find less stressful jobs and staffing becomes a critical problem. This is another area where improved pay would make a big difference.
The other long-term issue with social care is its separation from the NHS and the confusion arising from responsibility for its funding from money-starved local authorities for care and the NHS for illness. Old people like me and the long-term disabled remain the same person as we move from general dodderiness to acute illness, back, and then to chronic illness, perhaps dementia, and dependency. We spend time in hospital then can't get out because we can't be looked after at home and there is no longer an adequate rehabilitation service.
Such facilities were available early in my career but largely disappeared in the name of efficiency. Valuable buildings and land were sold and money apparently went to local authorities to defray the cost of social care, but those beds have disappeared. Now NHS money is subsidising the private sector. This is a major failing of the care system and an opportunity for an enlightened government. We need low-cost post-hospital rehabilitation accommodation to bridge the gap back to home or long-term care.
Staffing
These bottlenecks are all big problems and there is no easy solution in the short-term, but staff numbers are clearly insufficient for the demand in both NHS and social care. Moreover, the longer we wait to improve things, the worse they will get, as stresses increase and job satisfaction continues to deteriorate. Better pay, especially at the bottom, is now essential in both NHS and care services and this should attract more staff, in turn reducing stress. It will also discourage staff from moving to the private sector, where conditions are less stressful. More medical, nursing and other clinical staff need to be produced by the universities but this takes time.
In the short-term, I wonder why our UK Government is so keen to imprison or exclude immigrants rather than put them to work. We are short of people and the more we have working, the quicker the useful economy grows.
One really crazy thing could be put right immediately. Pension arrangements for hospital doctors currently incentivise early retiral and this should be changed urgently. At present, if consultants work past the age of 60, their pensions gradually decrease and tax liabilities build up. Thus, the NHS loses its most experienced consultants at a time of greatest need. Many doctors would gladly work much longer, even voluntarily, in a limited role in the NHS after retiring, and this is an opportunity that should also be examined.
I have, during Covid-19 (which is still around, with influenza and RSV and Strep A), pondered the idea of a reserve force of doctors and nurses, like the Territorial Army, available for emergencies.
What needs to be done
First, a two-tier service is not any sort of answer. Since there is a strictly limited number of doctors and nurses, almost all trained in the NHS, diversion of patients to a private provider means that NHS staff will also be diverted to it, to a greater extent than they are now, and will command higher fees. So will those who administer the service and take profit from it, as in the USA, where costs are the highest in the world and public health outcomes are notably inferior. England, where private contractors have taken over significant areas of hospital and general practice under Tory initiatives, is finding this already.
The idea that the private sector saves NHS costs by diverting patients is nonsense – it simply takes the easy work, diverts staff and resources from the mainstream, and takes its profit from the taxpayer directly or through the insurer.
Ideally, the NHS should be comprehensive and treat everyone equally. For most of its history it has done exactly that but equality needs to be qualified by another adverb, well or badly. To cause people to wait in anxiety for diagnosis and treatment is not good. The two reasons that the NHS has survived since 1948 are simple: the public appreciate it and the staff have a sense of vocation. Should either fail, it dies.
Most attempts to reform it have used business models which do not take account of the vocational element that gives a sense of purpose to staff and that allowed us to endure the stress and difficulties of its earlier years. This remains probably the most remarkable thing about the NHS – that individuals on the frontline come up with solutions and these spread through the whole organisation. A new treatment, a better means of rehabilitation, more humane management of the dying; I have seen all these, originally the enthusiasm of an individual, become standard practice first in the NHS then over the world. Rather than some new business idea, the NHS needs to build on this strength, the commitment of staff to serve their patients better, and spread best practice.
To a very large extent, the success of the NHS depends on this altruism, from ward cleaner to matron and consultant, and the approbation of the public; politicians need to reinforce both. Salaries are important but the most important factor in my view is working conditions. Thus, frustration is easily caused by major reorganisations which should be avoided. Public approval is easily reduced by long waits for treatment and influenced by individual horror stories in the press, so it is essential that the voters understand the link between their taxes and the service provided, since we pay for the NHS.
What is necessary urgently is more staff in key places in the hospital service, rapid increase in funding of social services and provision of a post-hospital rehabilitation service, and a review of the service provision in general practice. Whatever system of funding is decided, we will all pay for it. Extra staff can only be produced in the short-term by immigration and better retention of current employees, even after retiring age, while we wait for more new graduates to emerge. I suspect the voters would understand the matter better if we knew exactly which of our taxes pay for health and social care – national insurance sounds like a good name for a new hypothecated tax.
Climate change and the long-term
Behind all this are funding and politics but we now know that the political party in power makes little difference in the UK – all four are failing in the same way. But there is another factor that is not mentioned in this context and will be of overriding importance, our response to climate change.
You will remember the four horsemen that ride together, plague, inequity, warfare and climate change. The effects of climate change are now obvious and are already showing signs of damaging our Western concept of civilisation. This can now be expected to get worse rapidly and will obviously influence all our lives and the role of the health and care system with them. The only thing that will influence this beneficially will be a radical change in our collective lifestyles, especially those of us wealthy enough to have a house and a car and to take holidays abroad.
What we must do is simple to state: reduce our consumption of energy, food and all things that derive from fossil fuel and that have a carbon cost. We have to start to lead lives that derive value from benefiting those around us and the ecology we live in, contributing to the total of human happiness rather than to self-satisfaction and accumulation of wealth. Not easy, but essential if we are to avoid the inevitable alternative of civilisation collapse and anarchy.
You may think I am indulging in hyperbole, but I am not. The progression of climate change is frightening to scientists and to those, now even in the UK, who suffer from climate disasters. The public and politicians must begin to understand this. Its effects hit the poorest hardest and those of us who are not poor need to cut our consumption of everything. In doing this, we will spend less of what we earn – I expect in response to Covid-19 most of you will have started on this path already. If we are to avoid revolution, the era of wealth accumulation is now ending. What shall we do with the money we save? I expect it will be taken up by the need to pay more for the NHS, social care and education. This will end up with us paying for insurance or through taxes and I regard the latter as appropriate and just.
If we want to live in a civilised society, we must expect to pay for the privilege. This is what civilisation implies. We are indeed now in a crisis, a turning point, a time for decision – for all of us. Perhaps Scotland can show the way?
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
