It feels as though we are reaching the end game with the NHS. The Guardian has launched a month-long ‘special’ looking at all aspects of the NHS, and something about the NHS features in the media nearly every day. The official narratives diverge more and more with the publication of each new set of figures. Nine months ago the Kings Fund suggested that the NHS was heading for a financial crisis. Yesterday the Sun reported a 50% shortage in A&E staffing weeks after the Guardian reported that a crisis in children’s mental health care was increasing the pressure on A&E departments. Mental health itself has long been recognised as the Cinderella specialty of medicine, and it is now clear that mental health is seriously underfunded in comparison to physical health. This has been exacerbated by cuts in social care funding and changes to the benefits system that fail to recognise the need to assess mental illness by different criteria to physical illness.
There are so many aspects of the ‘NHS crisis’ that it is difficult to know where to start. Dominic Lawson apparently suggested that the increasing ‘feminisation’ of the NHS was partly responsible for the current crisis (I didn’t give him credibility by reading the whole article – behind a paywall in the Sunday Times) but he has been robustly (and amusingly) rebuffed by both male and female doctors. As one of them said, does he seriously think that women should revert to the Victorian era, deny their intellect, abandon education, and give themselves to the service of men and childbearing (in the course of which they have a good chance of dying)?
Accepting that Lawson’s ideas are ridiculous, it is clear that, whatever the cause, there is serious crisis of funding, staffing and morale in the NHS. I suggest that a major contributor to the latter two issues is the stance of the current government. David Cameron, Jeremy Hunt and Iain Duncan Smith have consistently failed to support the welfare system (which surely includes the NHS). In fact they have shown every intention of dismantling it. Successive Tory politicians have declared an interest in privatising the NHS:
“Back in the 1980s, Conservative MPs Oliver Letwin and John Redwood set out their vision in a think-tank paper with the ultimate aim of introducing universal private health insurance. The policies of the past 30 years have adhered to this vision with remarkable fidelity. The revolving door spins smoothly between the lucrative pastures of private healthcare and the Department of Health and top tiers of NHS management – to give one salient example, NHS chief executive Simon Stevens’ last job was as a UnitedHealth executive. Jeremy Hunt is officially on record as saying that the NHS should be privatised. Back in 2005, Hunt co-authored a book called Direct Democracy, which called for the NHS to be dismantled. David Cameron’s health adviser Nick Seddon, formerly of private healthcare company Circle, suggests that CCGs should be merged with private insurance companies and those who can afford to should contribute to their healthcare.” (Youssef El-Gingihy)
I know myself that working in an NHS that operates on a competitive internal market system, focusing on primarily on finance rather than patient care, is soul destroying for a clinician. Ten years ago I developed a specialised clinic within our chronic pain service that provided weekly psychotherapy for up to one year for patients with highly complex chronic pain problems. This clinic was valued by the hospital trust and by the then PCT, but each felt that the other should fund the service. The predictable outcome was that the service was dropped, and subsequently (after I finally threw in the towel and left) the entire pain service has been downgraded and run mostly by paramedical staff focussing on relatively straightforward problems. The complex patients are presumably still visiting their GPs as frequently as they can (given the difficulty of getting GP appointments now) and living in pain and misery. It goes without saying that all these patients had concurrent mental health problems that were not being addressed.
Psychiatry has difficulty in recruiting, and faces the same problems of job frustration. Patients with mental illnesses perhaps more than any other patients value a continuing therapeutic relationship with a single doctor or healthcare professional. Psychiatrists have seen their therapeutic role downgraded to a managerial role, where a community mental health team (consisting of a variable mix of nurses, occupational therapists, physiotherapists and others) provide most of the clinical care. It may sound arrogant and elitist, but I know that many professional people with mental illnesses want to see a doctor regularly, not a nurse or OT. This is particularly true of the increasing number of doctors who are prepared to acknowledge that they have mental illnesses. Consultant psychiatrists are leaving the NHS to work entirely within the private sector in order to practice the medicine that they were trained for. This cannot be right. Surgeons in the NHS may enjoy the variety of surgery in the private sector, but they can (on the whole) carry out a wide variety of surgical procedures within the NHS.
The current junior doctors’ dispute with the government reflects much of this frustration. Although the dispute is ostensibly over the juniors’ contract (and legally this has to be the cause of the dispute) there is no doubt that the dispute has reached the point of industrial action because of what is happening to the NHS. Junior doctors care about their patients, the vast majority entered medicine because they felt a vocation to do so. With the academic background required for medicine (generally ten A/A* GCSEs and 3-4 A/A* A levels) those wanting highly paid jobs with more sociable hours could have found them elsewhere – and left university with three years of debt rather than five or six. (And of course the increasing number of graduate students entering medicine shoulder even larger financial burdens).
The BMA website clearly outlines the main contractual concerns that the junior doctors have. The unspoken theme running through these is a lack of respect for doctors, for their dedication and willingness to work beyond their contracts when needed, for the length and arduousness of their training (there has been a need to explain to the general public that ‘junior doctor’ can refer to any qualified doctor up to consultant/ GP level, and that these doctors may have ten years of postgraduate training, one or two Royal College fellow/memberships and possibly an MD/ MS/ PhD). There can be a tendency for consultants of my generation (in their fifties and early sixties) to say the age old words “it was harder in our day” – when we worked one in two/ three/ four rotas, when we started a weekend on call at 8am on Friday and finished at 6pm on Monday…. However, these days if a surgical registrar works the weekend she may have to go home at 3am and return to the operating theatre an hour later – there are no on-call rooms to lie down in. The turnover of patients is much faster now as pressure on beds, waiting lists etc pushes patients out more quickly (even if they wish to stay), and I think that medico-legal concerns weigh more heavily on today’s junior doctors than they did on us. I have a daughter-in-law and also a friend who are both ‘senior’ junior doctors, and I think that neither has an easier time than I did at the same stage. The big difference is that I worked in an NHS where I felt respected by the staff with whom I worked, and where innovative medicine and dedication to patient care were paramount.
The big concern for today’s NHS is anxiety about the ‘bottomless pit’ – an ever increasing demand for more and more treatment. When this is combined with an ageing population and progress in medical and pharmaceutical science this may seem a reasonable misgiving. However two huge problems remain unaddressed. Firstly the disconnection between the various parts of the welfare system – the NHS, social care and benefits. Lack of funding for social care is currently contributing significantly to the number of patients who are ‘bed blocking’ – inappropriately stuck in acute hospitals (at enormous financial cost) because there are no suitable places for them to be discharged to. The solution to this is most emphatically not to expect women in their forties and fifties to look after elderly relatives at the same time as bringing up their own families and going out to work. Our society has not addressed the topic of older people. The well-off elderly continue to live in their own homes which they manage to avoid selling in order to pay for high quality nursing homes (if they need them), whilst the poorest older people struggle to heat a single room to live in and to feed themselves, and eventually find themselves at the mercy of dwindling social care budgets for the last years of their lives. The numbers of both groups are increasing. The under 60s today have not (by and large) grown up expecting to have to look after their elderly relatives, nor will they expect their own children to look after them. There is an urgent need for much more innovation in the development of residential communities that integrate independent living with higher levels of care, and that mix accommodation for older people with that for younger families. As usual the Scandinavian countries seem to be well ahead of us in preparing for population and societal changes. Sweden has invested a lot of money in (and legislated for) building new homes that are disability/ old person accessible, and also converting existing properties.
Managing expectation is important, and as a profession medics are as guilty as the media in increasing expectation amongst the general public. As a broad generalisation doctors view death as a failure (with the exception of palliative care doctors) and many seek more and more treatments to prolong life without always considering carefully the quality of the life prolonged. Nowadays people in their 80s have aggressive cancer treatments that would not have been considered twenty years ago. Octogenarians have joint replacements (and re-replacements) and kidney transplants. Increasing numbers of people have major health problems relating to lifestyle and obesity. Diabetes, cardiovascular disease and many cancers are all directly linked with obesity and could therefore be avoided or their healthcare burden minimised if the obesity epidemic was confronted. Poor mental health is a drain on the economy through time lost from work, unemployment, dependence on benefits, and cost to the NHS (mostly in primary care).
At a time when public health doctors are needed more than ever the entirety of public health medicine has been significantly divorced from the NHS and positioned more directly with local government. This seems like a downgrading of the role of public health doctors. The government has resisted calls from the medical profession as a body to confront the obesity problem for the major concern that it is. The government is clearly reluctant to tackle the food and drink industries, preferring to leave the doctors to deal with the end result of an over-eating, over-drinking, under-exercising population. This in turn leads to a demand on the NHS that is bound to go unfulfilled despite the best efforts of all the frontline staff in the NHS.
Jeremy Hunt has made no secret of his desire to pursue alternate systems of healthcare. The Tories have always wished to shrink the State, of which the NHS is a pivotal component. The NHS is under-resourced in comparison to most of Europe. The morale of its staff is in freefall. It has an unprecedented problem recruiting hospitals doctors in a variety of specialties. Hunt threatens to impose a new contract on junior doctors should negotiations fail. Meanwhile the government persistently refuses to introduce any meaningful measures to combat the biggest health problem in our society in the post WW2 era – obesity.
I fear that by 2020 the NHS as we know it may be past the point of resuscitation.