It’s not every day that the National Audit Office publishes a comedic masterpiece, but the bean counters of Whitehall should be congratulated for their recent report on managing NHS backlogs and waiting times (published November 17th 2022).
The sparse and laconic prose contains gems of humour that had me laughing out loud – and that’s not often said in reference to a document written by accountants.
One doesn’t have to be able to read between the lines to figure out what the national spending watchdog really thinks of the performance of our ‘wonderful NHS’ – sarcasm leaps off the page.
The Daily Sceptic staff have asked me to comment on the story behind the story – why, despite record levels of cash being shovelled into the Department of Health, despite record numbers of registered doctors, despite all the reports, plans and PR hoopla, the NHS is still not performing to the same levels as 2019.
I plan to do this in two parts. Today I will analyse several recently published papers on NHS matters. In a later piece I will consider factors preventing meaningful reform to the health service in the U.K.
Let’s have a look at the National Audit Office (NAO) report referred to above. I’m going to quote extensively from this document because it speaks for itself. Frankly, I couldn’t do better than the authors in exposing what is (or isn’t) going on.
On the first page, there is a list of figures showing that the NHS recovery plan calls for an activity target of 129% in 2024 relative to 2019. However, 26 out of the 42 primary care bodies have published their own projections showing they will fail to meet this target – and that’s likely to be best case scenario. I’d be amazed if any integrated care group gets anywhere near the central planning assumption, given that on the next page, the NAO states:
At the start of the COVID-19 pandemic, the NHS in England had not met its elective waiting time performance standard for four years, nor its full set of eight operational standards for cancer services for six years.
The report goes on to say:
NHSE’s elective recovery programme partly relies on initiatives which have potential but for which there is so far limited evidence of effectiveness.
And further:
In May 2022, elective activity for all ‘high volume, low complexity’ procedures was at only 85% of pre-pandemic levels.
It gets better:
NHSE has estimated that, in 2021, the NHS was around 16% less productive than before the pandemic… It believes that reduced productivity has continued in 2022-23.
You don’t say.
And the best bit:
It is DHSC’s job to hold NHSE to account for NHS performance, but some key metrics for measuring the recovery are hard to understand and could be applied inconsistently.
In other words, because of the bizarre and complicated way the NHS collates the statistics, they may be fiddling the numbers. Well, I’m shocked – never seen that before.
The NAO goes on to recommend the NHS sharpens up its act in relation to transparency and disclosure. These paragraphs are written in astonishingly direct language for an official document – the implications are clear.
The following 40 pages demolish the NHS ‘recovery plan’, exposing it as a utopian charade based on unrealistic assumptions.
I think this is the best line:
NHSE has opted not to produce a fully-costed version of its recovery plan, showing what it will spend on each of the programmes over three years. Consequently, we have not been able to give costs for the programmes on a consistent basis. It is not yet clear whether their cost will be equal to or greater or less than the overall recovery funding of £14 billion.
So, NHS England has been bunged £14 billion of extra taxpayers’ money, but is unable or unwilling to tell the national auditor what it’s going to be spent on. Can this be for real?
I could go on, but there are so many acerbic observations in this document I’d run out of space. I strongly encourage readers to have a look for themselves to discover how their increased taxes are being spent.
I next look at the Parliamentary Select Committee on Health and Social Care report on NHS workforce published July 25th 2022 and then the General Medical Council workforce report from earlier this month.
The Parliamentary Committee (chaired by Jeremy Hunt) concluded that the NHS has a major workforce crisis (who knew?) and this crisis is because the Government has not done enough ‘workforce planning’. I’m not arguing with the first point, which is self-evident, but the notion that the problem is due to inadequate Government planning is frankly ludicrous.
I commented on the real reasons for shortages of fully functional doctors in the NHS in a post earlier this year – spoiler alert: it has nothing to do with Government planning defects and everything to do with demographic change in the workforce, reduction in intensity of postgraduate training and onerous and coercive over-regulation. That’s before one even considers the idiocy of tax rules directly penalising the most productive senior clinicians, leading directly to early retirements.
The parliamentary report correctly identifies many NHS staff are suffering from ‘burnout’ and low morale. The politicians go on to recommend increasing the number of medical school places – without saying how that is to be done or who will teach the extra students; shortening postgraduate medical training still further – even though this is one of the reasons why NHS productivity continues to fall; and allowing everyone to work flexibly – which makes planning on-call rotas in emergency specialties virtually impossible. In other words, the Select Committee thinks all NHS employees should be able to work how they want, when they feel like it and be paid more. Unfortunately, the practice of medicine (including nursing) really doesn’t work like that – patients get ill 24/7, so doctors and nurses must be available out of hours and at weekends and bank holidays, irrespective of their ‘work life balance’. That really shouldn’t come as a surprise to new medical graduates.
The GMC workforce report is revealing. Headline points include:
- Two thirds of new medical graduates are female.
- 50% of new doctors joining the workforce in 2021 were from overseas.
- The rate of early retirement amongst the senior medical cohort has increased. 70% of these doctors are male and mostly work full time.
- Foreign doctors have a high tendency to leave the U.K. because working in the NHS system is difficult.
The report notes that new joiners outnumber leavers on the medical register, but fails to link this with the obvious fact that female doctors gravitate towards working part time in non-acute specialities. The GMC report is helpful in term of providing demography of doctors on the medical register, but that does not necessarily mean all these individuals are working in the NHS (or even working at all – one can remain on the register even having ceased clinical practice). So even though we have many more doctors on the register, we have fewer full-time effectives. Hence lower productivity despite larger numbers – a conundrum which frequently puzzles commentators in the media.
All of these reports and plans have a salient commonality – lots of warm words about making staff feel valued and making working life at the coal face of medical practice a more genial experience for doctors. I have to say, I see zero evidence of those aspirations being delivered.
Repressive and coercive regulation imposed in the name of ‘patient safety’ continually increases. Not a month goes by without some new unnecessary box ticking or form filling requirement being imposed on U.K. doctors. I sometimes think medical regulators are attempting to prevent doctors from providing medical care at all. Clearly the safest way of working as a doctor is not to see any patients. If one doesn’t see any patients, one can’t make an error of judgement, have a post-operative complication or be subject to complaint. I wonder what the National Audit Office might make of that?
The author, the Daily Sceptic‘s in-house doctor, is a former NHS consultant now in private practice.
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Ok, the NHS doesn’t work – but it’s not proper socialism. One more heave.
A plague on both main political parties for allowing this state of affairs to evolve. Labour for cynically playing on the emotions of a dumb electorate. Conservatives for not having the courage to stand up to them.
No blame to the public then? The massed ranks of idiots who keep voting for the two political Political Parties who cat-fight continually over in whose paws it is safest and who can piss away the most taxpayer cash over it and should anybody suggest it would be better for medical care to be insured and provided in the private competitive, free market there is uproar… Hands off Our™️ World Class™️ NHS!
My phrase the emotions of a dumb electorate was intended to put a proportion of the blame on the public.
In defence of accountants (Chartered ones at least) do we know how many work for the Audit Office. I suspect very few and few of them have any real world experience at a worthwhile level.
Our wonderful NHS is dying, just like the ToryCon Party, and needs to be put out of its misery for good.
When was it alive? Gestated in wartime, emergency central planning and control model to cope with mass casualties from bombing raids and repatriated wounded military, it was delivered stillborn in 1948.
Just like everything else run on wartime central planning and control – Socialists’ wet-dream – it doesn’t work in peacetime for a whole raft of reasons, as 70 plus years so well demonstrate.
An excellent commentary. The problems of the NHS are its core design features; it is operated by government bodies, funded out of taxation, and free to users. Such a system is bound to have poor productivity, poor customer service, and poor quality. That the NHS was tolerable in its earlier years is testimony to the sense of vocation of its medical and nursing staff which largely compensated for the system’s weaknesses.
The NHS has become so bureaucratic and centrally directed, and increasingly overtly political in its activities, that vocationally inclined clinical staff are leaving in their droves. And well they might.
The NHS is incapable of being reformed meaningfully. It needs to be replaced by a system in which the overwhelming majority pay healthcare providers via insurance policies and/or health savings account with state funding reserved for the tiny minority incapable of providing for themselves. A system in which the patient is empowered is one in which clinical staff can be allowed to practise their skills and not be micro-managed by politicians and bureaucrats.
The NHS is incapable of being reformed meaningfully. It needs to be replaced by a system …
Indeed, but how do you do that without there being a massive health-care gap in and between the times while the old one is being dismantled/dying and the creation of the new system?
When you look at the staffing problems apparent in the NHS, let alone the organisational ones, it seems to me it will be many years before anything can be improved much.
I get this strong feeling that too many doctors just aren’t on the side of effective health care, and that ethos will be many years in the sorting.
Curiously, we were looking at the cost of the memsahib having a hip done privately. The last time we looked say 5 years ago, it was about £5 or £6k but you could go to Latvia and have it done for £3k. So off to the internet. Current price £12-16k. Now for three hours routine surgery, I’d imagine that £16k less costs and a three day stay in hospital is a pretty good earner for a surgeon. No wonder they are cherry picking their lists and doing as much private work as they can while the poor NHS patients can’t even get on the waiting list if their BMI is over 25.
You know all these diversity and equality people..? What good are they actually doing. Are there any stats of performance before they made everyone equal and after. Sounds like they need to recruit White Male Doctors, at least Male Doctors who will work full time and take on the more challenging treatment areas. That’s what men are good at, taking responsibility and they don’t need a ‘family break’ for child bearing/raising either. Do you think I should mention it..?
One approach, previously advocated I think by Douglas Carswell and Daniel Hannan, is to allow individuals to opt out of the NHS, receive a tax deduction equivalent to their share of NHS funding based upon an actuarial calculation, and make alternative provision via a health savings account and health insurance. Should NHS treatment be required, recognising that private provision is not universal in scope, it would be chargeable at full cost as with overseas visitors.
I think the strategy should be to move the welfare state away from universalism towards targeted intervention for the small minority needing support. This is probably best done in a steady, evolutionary manner to mitigate the risks of major gaps in provision during transition.
Excellent analysis. If its employee numbers are anywhere accurate, one in thirty adults of working age work in the NHS. Yet find one if you are ill and need treatment.
I’m afraid like all ‘spastic organisations’ (definition from C Northcote Parkinson…), it has lost any sense of what its purpose is, and exists only to provide employment for those employed by it. It is Europe’s largest job creation scheme for the perpetually useless.
Sounds great but entirely wrong.
I’ve worked in the NHS for 21 years and when I started it functioned reasonably well.
The present problems are due to one thing and one thing only, the 2004 GP pay deal.
That’s when they got a 100% pay rise, from 50K to 100k overnight.
Great idea but it had the totally unforeseen effect that the GP’s realised that instead of working full time for 100k it would be far more logical to work part time for 50k.
That’s why today 9/10 GP’s work part time, no one can see a GP and instead of bothering to try and see them the public have given up and taken to calling 999 or turning up at A&E instead. This influx of the timewasters and worried well has completely overloaded the hospitals and why they’re groaning at the seams with patients who have very little wrong with them.
Covid has simply given these overpaid workshy GP’s another excuse to do even less work than they used to, using the ludicrous ‘danger, of Covid infection as the reason.
The problem is that they can’t be paid even more (they’ll work even less!) and they can’t have their pay cut as they’ll simply move to a more lucrative position within the NHS or private.
The only solution left now, like it or not, is to cut the demand by charging the public for GP’s, Ambulances and A&E.
I did a couple of projects looking at frequent flyers for Ambulance Services 20 years ago, and the worst culprits were having 100 plus calls a year then. We found one lady who had 250 plus calls, primarily because she was lonely, and she always had the tea and biscuits ready when the full response crew arrived. I’m sure you have similar experiences. I do agree, free at the point of use should be limited, and I also agree that GP’s, as the primary point of contact in the community is where it all starts to go wrong.
Those running Leviathan have never known how much anything costs, because the beast immediately consumes whatever money it is fed with no observable increase in output but constantly demands more.
‘… the Select Committee thinks all NHS employees should be able to work how they want, when they feel like it..’
Perhaps it would help if people were able to get sick how they want and when they feel like it – and coordinate it with the lazy, useless tools riding Leviathan.
No different in Australia.
Once upon a time, when I was a young doctor, doctors and nurses worked hard, weren’t afraid to get their hands dirty, and had little paperwork to distract them.
Nowadays with the system completely socialised, the bureaucratic requirements are extensive, the feminised workforce doesn’t like to do procedural medicine, and young doctors want to work 10 hours per week.
Nurses were previously trained in hospitals and not in university. Modern nurses refuse to do traditional nursing duties and will not work in the hospital system.
Money cannot fix this, but the morons running the system will never understand this.
With 2/3rds of medical graduates now female, if the NHS is still in existence in 20 years’ time (I doubt it) it is going to collapse when they have their first hot flush and decide to work from home.
NHS management is on a par with the lunatics running the country (Civil Service and Parliament): massively expensive, utterly incompetent and run for the benefit of the workforce.