I’m frequently asked by friends and colleagues why the NHS can’t sort itself out – it now seems self-evident to many that we simply can’t go on like this. Leading commentators in the media and public life now acknowledge that social insurance schemes operating in mixed healthcare economies popular in mainland Europe have both better outcomes, wider choice for patients and generally higher satisfaction scores than our ‘world beating’ NHS.
The proportion of people choosing to pay for their own care outside the NHS system is rising because the NHS simply can’t meet patient requirements. A few weeks ago I wrote a piece looking at the substantial operational challenges facing the service. This week I’d like to look at some of the inside reasons and hidden agendas which mean the NHS can’t change even if it wanted to.
Broadly speaking there are four groups who need to be onboard the change bus if structural reform of the NHS is to succeed – the electorate, the political class (cross party), the NHS management cadre and NHS professional groups. Unless all of these groups agree on both the need for and the direction of change, nothing is likely to happen. The barriers to meaningful reform are not obvious to the lay person. I have written previously about structural changes in the workforce and the increasingly intrusive burden of regulation, which hinder efficiency. In this piece I will focus on the hidden road-blocks to restructuring.
Firstly, let’s consider what the NHS does well. A wide variety of think tanks and supra-governmental organisations produce score boards to compare healthcare systems. The NHS often scores highly in domains such as equality of access or management of chronic disease but performs consistently poorly on virtually all major outcome measures such as cancer survival or recovery from heart disease and stroke. This has been the case for many years. Failure to recover after the pandemic has widened the performance gap between the NHS and continental European systems. So, the NHS does well on equality, not badly on value for money, but consistently fails to deliver what the public want – rapid access and quality outcomes. This is not surprising from a socialist system – not too dissimilar to a Soviet tractor factory.
Where the NHS really excels is at protecting itself from externally imposed change. Nigel Lawson’s oft quoted remark about the NHS being the closest thing to a national religion is uncannily accurate – it genuinely does share aspects of religions: a foundational myth (1948), a strict moral code (free at the point of use), sacred rituals and devotional display behaviour (clap,clap,clap), a social group bound by common beliefs and hostility to unbelievers and heretics (NHS = good, private sector = evil).
Another point of excellence is the way in which the NHS has managed to elide its brand with delivery of healthcare in the U.K. Let’s be clear – the NHS is a system for managing the activity of healthcare professionals. It is the organisational structure within which clinical staff function. When one hears a virtue signalling celebrity claiming that “the NHS saved my life”, this is a triumph of cuckoo branding. The doctors and nurses involved in the case may or may not have saved the life – the NHS is the employer of those clinicians – no more, no less. If the NHS had not existed, the life would still have been saved. If the patient had been in France or Germany, the life would still have been saved. Yet the U.K. public persist in believing that without the NHS, people would be dying for lack of affordable healthcare. How can this be?
The NHS is also excellent at extracting money from the taxpayer. The current NHS budget for England in 2021-22 is £180 billion. (Total healthcare expenditure including the private sector was £277 billion in 2021, or 12% of GDP – well above the OECD average.)
In 2019-20, 46.6% of the NHS budget money was spent on staff salaries (£56.1 billion) and this figure does not include GP salaries – so the vast majority of NHS funding goes on paying the staff.
In 2021, healthcare spending accounted for 20% of all public spending and 45% of day to day spending on public services by the U.K. Government.
Why do these dry statistics matter? Because NHS funding is entirely contingent on winning arguments in Whitehall about how the national pie is divided up. Ed Miliband may have unwisely bragged about ‘weaponising’ healthcare, but the NHS executive got there well before him. In 33 years of professional life, I have never known a time when the NHS wasn’t in a ‘funding crisis’, even during the largesse of the Blair administration. As their entire funding stream relies on the big state, it would be intellectually incoherent and self-defeating for NHS leaders to be anything other than left leaning in political terms. In the current parlous economic situation this provides a strong incentive to ‘play it long’ – to foot drag and temporise until such time as a Labour government can unconditionally hand over the taxpayer’s chequebook once again.
The key driver of change in a representative democracy is supposed to be public opinion. This view discounts the ways in which the public can be manipulated. In the case of healthcare, this is usually achieved by inculcation of fear, often by presenting a U.S. Style system as the only alternative to “cradle to grave, free at the point of use NHS”. This approach conveniently ignores multiple better options in the mixed health economies of continental Europe and Australasia. No matter how bad NHS performance becomes, the public have been conditioned to believe that change would be worse. The fear narrative is backed up by a 24/7 media, hungry-to-amplify catastrophising messages. Déjà vu all over again perhaps.
Fear is also generic in politicians aspiring to move towards a more sustainable mixed health economy model. As Jean-Claude Junker remarked, “We all know what to do, but we don’t know how to get re-elected once we have done it.” Keir Starmer’s Labour party have already committed themselves to the NHS model as a ‘constitutional right’ and will go into the next election wedded to the existing system. Sunak’s administration is exhausted and battling on too many fronts to take on the problem before 2024. Andrew Lansley’s much derided structural reforms of NHS management in 2010 were an attempt to take the first step down the road of meaningful reform. Lansley sought to devolve day-to-day management of healthcare to the NHS executive believing that public annoyance about poor NHS performance would then be directed towards NHS managers rather at elected politicians. Sadly, he failed to take into account one crucial point – the public can sack elected representatives, but they can’t sack NHS managers.
By devolving operational control to unelected managers, Lansley inadvertently also handed over tremendous power to a cadre of unsackable mandarins in the newly created NHS England. In my view, Lansley had the right idea, but was stymied by the ‘power of the blob’ – the stubborn resistance of a managerial structure with a vested interest in resisting change. The tactical techniques by which this is achieved are familiar to many in the system. If an unwelcome change is proposed, a consultation must be held and a stakeholder group invited onto a committee to consider the matter. Advocates for change are identified and excluded at an early stage and the committee is packed with malleable participants who can be relied upon to oppose reform. The committee deliberates at length and comes up with a variety of reasons why the change would cause serious damage to patient care. Leaks to the press put pressure on MPs. ‘Patient advocacy’ groups are incited to lobby against the proposal. If all else fails, the tactic of ‘consent and evade’ can be deployed, whereby the change is agreed to in public but sufficient administrative grit is tipped into the gears to make sure it never happens. Eventually the proposal is quietly dropped.
I finally turn to the fourth key group needed to enact change – the professions. Listening to the constant litany of complaint from doctors about the NHS system, one might think that the medical profession would be keen to move to a more market-based approach. Sadly, not so. The notion that most doctors are earning a fortune in private practice is a myth. There are 53,000 consultant level doctors in the U.K. Only 20% of these do any private work and the majority of work in the private sector is undertaken by about 5,000 doctors, based mainly in the SE of England.
The main complaint of NHS doctors is that they are paid too little and are worked too hard. Yet very few of them are keen on openly competing in a free market for healthcare services, preferring to agitate and threaten strike action to extract more money from taxpayers rather than push for meaningful reform. Doctors pay in the NHS certainly has fallen behind other professional groups in the last 20 years, but on the other hand medicine remains a stable means of employment with an index linked pension on an upward only salary scale with guaranteed increments for seniority. Readers wishing to understand the dynamics of medical remuneration may wish to read this excellent blog post I came across recently which summarises the situation very well. Being written in 2017 it’s a little out of date – for example, remuneration rates in private practice have been steadily falling as increased corporatism squeezes practitioners incomes. But it is nonetheless a highly insightful piece.
So, there we have it. A failing system with a management cadre incentivised to entrench the status quo, a workforce demanding more money for less work, a population convinced by the media that any meaningful change would be catastrophic and a political class terrified of intervening. I agree with Kate Andrews who recently observed that: “The upcoming strikes may be designed to address the pay and working conditions, but their walkout may shine light on a harsh truth many within the NHS are still unwilling to admit: the system isn’t working for anyone. And no amount of cash is likely to save it without reform.”
Don’t hold your breath, Kate. Reform isn’t happening any time soon.
The author, the Daily Sceptic‘s in-house doctor, is a former NHS consultant now in private practice.
To join in with the discussion please make a donation to The Daily Sceptic.
Profanity and abuse will be removed and may lead to a permanent ban.
I thought the whole point of Our Wonderful NHS (Peace be upon it) was to encourage people to keep well and healthy so they never have to use it.
Post war, with obesity levels very low, rationing in force, many young men and women just coming out of military service, we were pretty healthy, in many ways. As time has gone on the population has become health poor, and the NHS has stopped being the place to go when you are ill, but when you are ‘not well’, not well being subjective and the place where many people who don’t need medical assistance end up. Add to it the range of care provided, the increased breadth of treatments and service. It has become a monster that so many people think should respond to them for the very slightest concerns, for free, from cradle to grave. The NHS has to redefine its purpose, imo. It cannot be all things to all patients.
In 1948 there was absolutely no perception of the advances to be made in medicine, which has kept people alive for much longer and allowed them to contract many more serious, chronic conditions. Can we think of any other organisation that has not changed for over 70+ years?
Also, increasing prosperity has led to a massive increase in obesity and associated illnesses. The obesity crisis was noticeable in the USA back in the 1970s, so why did our ‘sainted’, ‘envy of the world’ national HEALTH service not consider the implications for the UK? Because the whole mangement structure is totally useless. They see the NHS as a job for life so there is absolutely no need to think about changes or improvements for the future benefit of the organisation as they will always be able to demand more taxpayers’ money to waste on useless issues; such as reorganisations and the creation of EDI posts, while claiming the NHS is in crisis. The so-called crises are a function of the incompetent management. The more crises they have, the more managers they need to resolve the crisis. QED
If you were running an organisation where 44% of the budget went on staff costs and 14% went on medicines which budget would you look to first reduce? BTW the proportion of the NHS budget spent on medicines has remained around 12/14% since the 1960s
Wrt “any other organisation that has not changed for 70 years” How about the House of Lords for a start?
Post war people coming out of military service were pretty healthy… yer wot?
PTSD, hearing impaired by gunfire, limbs blown off, organ injuries from bullet wounds, blinded by shrapnel, malnourished, long term effect of tropical diseases and other illnesses because of insanitary conditions, long spells in POW camps, cardiovascular problems caused by constant high adrenaline levels, and the many mental problems of having lived in Hell for years on end.
Most serious health conditions are a function of older age: dementia, arthritis, diabetes, cancers, joint replacement, cardiovascular, pulmonary, kidney, liver conditions, anaemia, high/low blood pressure, etc.
An NHS supposedly to make people healthier and thus live longer, inevitably will have to do more and cost more because more people will live longer to get diseases that need treatments, plus advances in medical science and technology will mean more things can be treated.
Bonus: increase life expectancy could only ever bankrupt the State pension scheme.
The Welfare State was the huge bribe to get the British to vote Labour in 1945. It was also a huge con, and the British people have enjoyed being conned ever since.
The NHS almost entirely treats symptoms of illness, without removing the causes of illness. The treatments have side effects which can create more symptoms, which are treated by treatments which have more side effects, for which more treatments may be needed.
Meanwhile, as the original causes of illness have not been removed, further symptoms will sooner or later develop, along with the symptoms arising from the treatments.
So it’s a never-ending cycle of symptom treatment, which, funnily enough, is great for the profits of pharmaceutical companies, as well as for the doctors who treat symptoms, as they will never be short of work.
Whereas there is not so much profit to be made from removing causes.
But the NHS appears to have reached the point where doctors are not just never short of work, they are becoming overwhelmed with the amount of work they are being faced with. Because they hardly ever treat causes.
So true about not treating the underlying cause! I had a private SLT practice for a number of years, the aim being to cure & discharge. At one conference one of the presentations was about models of business, the presenter couldn’t get his head around how by curing we did away with repeat customers!
It was & remains the only time in my clinical career where I was afforded the freedom to treat & cure with the patient’s clinical needs central to the interventions.
The majority of the patients self funded, very few had insurance & the insurance only paid out for 8 – 10 sessions, yet with highly motivated patients to carry out daily therapy was more than sufficient. The lack of motivation in patients in the NHS to carry out independent rehab is a juge block to successful therapy outcomes. As it is a ‘free’ service, the patients expectation is that therapy is done to them rather than they actually have to take responsibility for their recovery.
Like the author, I have only ever known the NHS to be in financial crisis. My profession has always been a Cinderella service – being able to communicate isn’t life threatening – & is a luxurious addition to the vital life saving professions, even where being unable to swallow is part of the disease.
I concur that the number of patients one is able to treat each day has reduced due to increased demand for ‘accoutability’ & processes inflicted in the name of ‘efficiency’. So glad to no longer be a part of it.
I think you mean “basket case”, not “basket cast”.
Great, thanks. One small picky point:
“Failure to recover after the pandemic”
There was no pandemic.
Thank you, tof, I won’t bother writing my comment now!
We have to keep pointing this out, don’t we?!
Abolition of the NHS is essential but politically unfeasible while the NHS retains sufficient public support for advocacy of abolition to be politically highly risky. Public support for the NHS is probably shallower than is commonly supposed, however, and could ebb away quickly if the string case for abolition was made. The destruction of the utterly corrupt and useless Conservative Party is necessary for the British people to be liberated from the bloated and increasingly autocratic state sector including the NHS.
A policy allowing individuals to opt out of NHS cover and receive a tax rebate proportional to the actuarial value to the individual of the NHS would be a way of generating real change in healthcare provision while reassuring those not ready to give up on NHS style healthcare.
And you think that “the bloated and increasingly autocratic state sector including the NHS” will be improved when the Conservatives are voted out and Sir Keir Smarmer’s lot take over? Based on years of experience of the socialists running the country into the ground, you’re having a laugh.
Can you give me an example of one Blair/Brown policy which the Pretendy-CONs haven’t either meekly accepted or made worse over the past 12 years.
I can’t think of a single positive policy they’ve implemented – except a weak version of Brexit which they were forced to do by Farage and the Brexit Party or see their Party annihilated.
As an experienced patient over the years, I think it’s worth pointing out that many specialists are not solely employed by the NHS at all. Sometimes they work independently, or for another firm, and sometimes for an NHS branch. E.g. some years ago, with private insurance, I saw the same guy rather earlier than I would have done if I stayed on an NHS “waiting list”. No shortage of Bupa run places just round the corner from an NHS building, after all.
The organisation is hard to understand, but it is quite different from many company structures.
During the covid saga, my mum needed an urgent cataract operation. She was referred to a surgeon at the local hospital who told her there is a long waiting list due to the hospital being overloaded because of covid. He said he could do it privately though, which she went for. The surprise is that the operation was done at the same hospital, although in a different private only wing.
The social insurance schemes in Continental Europe work well because patients know the true costs of consultations, treatment and medication. Often they have to pay for them and claim back the part covered by insurance.
“Free at the point of use” is as much of a chimera as the Magic Money Tree. There’s no such thing as a free lunch.
This is total BS.
The insurance component has absolutely nothing to do with these systems higher efficiencies at the point of care.
To the contrary, they add just another layer of bureaucracy and cost.
The 90% mandatorily ‘health insured’ Germans at the hundreds of Krankenkassen with their hundreds of CEOs&co have absolutely no such transparency or incentive. A totally unrelated policy of charging them a nominal 10€ per quarterly practice visit actually had that effect, but it was cancelled after protests by the very same doctors that wanted it to be inteoduced, because it was so successful that they had too little to do and charge! The 10% mandatory ‘private’ insured at about 150 private Krankenkassen with hundreds of CEOs&co again have that transparency and some incentives to save, but that is more than made up for by doctors&co charging them 2.3 to 3.5 X as much as the 90% quasi-state insured are charged for the exact same procedure by the exact same doctors.
At the poc, it’s a question of education, organisation/bureaucracy, incentives, politics and work ethics which result in higher efficiency there.
No other health system was Covid only for a year, only the UK’s.
Dentists operated as normal after 2 weeks.
German GPs are usually operating as a private practice for 3 decades before the next one, often a relative, takes it over, have little staff turnover, see their patients directly and do house calls, and unlike the dentists, their charges and reimbursements are so that usually they can’t and don’t drive Porsches.
(Which is why many jumped eagerly on the gene-therapy bandwagon, which paid them royally in contrast.)
In short: the British health system and services could be improved, but replacing single receiver and payor NI and free at the poc with a hodgepodge of ‘insurances’ and part payments and part aid payments etc. is not something that will increase efficiency and lower costs- it will only lower efficiency and increase cost.
Because it is long term programme for introducing socialism, masquerading as a health service. You only have to look at the ever increasing proportion of the national budget that it consumes, the belligerence and arrogance of the people who work there, the complete lack of accountability for their many and continual failures, the total lack of focus on delivering a quality service to the payers, and the political untouchability of every aspect of the organisation.
While I agree that the NHS is mainly an Ill-Health Service it’s rather unfair to accuse its workers as belligerent and arrogant, though I was the latter. My belligerence was aimed at managers who tried to stop me working so hard – by trying to limit outpatient numbers without examining why patients were being seen (a joined-up thinking problem) and by reducing my surgical colleague’s theatre hours by insisting on rigid start and finish times. Thus, if a theatre session was due to begin at 8.30 that was not the time of the first operation, but the time at which the theatre was set up, and lists were not allowed to overrun. I also tried to stop MRSA patients being admitted to my rehab unit, where my patients with serious long-term illnesses were at significant risk, only to find myself overruled by managers. Then there was a failed hospitals merger (which I had predicted, and over which I was given a verbal warning for dissent, and this is over a decade ago). But you are right about the lack of accountability; the CE who oversaw the failed merger was promoted! Try my book…
Any public service is essentially like an obese person with a sugar addiction.
Over time it will get fatter, sicker, more lazy, harder to shift, and then die.
In Australia, before our health system became socialised, the small, rural town I hailed from had 3 GP’s who performed obstetrics including Caesarian, did surgery and anaesthetics. There were visiting general surgeons and a professor of ENT.
Now the town has 1 visiting GP, who does no procedures whatsoever.
But we have loads of managers and admin staff to tell the medical staff what they are doing wrong, and to teach the DEI principles.
Socialism never works!
And it always runs out of other peoples’ money
A thoughtful piece. My own experience (39 years in the NHS and 11 years retired, plus growing up with two GP parents) identified the same issues, but there is more to be decided. Part of the reason that hospital care costs have burgeoned is that we can do far more, with new surgical techniques, new investigations such as MRI, new drugs. Another part is the additional cost of single room hospitals. A third is the most uncomfortable to confront; I believe we are to often spending vast sums on people who should not be treated. Consider an elderly lady, admitted from a care home after a fall, partly blind, deaf, struggling with a seized hip and with a chronic urine infection (drug resistant), aged 94 and tired of life. You could operate on the broken shoulder, do the hip as well, and send her to ICU post-op. Or you could decide that life after discharge will be as difficult and expensive as it was before, and grant her a quiet and dignified death by doing nothing. Shorter and cheaper hospital stay as a by-product. And before anyone says anything, that was my mother, a long retired GP. Treating her would have been what I have termed futility medicine.
Reform? But what reform? Since the NHS began there have been numerous attempts at reform. That none has worked suggests that reform may not be possible, but see my book “Mad Medicine” for some ideas (www.amazon.com/author/andrewbamji)
The intervention arm of not intervening with patient consent is too often overlooked as one has to do something.
Currently there are drug protocols being used on patients such as your mother in hospitals comprising of midazolam & morphine, prescribed together, which have no such benign outcome as being in the patient’s best interests.
The very best care homes used to do everything within their abilities to keep an elderly, frail individual comfortable & in familiar surroundings, not so sure now.
It’s a basket case because successive governments have treated it like a political sacred cow and drenched it with money it hardly knows how to spend, aside from meaningless management positions and they know that their job performance is beyond criticism. It will carry on because politicians haven’t the backbone to confront it.
The increasing costs and the possibilities of more complex procedures, costly drugs and diagnostics together with a growing population mean that the NHS model is unsustainable.
Furthermore the increasing obesity levels have a major impact on general health (diabetes, cancer, arthritis) resulting in rising demands on the NHS.
I’d refer everyone to Ed Hoskin’s excellent piece here on November 29 2022 (https://dailysceptic.org/2022/11/29/how-to-fix-the-nhs/) about how well the French system works by contrast. Which I can confirm from personal experience after living there for 5 years. They have more doctors and nurses and other health professionals, who are paid less (!), fewer administrators and managers, and they spend less as a % of gdp than we do. The only cure for the NHS is to blow it up.
Eat a decent, varied diet; exercise; take ginger and eat oily fish or take fish oil capsules. There is a wealth of information about natural alternatives to prescription medicines on the net.
Look after your own health. The NHS won’t do it for you and many working in the “medical profession” are compromised by their association with Big Pharma.
…and steer clear of fake ‘vaccines’ and anything created with warp speed…
The People’s Health Alliance is a growing group of healthcare professionals set up as a viable alternative to the failing NHS which is growing rapidly in the UK & the model is being used around the globe.
The People’s Health Alliance – For The People, by The People
Excellent summary. But the consequences of this latter-day religion are even more dire than merely the unending huge cost for a poor service.You put your finger on it with:
“We all know what to do, but we don’t know how to get re-elected once we have done it.”
Collapse of the NHS means exile for a 1,000 years for whichever party is in power. This was the major reason for Johnson inflicting the scourge of a ‘Lockdown'(a word that should be banned from the English language!). We were within a whisker of stopping the collapsing dominos across the world, but for the cult of the NHS. Recall the first of the government’s 3 commandments: ‘Save the NHS‘. ‘Save Lives’ came only second. (God only knows what rubbish came third!)
Why?
Because it is a State run, non-contestable monopoly operated to meet ideological and political aims.
It does not therefore have any of the normal incentives of private business in a free, competitive market, it does not have to serve consumer interests to survive because it can never go bankrupt, no investor can lose their money as it has no investors just people coerced to pay for its losses, no worker can lose their job.
This why every State-run enterprise, in any place at any time was a basket case, and why we got rid of all the others here in the UK.
I am weary of people keep asking why the NHS is such a sack of merde and how can it be fixed.
Why can’t an elephant fly? How do we fix it so it flies?
Fred Karno’s army on steroids. Privatisation is the only way I’m afraid.
Have some knowledge of the French, American and English versions of healthcare. In France patients pay a small proportion of the cost of treatment which is covered normally by a moderately priced insurance almost everyone in France has. My mother in law was treated very well in France for what was eventually terminal cancer. My son married an america young lady and moved to America where he was terrified of health costs if the need arose and decided it was necessary to buy health insurance at a very expensive rate which at that stage he could hardly afford. It is not uncommon for people who develop health issues in America with inadequate or non existent health insurance to be financially broken by the cost of their health treatment. Fortunately he now has a job where part of his salary pays for good health insurance which is quite common for professionals in America, but many others need to pay the high insurance cost or risk the very high American health treatment costs. In the UK I need an operation for joint problems, but had a full pre-op examination which discovered in addition to my high blood pressure, I had heart problems. since then I have had very good care from the cardiac specialist and cardiac specialist nurse at Yeovil Hospital with the objective of dealing with my heart problem and reducing my blood pressure which now seems to be improving towards the point where I should be able to have my operation. I can’t fault the treatment I have had from the NHS, but I understand there are issues and shortages which need to be dealt with, more by reoganisation than just providing more money. I think it is necessary for government to listen to health professionals within the NHS at every level and develop a viable plan to put things right.
You can criticize the NHS all you like for its truly scandalous waste of manpower and materials but abolition will achieve nothing while UK management is so inefficient, corrupted and class ridden.