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.
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It’s as much as a scandal as the revelation that small businesses in Chicago in the 1930s were paying protection money to the racket. This is Organised Britain, 2024.
Also called Council Tax.
“...65% of the output has instead been purchased by Tesco, which says Cleve Hill will help it cut emissions by powering up to 144 of its supermarkets.”
So Tesco are going to run cables from Cleve Hill to 144 supermarkets.
And I’m a Labour voter. FFS!
Now that anyone can own a power station, there are different ways of selling the output. This ranges from what are called private-wire deals, a cable from one generator going to one factory, to ‘sleeves’ [Cleve Hill], where the actual electrons are not used by Tesco/Shell, but everything associated with the economics of producing them are met by Tesco/Shell, to Grid-only, where the power is sold to National Grid through one of the Big Six DNOs, such as eOn. Earnings from the latter have usually been below the former, but it is a simpler structure and AAA credit risk. It’s quite a complicated marketplace
Thanks for this.
Sometimes my sarcasm doesn’t travel well.
It does don’t worry
Thanks Freddy.
Viewing what is going on in the US with tech companies buying control of electricity/power generators ostensibly to power AI do you see the AI being a front for them to take control of power supplies?
I ask because I understand AI’s energy demands are so great that it will have to be powered by dirty electricity as “renewables” which will not provide enough electricity to meet AI’s demands and supply the rest of us. AI is going to be asked by Sam Altman how it can monetise itself apparently. So does it get ditched at some point and its developers are left in charge of the power supply?
You voted for Starmer? And admit it? Jesus. Starmer is a man with no soul, and publicly admits to having no inner life (e.g. doesn’t read books) – a sure sign of a personality disorder. His facility for lying all the time would suggest that.
First person I have seen admit to voting for the destruction of the UK and our Parliamentary democracy.
No. He really didnt, Jeremy.
Hux, your humour is too good
Thanks M A K.
I m not condoning this but the solar output will probably be connected into the grid & the electricity will reach Tesco etc through existing cable infrastructure .
Yes, I do understand how the system works Freddy. My Northern humour.
How many of Tesco’s stores will it power overnight..?
The idea of Tesco running its own nuclear plant so it can operate 24×7 scares the hell out of me.
Oh come on! They can’t even do decent stock control.
Maybe all the power will be used to power the pyrolysis of soft plastics that Tesco is still promoting, since it uses more energy than it produces in fuel.
London consumes a colossal amount of electricity yet generates virtually none. So why not cover all the open spaces in the capital – Hyde Park, Parliament Square, Clapham Common, Hampstead Heath etc. with solar panels? No need for long transmission lines!
Careful what you ask for… Don’t let Genghis hear that thought.
CPRE are complaining that the output was supposed to be for powering homes. The basic concept of the energy produced being put into the grid and disappearing in the mix seems too difficult for them to grasp.
“Tesco said the 15-year power purchase agreement signed with Quinbrook would help green its stores.”
Conveniently running out before the panels have to be scrapped by somebody else.
The panels can’t be recycled I’ve been told .
Not without some difficulty.
See https://www.thisismoney.co.uk/money/bills/article-12266801/Millions-solar-panels-destined-landfill-theres-recycle-them.html
Cross balancing consumption on paper, over a period of time, not physically, presumably. Deals like that have been around for years, with most of the utility companies (like OVO) doing things like that. Renewable energy generation targets are financially tradable, after all.
So therefore the power supplied to the 100,000 homes now deprived of their promised solar output will still have to rely upon fossil fuel based infrastructure for their energy needs… But hang on – won’t Tesco also be relying on some of that too, since they’ll need a backup source to keep their freezers running? If it all defrosts the whole stock will have to be dumped because of food hygiene law!
In energy terms, the corporations are getting the lion’s share and local residents are getting the scraps.
The nearest large Tesco to us had a power cut about three weeks ago. They had to empty all their freezers. Must have cost thousands although I doubt the costs were borne by Tesco.
But if I understand correctly, this is a private solar farm, generating its own electricity (when it’s bright out), and agreeing to sell it privately, via the national grid (at a cost), to two large corporate customers. What’s any of that got to do with the public? Obviously there’ll be a subsidy element, but put that madness to one side for now
It does have to do with the public surely, because this would not have been approved without that lying guarantee that it would power 100.00 homes, not Tesco stores?
I think Vicky needs to familiarise herself with the concept of charging points for EVs. That’s where the majority of the power will be needed. The amount needed to run the pumps and keep the lights on is neglible by comparison.
It’s the increasing burden of charging all these vehicles that threatens to plunge us into darkness every winter.
Heat pumps require 4kW to 10kW depending on size and external temperature. That is significant. A battery charger requires about 7kW.
The calculation made for domestic supply is that each property on average will require 1kW to 2kW. Of course at times this will be higher in some properties if people are using cookers or clothes dryers for example.
Local supply equipment is set however to cope with the average over the number of properties it supplies, on the basis they won’t all exceed the average at the same time.
However the 4kW plus for the heat pump and 7kW for the charger will be continuous and if many of the properties served are drawing this power, the local equipment will fail. Even just heat pumps running continuously on many properties will surcharge the local supply and it will shut down.
This is the factor that the idiots in charge and other commentators either do not understand or ignore.
The focus is on how to generate power but there are no plans or preparations to upgrade local supply network to cope. Indeed no plans to do the necessary expansion and upgrade of the grid from power station to points of consumption.
I recognise that you are talking about average load and that you’ve already stated that there will be times when some properties will be drawing more and others less. This is just to emphasise the point.
Our cooker is rated at 9.6 kW. That would be with oven, top oven/grill and all four ‘rings’ going at the same time – it rarely happens but it has happened on at least two occasions that I can think of. These occasions were Christmas and Easter within the last few years – if we’re doing that, so will some of our neighbours.
In addition, our gas boiler is rated at 30 kW. If we all have to dump that in favour of electrically heated water, morning showers are going to become blackout time.
On top of that if we have to charge EVs we’ll probably need ‘smarts’ to stop charging the EV when we want hot water… and to hell with needing the full range of the car later in the day.
Lastly, our incoming electricity cable is an old 60 Amp supply (14.4 kW). Cooker, leccy shower and EV charging will not run off such a puny supply, so that means a new cable from the substation – and the same for most of our neighbours on the estate.
Thanks for the info.
“Tesco and Shell to Buy Up Output of Controversial Kent Solar Farm Intended to…
… make ££££tens/hundreds of millions from taxpayer funded subsidies and trading Carbon Credit Certificates on the Carbon Credit Market.
Will power 100 000 homes – for how long? Not at night and not for most of the daytime in Winter when demand for electricity is at its highest, not every day or even every week.
“… by Tesco, which says Cleve Hill will help it cut emissions by powering up to 144 of its supermarkets.”
Which is a lie. Tesco will buy electricity from the grid much of it from gas power stations but use the Carbon Credit Certificates they get from the solar power boondoggle to “offset” the CO2 emissions to pretend they are using only “green” electricity.
It is a scam, and merely an accounting trick on paper which will save no CO2 emissions.
Aside from who’s using it, why is this solar farm so close to sea level?
I thought they’ve decreed it will all be underwater by a week on Tuesday?
Seeing all the destroyed solar panels in Florida after Milton passed through made me smile.
No, no. You see if we put in these solar panels then the sea level will stop rising so then they won’t get flooded. Also, there will never be any more storms so they will last forevah.. /s
This is exactly what an acquaintance told me recently. He was deadly serious. It’s terrifying and hilariously funny at the same time.
Kerching, kerching jackpot
Unless the feed from this “farm” goes directly to Tesco and Shell premises and nowhere else all they’re doing is purchasing an amount of electrons equivalent to those motivated to higher states by this abomination and fed into the national grid.
Sorry, but I’ve obviously lost the plot. How do you buy the entire output of a solar farm and then direct it to specific premises? Surely it can only go into the National Grid for general use?
Smoke and mirrors.
So will Tesco and Shell fully fund the construction of this site or will it be subsidised by the taxpayer?
Does this mean that the 144 Tesco stores will only open when it’s sunny at Cleeve Hill?