I have been retired from the NHS for 11 years but I have remained a keen observer of events, and think I have been around a little longer than the ‘in-house doctor‘. I became a medical student in 1967, qualified in 1973 and was brought up prior to that by parents who were both GPs – so my exposure to primary care medicine started when I was five and first went out on house calls with my mother.
It’s not a question of whether the NHS will accept reform. It has. Frequently. As I outline in my book Mad Medicine: Myths, Maxims and Mayhem in the National Health Service, I have seen many ‘reforms’. None of them have worked. Over 70 years have passed since the NHS was established; if the best minds in medical and organisational thinking have been unable to come up with solutions in that time, perhaps there are none. I find the suggestion that doctors are to blame for inertia in promoting change is unfair – at least so far as hospital medicine goes. I spent the last three years of my professional life fighting managers who wanted me to do less work (i.e. see fewer patients) based on ideology developed by non-specialists. I was not supposed to overbook clinics, but did so regularly, as well as accommodating patients with an emergency problem. I wanted to prioritise appointments by need (by looking at referral letters); with the advent of computerised booking that became impossible. The brilliant diary appointment system of one of my obstetric colleagues was destroyed by the same system. I adopted the ‘treat early and treat aggressively’ mantra for rheumatoid arthritis a full 25 years before it became generally accepted in rheumatology circles. My surgical colleagues were constrained by the rigid application of operating theatre opening and closing times; thus, if an operation at the end of the list would be likely to be long, and therefore overrun, it would be cancelled. Was this the surgeons’ fault? Certainly not.
We must ask ourselves not what the problems are, but why they are there. One recurring issue, though, is the loss of NHS institutional memory. While people may dismiss aged, retired people like me as yesterday’s men, they carry such memory. Managers (and politicians) are here today and gone tomorrow. In my career I have lost count of the number of times that a new proposal was brought forward and I had to say, “We have been there and done that – and it didn’t work”.
For hospitals, primarily there is a lack of capacity. Some of that is because it is expensive to run a system where for much of the time there is spare capacity, with bed occupancy less than or up to 85% and therefore room for increased need at peak periods such as winter. Empty beds are still maintained and staffed, which costs a lot. Cutting beds, closing wards and running at over 95% occupancy saves a lot, which is why it has been done, but you get into trouble in winter (as the NHS has done for 20 years or more). The old overspill network of cottage hospitals closed because they were too expensive to maintain – small units are less cost-effective so are first to go when money is tight.
And the rest? People who 50 years ago would have died because there was no treatment for their conditions now have expensive investigations, even more expensive treatments and as a result live longer with multiple pathologies. When I became a hospital consultant, the biggest pharmacy spend in my hospital was on oncology drugs; with the advent of biologic therapies for inflammatory arthritis my departmental budget overtook it, and increased from an annual cost in the low thousands to over seven figures. Complex cardiac or neurosurgery and interventional radiology are time-consuming, labour-intensive and very expensive. There has been a recent resurgence of the idea that preventive medicine is the answer. That was what Aneurin Bevan thought in 1948; disease prevention would cut the costs. But he failed to foresee the enormous expansion in techniques, drugs etc. that make that a pipedream. When I qualified there were no CT or MRI scans, almost no ultrasound, no coronary artery surgery, no organ transplantation, no genomic investigation, no thrombolytic therapy for stroke and very limited drugs for cancer. Now we have all these things any savings made by shortening hospital stays is matched by the spend on them. Of course, if the current epidemic of obesity and consequent diabetes could be stemmed by education then a lot of medical work would vanish.
The strike issue is less relevant than an ongoing, year-round problem in the NHS – that of sick leave and maternity leave. Neither is predictable and both require locum cover at great expense. When I was a clinical director I had, at one point, three physiotherapists on maternity leave, all of who were being paid, and to cover their workload I needed to employ three agency staff, which more than doubled the cost. My budget was horribly overspent. Management was more concerned with the overspend than the clinical consequences of leaving the posts vacant. As for sick leave the sudden absence of a doctor required a major re-jig of rotas – or an expensive, short-term, at-no-notice locum which was often hard to find. If there is no slack in any system then a sudden problem will catch you out.
Managers and doctors will always be in conflict because the role of managers is to save money in a constrained budgetary system and the role of doctors is to spend it. So on the one hand you could reduce the constraint by increasing funding (which has been the way the NHS has sort of coped), and on the other you could get the doctors to spend less. But there is one major sticking point on that approach: doctors are programmed to treat, not to abandon hope. One could address this latter by not indulging in what I term futility medicine, where for example elderly patients have heroic surgery, require long ITU care and are then discharged back to their care home with their dementia probably worsened by the disruptive experience. Should we spend tens of thousands of pounds on cancer therapy that extends life by three months? Just because we can does not mean we should. Regrettably it is not just the health professionals who are averse to defining constituents of futility medicine, but a public who have been conditioned to expect that if a treatment is available then it must be employed.
An example. Take a 94 year-old lady in a care home who is very deaf, has lost some of her sight to macular degeneration, has lost half of what’s left to a minor stroke, who has a stiff hip, a chronic and resistant to antibiotics urinary infection and double incontinence and intermittently does not recognise her family. She becomes confused because she develops sepsis, and falls, breaking her shoulder. Admitted, her family has a meeting with the orthopaedic team who suggest they could pin the shoulder and replace the stiff hip in one operation. For what purpose? And before you say that I am callous, this is my ex-GP mother who I am talking about, and she is lucid enough to say she doesn’t want any more treatment and has already signed an advance directive. She occupied a hospital bed for 11 days before she died; it would have been three times that to get her fit enough after major surgery. Treatment would, in my eyes, have been a classic example of futility medicine. Just because we can does not mean we should. We must have a rational debate about what parts of medicine will be abandoned, either completely or to the private sector.
The pressure on A&E departments is heightened by patients’ perceived inability to get a GP appointment. In my parents’ day, in the 1950s and 60s, there were no booked appointments; you turned up at the surgery and sat and waited. If the wait was not justified by the severity (or lack of it) of the medical problem you went away. Indeed people were attuned to the system and it inhibited their demand. No-one in real need missed out. Why not abolish appointment systems? I concede that GPs might rebel at such a suggestion. Alternatively, or as well, introduce a charge for appointments. It won’t be the doctors that kick up, but patients will!
The cost-benefit of some interventions needs to be re-examined. For instance, statins are cheap but prescribed in vast quantities, so all in they are not cheap at all. Monitoring takes up GPs’ time. Re-evaluation of the evidence in their favour suggests that they have little absolute benefit, and anyway probably don’t work by lowering cholesterol. Such evidence – and there is a lot of it – is ignored by those with vested interests and conflicts of interest, and there is too much tramline thinking for an independent assessment to be easy, and acceptable – not for want of trying. But the money (and time) that would be saved by abandoning them is very large.
Elective surgery units are only a partial answer to the routine waiting list issue. You cannot safely operate on patients in such a unit if post-operative care requires an ITU, which elective units don’t have (too expensive). So complex surgery cannot be done there. Furthermore, if such units are contracted out to the private sector, experience has shown that contract over-ordering is common, so NHS money is being spent on work that is not being done. Using hotels as pre-discharge overflows is an idea that has been proposed before. I doubt it’s a safe option. Just before I left the NHS my hospital, as part of a group, became what was known as a step-down unit. A significant number of admissions had been rushed out of their acute bed too fast, were not well enough to be in the step-down unit and had to be returned. But everyone has forgotten this. Who will monitor patients in hotels? The nurses we don’t have? (Will ‘guests’ pay for their food? Probably not, although as everyone eats every day I don’t see why they should be fed for nothing, even in hospital.) This week’s news suggests that care homes may have spare capacity. Is delayed discharge the fault of the doctors? Certainly not; the assessment processes by social workers and therapists act as a gigantic drag anchor.
The idea that there is some sort of fast track for senior apparatchiks to access NHS care seems ridiculous. The reason that senior staff might be able to pull strings is that they have the knowledge of what strings to pull. They may be better placed to judge what needs more urgent attention and communicate this in a way that speeds up access.
The in-house doctor says: “The British medical establishment will die in a ditch before allowing remuneration to be linked to measurable productivity of individual doctors.” I would like to know how one might measure productivity. What a doctor does, and how he or she does it, will differ between specialties and grades. Comparing a neurosurgeon to a dermatologist is like comparing apples and pears. Outcome measures, perhaps, like surgical success rates? That will encourage all surgeons to stick to the simple, no risk stuff. Been there, done that. Outpatient numbers? As I have pointed out, it was managers who attempted to reduce my numbers, not clinicians with any knowledge of why I could not. I suggest that anyone trying to introduce a remuneration system linked to productivity will be the one dying in the ditch.
A few years ago I spent some time comparing the NHS with health services in Canada and Australia, and concluded that each had different advantages and drawbacks; overall, none was better than the others. The French system works reasonably well, but patients pay (not a lot). I believe that today a service that is free at the point of delivery is an unaffordable luxury. We pay prescription charges, so why not appointment charges? Usual exceptions of course, but the one principle that is truly outdated is that ‘Our NHS’ must be free. Dispose of that and we might make some progress. Identify and ditch futility medicine and we will make more. Streamline the discharge process. More still. If politicians were ready to listen to those who hold the institutional memory, and thus avoid introducing already tried and proven-to-fail ideas, we could be flying.
Dr. Andrew Bamji is a retired consultant rheumatologist.