I was delighted to read Dr. Andrew Bamji’s recent piece in the Daily Sceptic and particularly grateful for his kind recognition of my contributions. The first rule of journalism (even for the amateur) is to acquire a readership – if that readership choose to engage, so much the better. I’m equally delighted to be able to discuss these matters in the Daily Sceptic. The DS and the Free Speech Union provide forums for testing ideas that our public squares seem incapable of accommodating – a vital feature of a free society.
I agree with much of his article, especially in relation to futile care, having had a similar experience with my mother to the one he describes. Dr. Bamji takes issue with some of my observations, but in general his comment are, perhaps inadvertently, highly supportive of my thesis that the current system is incapable of meaningful reform. The importance of historical memory in understanding how we ended up in our current situation is raised. I couldn’t agree more and will elaborate.
I have previously alluded to the central question of where power lies in U.K. healthcare. Most commentators consider the foundation of the NHS in 1948 as the key date in the history of medicine in the U.K. My view is that the passage of the National Insurance act in 1911 is a more significant moment. The centrality of this date is admirably explained in David Green’s important book Working class patients and the Medical establishment. I commend it to interested readers.
To summarise Green’s book, 1911 marked the moment where the state first became involved in healthcare provision via a general taxation levy. Prior to that, medical provision for working people had largely been provided through the ‘friendly societies’ – mutual ‘self-help’ subscription organisations run by the working class to spread the risk and cost of medical treatment. The destitute were provided for by the multiple iterations of the Poor Laws. Friendly societies directly employed doctors on modest rates and were not universally popular with the medical profession – partly due to the low pay, but also due to the perception in some quarters that being beholden to working people reduced doctors’ social status. Doctors generally preferred providing services to the middle and upper classes who could pay more. But economic reality forced most to sign up to friendly societies’ remuneration structures. Economic power was with the societies and their members because they paid doctors’ wages.
1911 marked the point where economic power tilted from the consumer to the provider. The state inserted itself as an intermediary between the citizen and the providers of medical care. Medical remuneration rates increased, eventually very significantly, because of effective professional lobbying of the Government. Friendly societies participating in the National Insurance scheme were sidelined. The mass of the working public were deprived of economic power in the medical arena and excluded from active participation in deciding how their money was spent. 1948 marked further encroachment by the state in the administration and centralisation of healthcare. Attempts during the 1980s and 1990s to rebalance the system in favour of the taxpayer failed, not least because of vocal and sustained opposition from the BMA.
Dr. Bamji’s points about the increase in medical capability, the cost of drugs and diagnostics, the burgeoning care needs of the elderly and the effects of obesity and diabetes are well-made, self-evident and incontestable. These features are not unique to the U.K., but consistent across most Western economies. I part company with his analysis over his assertion that the medical profession has been supportive of reform in the NHS. All the changes in relation to working practices he describes are not reforms, because they don’t shift the fundamental locus of power away from the medical establishment and towards the service user. This is the sine qua non for any meaningful realignment of power in U.K. healthcare.
The editorial in the British Medical Journal last week describes fundamental reform of the NHS system towards a social insurance model as “a monumental waste of time”. Keir Starmer, writing in the Daily Telegraph, can only offer to dispense with the current model of independent GP practices contracting to the NHS and replace it with directly employed NHS GPs. This is not reform – it is an expansion of the current system. His Shadow Health Spokesman, Wes Streeting talks a better fight in an interview with the Independent. Streeting explicitly says, “I think the history of the NHS since its foundation 75 years ago is one where successive Governments do run into resistance to change within the professions… the status quo is driven by provider interest, producer interest and not by patient interest. And change is required.” It is notable in the same piece that Rachel Reeves, the Shadow Chancellor, fails to commit to increasing NHS funding. Finally on this point, lest any reader think that these observations are a new phenomenon, I include a link to an article written by the recently deceased Paul Johnson in 1991. It’s well worth a read – could have been written yesterday.
Successful healthcare systems in Europe and Australasia incorporate elements of co-payment, a variety of insurance top-ups with a guaranteed basic level of acceptable care for the unwaged and impoverished. Bismarck’s original social insurance model was in part designed to integrate the German working class into the social fabric of the newly established unitary state. The French Mutuelles are the legacy of the friendly society model, where subscribers have influence over how contributions are spent. These features establish a clear understanding that healthcare is not ‘free’ and that patients are paying. Consumers in mixed healthcare economies are empowered with genuine choice over which doctors to consult. Critically, social insurance schemes prevent insurance companies from ripping off customers by ‘exclusion of pre-existing conditions’ or by rapidly inflating premiums – because everyone subscribes, the risk is spread wider across the population than in our existing private healthcare insurance market. NHS ‘reforms’ in the first decade of this century purported to empower consumers in a similar way. In reality, they were deliberately confected chimeras intended to project an illusion of choice without any substance. The real purpose was to maintain centralised control. As Professor Alastair Lee pointed out in the Telegraph yesterday, “The public has little or no sense about the money put into this system or how it is used, and this disconnect is one of its fundamental problems.”
No system of healthcare is perfect – they are all subject to a variety of user complaints and workforce stresses. But a key distinguishing feature of continental systems in comparison to the NHS is the higher degree of choice for the consumer and a direct link between delivery of service and professional remuneration.
Dr. Bamji contests the effectiveness of surgical treatment centres. He was an opponent of the Blair administration’s policy around independent sector treatment centres (ISTC) in 2005 and submitted written evidence to the parliamentary select committee enquiry on the issue.
Readers may wish to consult this lengthy document – it runs to 175 pages. Dr. Bamji’s contribution is on page 159. Evidence was submitted by many interested parties with an astonishing concordance of opinion from all medical bodies in opposition to treatment centres. Several leitmotifs run through these submissions – ISTCs would provide unsafe care; they would deprive NHS hospitals of routine cases for surgical training and leach funds away from NHS hospitals; foreign surgeons would do most of the operating and ISTCs would destabilise pay rates for doctors. Yet, years later, more sober analysis showed that ISTCs had provided good quality of care with high rates of patient satisfaction.
The treatment centre model was so successful that it was copied within the NHS, the best example being the excellent SWELEOC orthopaedic centre in Epsom. It is perhaps telling that all objections about elective treatment centres vanished once the NHS retained control. For clarity, I am completely agnostic about which organisations provide elective surgery. The core point about elective centres is that they are geographically separate from acute centres, so routine operations are not cancelled due to emergency pressures. Whether they are run by the NHS or private sector businesses is completely irrelevant. It is also self-evident that risky complex cases require surgery in larger hospitals where critical care is available. Audit records show that surgeons and anaesthetists are highly proficient at risk stratification and minimisation of post-operative risk – they are quite capable of identifying the majority of routine cases suitable for treatment in elective centres and which need surgery in acute hospitals. This criticism is a canard and a classic example of provider interest ‘shroud waving’.
I’m further surprised Dr. Bamji considers paying doctors by levels of clinical activity problematic and unworkable. The French and the Australians operate their primary care system in that way and the private sector in the U.K. has been doing it for decades. Introduction of such a change would take time and would need to be gradual, but it is demonstrably possible, because other healthcare systems already run such models. Parity of pay between different medical specialties has long been a core tenet of the British medical establishment – but is it really necessary? Do patients care if a neurosurgeon is paid more per hour than a dermatologist, as long as they both provide a good level of service and a good outcome? Only the medical profession has an interest in parity of remuneration, along with maintenance of doctors’ inflation-linked pension schemes. Proper performance-related pay is crucial to incentivising doctors to spend more time in direct patient care and less time on non-clinical activity. I expanded on the issue of getting financial incentives correctly aligned in the NHS in a previous post and I see no reason to change that view.
The British medical establishment will resist tooth and nail any attempt to link pay to clinical activity. The very mention of the idea has British doctors reaching for the smelling salts – this should tell taxpayers something about how the system really functions. Arguments against change are classic features of the provider interest which pervades the NHS and is the real reason meaningful reform is highly unlikely to be implemented. Readers and the general public are likely to observe the provider interest in action in the near future if, as widely predicted, junior doctors vote to take strike action in pursuit of a 30% pay rise. The increasing political radicalism of the BMA junior doctors’ committee is highlighted by Andrew Gilligan in an important new publication.
The core tension in this argument goes to the question of who makes the decisions within the NHS and who subsequently pays for the consequences. Until the mid-1990s, a paternalistic medical establishment made most of the decisions. Since that point it has been an increasingly assertive but ineffective managerial cadre incorporating politically malleable former clinicians co-opted into the managerial structure as human shields for the executive. The taxpaying public has consistently footed the bill for multiple failed experiments masquerading as ‘reforms’, which in reality have been motivated by political ‘optics’ rather than meaningful beneficial change. Like non-player characters in a video game, the section of society paying for the NHS has been relegated to the role of impotent bystanders as the entire edifice collapses under the weight of its internal contradictions.
NHS reform does not mean adjusting the number of patients seen per clinic session, or arguments about maternity leave provision. Meaningful reform means a fundamental rebalancing of power in the system away from doctors and managers and towards the people who pay for medical care in this country. It requires disintermediation – the removal of middle men between the person paying for a service and the professional providing it.
Meaningful reform is obviously necessary. My expectation is that the NHS and medical establishment will adopt a ‘consent and evade’ strategy. Sensing public dissatisfaction with the manifest failure of the NHS socialist model, they will vocally endorse change. while simultaneously preventing any real shift in where economic power lies. We risk ending up with the worst case scenario of an inadequate politicised NHS run by and for the provider interest and a ruthlessly exploitative private medical sector. I rest my case.
The author, the Daily Sceptic‘s in-house doctor, is a former NHS consultant now in private practice.
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I appreciate it’s the bleeding obvious but whatever happens we’re stuck with the same hospitals, the same doctors & nurses, the same patients. There seems to be a naive view from the man in the street that somehow all these things can be changed. They can’t.
What’s needed is for someone to set out a target 10, 20 years off, what health care provision will look like then. Only then can the steps necessary to get there be put in place.
In Australia, when seeing a doctor outside the hospital system, the doctor may accept as payment what Medicare (our version of the NHS) pays, or charge a higher fee, with the patient paying the difference.
In hospital, the patient may elect to be treated at no personal cost (other than through taxes) in the public system, where surgical waiting times are 1 year for non-urgent operations, or pay for private health insurance, and be treated rapidly, often with a variable gap payment, in a private hospital.
Not perfect, but the combination of private insurance, government payments, and patient contributions seems the best option.
Fine, let’s do it. But how to get there. Are both levels of service available through the same system of delivery or do we need parallel infrastructure? Will our taxes go down as we shift 40%, or whatever, into a self funding, insurance paid scheme? If taxes don’t go down are we simply throwing more money in.
It seems to me the only area for manpower savings, which are the biggest cost, are in non-clinical. From the outside it looks like a gordian knot.
Just underlines the disappointment that Bunter proved to be.
An 80 seat majority should have been ample to get to grips with the NHS and much else.
He even had a blueprint for NHS reform available to him:
‘Universal Healthcare without the NHS’ IEA 2017
Instead, we have the country in the worst economic shape it has been in since Harold Wilson.
Incompetence in government must have consequences……and so it will next year.
Excellent article. I did think it was going to be a one or two paragraph read but kept me to the end.
“Meaningful reform means a fundamental rebalancing of power in the system away from doctors and managers and towards the people who pay for medical care in this country.” Exactly this. A market instead of a monopoly. Market forces, accountability and excellence instead of box ticking, waste and money for old rope. Oh and expensive diversity, inclusion, equity and ‘lived experience’ ie institutional racism managers sucking up taxpayer money that could pay for hospitals, doctors and nurses.
Yes exactly. They market the NHS as ‘free’. Anything but. I pay a shedload of taxes into it, we don’t use it, it does not meet our requirements or needs and offers zero value for our money.
And there is no way of opting out.
Well this is a very revelatory and damning firsthand account of what goes on in the NHS and how they’ve been operating during the scamdemic, written by an ex director of End-of-Life care, and why he left his job as a result. An excerpt;
“55. The highest cause of death at every hospital per annum pre covid-19 is Pneumonia. Pneumonia is a respiratory disease like covid-19.
56. Pneumonia can be broken down into 4 different causes of death: Bronchopneumonia, Aspiration Pneumonia, Community-Acquired Pneumonia and Hospital Acquired Pneumonia. These four causes when added together kill the largest number of people on an annual basis prior to the pandemic.
57. The Medical Examiner (one individual in each hospital), was certifying all these pneumonia deaths as covid-19 deaths. When four different diseases [are] grouped and now being called covid-19, you will inevitably see covid-19 with a huge death rate.
58. The mainstream media was reporting on this huge increase in covid-19 deaths due to the Medical Examiner System being in place.
59. Patients being admitted and dying with very common conditions such as old age, myocardial infarctions, end-stage kidney failure, haemorrhages, strokes, COPD and cancer etc. were all now being certified as covid-19 via the Medical Examiner System.
60. Hospitals were switching to and from the Medical Examiner System and the pre-pandemic system as [and] when they pleased. When covid-19 deaths needed to be increased, the hospital would switch to the Medical Examiner System.
In addition, “hospitals were incentivised to report covid-19 deaths over normal deaths, as the government was paying hospitals additional money for every covid-19 death that was being reported,” Sai said. “I have no doubt in my mind, that the Government has planned the entire pandemic since 2016 when they first proposed the change to medical death certification.”
https://expose-news.com/2023/01/17/how-uk-hospitals-manipulated-cause-of-death/
In the years before the scamdemic pneumonia accounted for around 15,000 deaths p.a. in the UK. In 2021 pneumonia deaths dropped to the hundreds. As some wag suggested, covid 19 was a cure for pneumonia!
The last paragraph says it all. I’ve been involved with the NHS since the late 1960s and have lost count of the number of reorganisations that have taken place. They all had 2 things in common: they had the same impact as rearranging the deckchairs on the Titanic and the numbers of administrators increased.
Clearly the In-House Doctor and I should be on the Health Commission set up by “The Times”. We appear to have the same questioning spirit and though it is not explicitly stated, the same approach to plans: before any plan is implemented, examine what could possibly go wrong. I am also impressed that they have uncovered my contribution to the elective treatment centre debate, where I had one specific example in mind; that of the independent centre planned in Lancashire for musculoskeletal medicine. It was clear to me, and my colleagues and friends up there, that if you have a constrained budget and spend a large part of it on a new service then the old services will have to be scaled back. In this case the existing NHS units would have been denuded, there would have been a conflict of time management if orthopaedic surgeons were off the acute site and could therefore not manage emergencies, the consequences for training were catastrophic and much time would be wasted travelling between sites – something I had found for myself (it’s in my book “Mad Medicine”)
I will debate a couple of other points where we are not quite in agreement (for mostly we are).
Is the customer always right? In other words, how much weight do we transfer, when we plan, to the public? I have often said that as doctors are human beings subject to the same conditions as their patients they are in a unique position to judge what’s best. The only example of patient power I can recall personally is when we were building a new rehabilitation unit and the project was heavily influenced by a single very vocal and convincing individual whose lack of insight was profound. One of her demands was that there should be tablecloths at mealtimes – highly inappropriate for a population of people with severe weakness and/or ataxia. Public consultations in Canada produced a rather bizarre collection of priorities. That said, any debate on futility medicine must include the public but they must be advised at every step by people in the know.
I wrote a paper on performance-related pay for my specialist society – in 1994. Who will judge performance? How does one define performance? Numbers of patients seen? Outcomes? Hours worked? Technical difficulty? A combination? Pick any one, and I can explain why it won’t work. As an example, if one was to reward medics for seeing more patients that would be in direct conflict with one of the most important things delineated as a public want – that the doctor should listen. See https://participatorymedicine.org/journal/evidence/research/2015/06/25/what-do-people-want-from-their-health-care-a-qualitative-study/. Rushing through lots of patients won’t allow time to listen. In fact there is already an element of hospital doctor performance related pay in the shape of Clinical Excellence Awards, which reward contributions over and above the contracted work (although some will argue that the awards reward managerial and research contributions rather than clinical excellence). In 1994 I concluded that the Clinical Excellence Awards system (then known as Merit Awards) was the least bad option. And GPs get extra for various “quality” initiatives. But I still think there are too many pitfalls in differential payscales to spend a lot of time working out the details. Parity has ensured, at least up to now, that less popular areas of the country (and less popular specialties) are not disadvantaged financially.
Perhaps we should establish an alternative Commission under the auspices of the Daily Sceptic…