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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But this is the real problem:
February 2024
More than 700 Nigerian nurses under investigation for taking part in ‘industrial-scale’ qualifications fraud could be working in the NHS | Daily Mail Online
May 2024
500 NHS nurses from Nigeria could be struck off over ‘fraudulent or incorrect’ exam results | Daily Mail Online
Some DM comments from the public:
— “And yet you show a photo of a white woman lol”
— “They are the most dishonest people I have come across, they get these false documents as nurses and go and work in care homes exploiting them I have seen them all it’s time someone did some investigation on these care home nurses.”
— “I asked this question 8 years ago and my shifts were cancelled. The hospital know this happens but ignores it, not exactly patient centred care.”
— “It’s obvious when you have to work with them!”
For me the question would be purely an economic one. What is the extra cost to the nation of the training involved, and what cost savings does that drive for the NHS?
But there is the problem : When you have a Communist Health Service, the first thing they do is break all relationship to free market pricing. So answering my question is impossible. And that, of course, is deliberate.
What really happened in Amsterdam…
https://youtu.be/DvTyg1kJGzM?si=-PwR6ncKHSl9utD3
We must be extremely careful what we believe in media in this modern age of misinformation..
Question absolutely everything..
I wont bother saying it…….. Yes i will… I told you so..
Astounding. That confirms what I read about a few days ago, but couldn’t find the link again: that Israeli youths actually started shouting insults and attacking first.
Yep, we seem to now be living in a true post-truth world.
I have a theory, where I spin everything in the msm on its head…. It’s served me well over these years…
Once one accepts that all the msm is one big lie.. You start to think about what was the reason for the lie….
https://youtu.be/LJxBnSyH0T4?si=_rI1AGoLZMb2FYK0
The media is lying to us… Eric Weinstein, what a brain this guy has..
I “checked out” decades ago…
There is so much you could say about this you could write volumes on every avenue and people have done so for those who are interested. I read a study in the Nursing Times a while back, before the recent exacerbation of the crisis, and if I remember correctly a survey found that within two years of working something like eighty percent of nurses reported feeling that they had lost all of their compassion. There was some speculation about the reasons and an acknowledgement that this detoeriotation would inevitable affect patiernt well-being. It is a hard job even under the best of circumstances ie good funding, low patient numbers, high staffing levels. But if you have someone who needs to go to the toilet and you know that they are about number six in your list of priorities because of the workload then perhaps a defensive numbness develops. People from overseas, especially America, often remark when working or receiving treatment within the NHS that it has a military feel which is understandable given its roots. The armed forced send their nursing students to the same lectures and placements as civilian nurses and this works seamlessly. Regardless of the sociopaths and psychopaths the cream of British society work in these institutions. The rot is the deep rot that pervades everything. The Jeremiad stuff is just jive talk which is sometimes disingenuous and more often just naive.
I don’t understand why it is not possible to have both graduate and non-graduate nurses. That would open up more opportunities for people to nurse and deal both with shortages and importing nurses from countries which no doubt need their own.
The problem is that getting well from a substantial illness requires nursing: not just getting the necessary tasks done, but being reconnected with the living: a little TLC, even if it’s ‘tough love’.
When school leavers, aged 16?, went straight into nursing, and on the wards soon after, it was an apprenticeship that included strengthening this connection to other human beings. Now, with the greater emphasis on knowledge and technology, this connection is, in fact, weakened: life becomes driven by theory: yes, a medical theory, but it is still an ideology, impersonal, and not helpful to nursing the sick. It why there are separate doctors and nurses, and patients can tell there’s a difference, even if they are not conscious of it. And once the connections to the rest of humanity, or even the community, are lost, it’s so hard to reconnect. Just look at the current Cabinet, lost in their political bubble, being bewildered by aliens, like farmers, manufacturers, shop keepers, and anyone running a small to medium sized business.
Of course, you can have traditional nursing skills with technical skills, (both nurses and doctors with both are usually outstanding), but emphasising the technical, at the expense of traditional nursing for all entrants, discards so many with the skills lacking in the NHS, and turns it into a regimented outfit, whether Military or Marxist, who cares?
You missed out that the current Cabinet also struggle to define what a ‘working person’ is let alone whether or not they have a penis.
People don’t know and they don’t even make the effort to understand and yet they simultaneously feel entitled to comment on a situation. Nothing new there. It is just intellectual laziness. They wonder why they are so disenfranchised. Maybe if you dig your finger out of your arsehole you might gain some understanding.
Hi standards are what matters. But the mindset of many graduate nurses is of climbing the management ladder ro get out of day to day nursing. We need good front line people to stay in nursing , not ro bugger off to damagement the first chance they get. And the demand foe all nurses to be graduates and for all management candidates to be so, is utterly foolish and quite spiteful by the graduate class.
And, get most of the immigrant nurses out of our NHS
Obviously there are some distinct benefits in training nurses to degree level, but not at the cost of provision of excellent nursing care. The patient essentially depends upon the doctors to determine the treatment and the nurses to administer it safely in a caring and competent manner.
There has been a definite shift in this situation since nurse graduates became the norm.
My own personal experience is that many nurses now regard themselves as too well trained to care for the holistic care of the patient. My own experience of nursing care bordered on what I and the Care Quality Commission considered gross negligence because the nurses mostly ignored the doctors’ instructions choosing to determine their own preferences without any consideration of the considerable medical needs of me the patient. They acted as neither competent nor caring nurses, doctors or health care assistants.
I’ve just written a supporting past, but under another post. But I would like to add that there was a nurse who came into my ward and briskly tidied up anything not in it’s place. She did so, slightly blaming those who had gone before, not vinductively, but to clear the air. It only took a couple of minutes, but I did feel more at ease. She knew what was acceptable, and what wasn’t really tolerable, for long, anyway.
I gather she had been at least a senior sister, and had come back to work, possibly part time, though she could have been like those ‘secret shoppers’ that provide feedback to management.
Whatever, I knew she had been trained in traditional nursing, because she exuded it. In a similar manner, I was, in my youth, a silver service waiter, and those subtle skills learnt were so useful in my career, which was always very technical. In the land of the blind, the one eyed man is king, or at least he’s less confused than most.
Surely the answer is multiple routes to training.
those that want to be ward nurses only could train in the job and those that wish to specialise, such as theatre or paediatric nurses should do the degree first followed by specialist top up training like the doctors do.
So two heads of university nursing units say that educating nurses at universities is a great idea…..
The problem is a State-run, Socialist health care system. Until people come to terms with that instead of writing about what’s wrong – we know! – and offer solutions to solve the insoluble, nothing will change.
Remove the State monopoly, restore healthcare to the competitive, private sector whence it came before Government nationalised it… starting in 1911 by the way.
Am I right in believing that nurses used to be trained completely on the job but received a small salary and accommodation in a nurses home; then entered the profession as qualified but without any debt? If so, what was wrong with that? If more academic study is required then with day release it could be provided and, if necessary, the course lengthened.