Why Does the NHS Become Less Productive Every Year?

I’m going to start this piece by making a statement which will enrage many readers. Professor Chris Whitty has produced a very good report on the future of medicine in the U.K. Having just lost three quarters of the dressing room, I will attempt to explain why I’ve transgressed a cardinal rule of journalism by alienating my audience in the first sentence.

For those of you still interested, here is the link.

The first thing to note is the length – 267 pages. Definitely TL;DR (Too long; didn’t read). To be frank, I haven’t read all of it either. However, there are a couple of important gems in amongst all the verbiage. Whitty rightly lays out the medical challenges of aging populations with some very useful quantitative graphics. Along with all the mandatory faux optimism of an official report, here is the key paragraph:

The medical profession and the NHS need to respond to the rise of multimorbidity; further sub-specialising training and clinical care is obviously not the correct response on its own. It is essential that doctors maintain generalist skills alongside their specialist ones. [emphasis added]

There is a lot in those words, which I will attempt to unpack for those sticking with me. Non-medical readers may consider Whitty’s remark to be self-evident – and they’d be right! As ever, the devil is in the detail. You won’t find any detail in the deadwood press. It’s a lot easier to mindlessly chant about inadequate funding than to find out what is at the root of the problem. Here at the Daily Sceptic however, we love detail.

Whitty’s statement goes against a 20-year trend in medical education and training. Relentless drives to shorten training time, narrow the breadth of trainee experience, early subspecialisation and increasing ‘protocolisation’ of medicine have intensified over the period to the point where generalists barely exist anymore.

There are some benefits to this approach – for example there is ample evidence that surgeons who do high volumes of specific operations achieve better outcomes for patients with fewer complications. But, taken to extremes, super-specialisation also carries a cost.

Unravelling this issue helps to explain the productivity conundrum, written about in previous articles. How can it be that NHS productivity deteriorates year on year, despite increasing numbers of doctors and huge amounts of taxpayer cash?

Firstly, consider the term multimorbidity. What does that mean in principle and in practice?

In essence it means a patient with lots of different disorders. Some diseases link together. For example, a diabetic may have had a stroke, a heart attack and be unable to walk far due to damage to the leg arteries. That’s multi-morbidity driven by diabetes damaging arteries in the brain, heart and the lower limbs.

On the other hand, older patients often accumulate common diseases that are not linked together. For example, an elderly patient may suffer from prostate cancer, Parkinson’s disease and severe knee arthritis.

Perceptive readers may already have grasped Professor Whitty’s point. All these disorders require input from different specialists. In the first example, the diabetic patient will need regular review from a cardiologist, a diabetologist a vascular surgeon and associated radiologists and specialist ultrasound technicians. The patient may also be referred to an ophthalmologist as diabetes damages the retinal vessels, and a kidney doctor as the same thing happens in the kidneys causing renal failure. There may be more appointments with paramedical specialists such as dieticians or stroke rehabilitation clinics.

In the second example, the patient needs to see a neurologist specialising in movement disorders, a physiotherapist, an orthopaedic surgeon specialising in the lower limb, a urological surgeon for the prostate cancer and associated oncologists (one for radiotherapy and a different one for drug treatments). Some of these appointments may be with specialist nurses rather than with the lead consultant, but they all occur at different time and often in different places.

In between these multiple hospital visits, each patient will probably book regular visits to the GP for various complaints related to assorted aches and pains, depression, confusion about which medication to take, getting a form filled out for a disabled parking badge and so on. Pretty soon, being a patient is a full-time job – the week fills up with multiple visits to different medical appointments.

Professor Whitty’s remarks on sub-specialisation are not exactly revelatory. There are 164 different medical specialities listed by NHS Digitals Workforce. Each of these has multiple subspecialties – at least 800 subspecialty categories in the U.K. In 2020 there were 30,000 different specialist medical journals listed on the PubMed database and approximately one million medical research papers and articles published each year. It is clearly not possible for an individual doctor to keep up to date with all these advances.

The problem created by super specialisation has been an issue for many years. In 2008, Lord Darzi proposed the ‘polyclinic’ plan, to achieve ‘integrated care’. The intention being to create clinics staffed by multiple specialists – so patients just needed to make one visit to sort out multiple different health issues. Whitty has suggested something similar – a drive to co-ordinate visits to multiple specialists. The polyclinic plan never got off the ground, running into opposition from various interested parties. Curiously, the BMA was vocal in its opposition – how strange, who would have thought it?

This goes to the heart of the matter. Integrated care by generalist doctors is not likely to work in 21st century medicine because the profession does not want it. Healthcare regulators, politicians and the media have relentlessly driven narratives around ‘patient safety’ to the extent that doctors now rarely venture out of their safe lanes of specialist practice. Every year, doctors are required to sign an annual appraisal form confirming they only practice within a specified narrow field and their procedure volumes are sufficient to maintain competence. Similar declarations are required for medical indemnity insurers. The days of the old style ‘general physician’ have passed, because the risk of complaint, litigation and regulatory sanction inhibit clinicians from taking the personal risks associated with cross silo medical practice – even if it is in the patient’s best interest.

Welcoming Professor Whitty’s report, the British Geriatric Society claims that 43% of consultants in care of the elderly are due to retire within the next decade and that recruiting doctors into the specialty is problematic. It is telling that the BGS doesn’t comment on why recruitment is difficult – discussing the real issues can only be done behind closed doors. I will shortly comment on other recently published reports about the medical workforce which have relevance to this subject.

I congratulate Professor Whitty for elegantly outlining the problem. I’d be more impressed if he had a solution, but to be fair, I can’t see one either.

The author, the Daily Sceptic’s in-house doctor, is a former NHS consultant now in private practice.