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.
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Gollum eyed Whitty is a criminal who has benefited from the Medical Nazism of Rona. Here is a news flash. The communist NHS is a dysfunctional monstrosity that has little to do with health. Time to break it up. Here is another news flash. The health-care industry from education, to training, to hospital management, to drugs, needs liberation, not centralisation. Health is NOT the prerogative of the State and its criminal mafia ally, Pharma. End Pharma control of health.
I thought that the productivity of GPs was down because of dealing with patients who can’t speak English.
And dealing with patients who only speak English
Immigration.
Wokism.
Bureaucracy.
Militant doctors.
Nurses who don’t want dirty hands.
CEOs on vast salaries.
The solution?
Take all tax off tobacco.
Reminded me of an old “Yes, Minister” script, in which the Minister was advised by Humphry that tobacco was a good economic solution – it reduced life expectancy, less load on the NHS, and tax revenue in advance!
He knew a thing or two……
I repeated that one to a 23 year old trainee lawyer who thought it was a good thing that the government had introduced a law prohibiting children born today from ever being able to buy cigarettes. I think the penny dropped.
I also pointed out that the prohibition on the sale of alcohol in the USA in the 20’s gave the Mafia thir big break.
Imagine having a programme like ‘Yes, Minister’ on TV nowadays…..
If the government is prepared to let citizens become morbidly obese, it should also be prepared to allow them to smoke and stay stick thin. The cost to the NHS is a great deal less from smokers.
‘Smoking cost was £3.3 billion, alcohol cost £3.3 billion, overweight and obesity cost £5.1 billion.’
Journal of Public Health, Volume 33, Issue 4, December 2011
Get out of our lives.
Aside from all the other good points made by esteemed commentators below the line here, one other thing strikes me. The NHS has attained the status of a religious organisation and worship of it is widespread. It’s difficult to think straight about something that should simply be a means to an end that you should change if it’s not working if you think it’s some kind of sacred edifice
I would say the main reason is not being able to admit the real population of the country! They’ve lied about it so long now that catering for 80 million would give the game away so NHS just as to grin and bare it!
Productivity is the measure of unit output per unit input. Mostly it is labour productivity – output per hour of labour over a defined period – but can also include capital and other resources.
The simplest way to determine productivity is profit or surplus, that is revenue minus cost.
Since the NHS is a cost centre and generates no revenue, it is not possible to determine profit/surplus nor the value of its outputs which can only be discovered via a pricing system.
So not only can productivity not be measured, but capital and resources are allocated not according to the value of the output they produce, but by committee of know-nothings based on political aims.
Productivity is linked to pay which is linked to profit. In the NHS this link does not exist and indeed since reward increases are linked to length of service and grade, no increase in productivity is needed to earn more.
Perverse incentive: NHS staff have been trained by politicians to reduce productivity, yell underfunding, overwork, Tory cuts, too few staff which sets off a political cat-fight which inevitably leads to more money thrown at it, and pay rises to reward the self-less, overworked angels, saints and heroes of the NHS. As they were post-CoVid despite have 50% less work and spending their time on full-pay, unlike many others – making videos for Tik Tok.
Until the State gets its nose out of health care, leaves it to the private sector, Leviathan will only ever cost more and deliver less.
People need to wake up to this.
Very well said.
‘In other policy debates, there is willingness to learn from international best practice, and a general curiosity about successful models abroad. English free schools, for example, were modelled on the Swedish friskolor. Healthcare is the exception to this rule. The healthcare debate remains insular and inward-looking, blighted by a counterproductive tendency to pretend that the only conceivable alternative to the NHS is the American system.
It would be far more insightful to benchmark the NHS against social health insurance (SHI) systems, the model of healthcare adopted by Switzerland, Belgium, the Netherlands, Germany and Israel. Like the NHS, SHI systems also achieve universal access to healthcare, albeit in a different way, namely through a combination of means-tested insurance premium subsidies, community rating and risk structure compensation. Unlike in the US, there is therefore no uninsured population (even homeless people have health insurance), and there is no such thing as a ‘medical bankruptcy’. When it comes to providing high-quality healthcare to the poor, these systems are second to none: in this respect, there is nothing the NHS has achieved which the SHI systems have not also achieved.
In terms of outcomes, quality and efficiency, social health insurance systems are consistently ahead of the NHS on almost every available measure. They combine the universality of a public system with the consumer sovereignty, the pluralism, the competitiveness and the innovativeness of a market system. We do not see any one particular country’s health system as a role model, because they all have flaws and irritating aspects of their own. But there are also plenty of interesting lessons to be learned, which we are missing out on by ignoring alternatives to both the NHS and the American system.
The Dutch system shows that a successful health system needs no state-owned hospitals, no state hospital planning and no hospital subsidies. The Swiss system shows that even substantial levels of out-of-pocket patient charges need not be regressive, and that people can be trusted to choose sensibly from a variety of health insurance plans. The ‘PKVpillar’ of the German system shows that a healthcare system can be fully prefunded, just like a pension system.’
https://iea.org.uk/wp-content/uploads/2016/12/Niemietz-NHS-Interactive.pdf
As an experienced patient, it’s evident that “the NHS” is not like a normal business at all. The bureaucratic structure is complex, and in many ways it is reliant on private contractors in various ways. Quite a few of their senior staff work for both sides in tandem – say a few hours private, a few for this or that NHS hospital each week, and so on. Not many companies allow anyone to work for potential competitors at the same time. E.g. in the past I was referred to someone who I went to see privately (under private insurance) who would have been the same guy in an NHS place, albeit on a waiting list for a while. No waiting list on the private side, except a day or two to arrange an appointment.
No shortage of private hospitals physically just round the corner from an NHS one, sometimes on the same site, then there are dental surgeries that do private work in the same room. That’s how it is.
Until doctors recommend daily doses of vitamins, and real food diets, public health will NEVER improve. Food is adulterated, and a huge proportion of people live off highly processed garbage food based on carbohydrates. Long term deprivation of essential nutrients leads to all those western diseases.
There, fixed it for you, can I have my £10,000,000 consultant’s fee now please? It’ll be cheaper than trying to improve the NHS, which gave up wanting to treat sick people about 20 years ago.
My fix would be the Vitamin D Club. Each GP surgery runs its own club, membership is voluntary, of course. Member applies and is given a VitD test, which will show how large a VitD deficiency they have. On that basis, they are advised on how much VitD supplement to take. They become fully-fledged members only when their tests show a blood serum VitD level of >50 nanogrammes/mililitre (125 nanomols/litre). This entitles them to an annual reward of £500 inflation indexed. No payment if their levels fall below the minimum. They can increase their VitD intake at will in order to achieve the target. No charge for the VitD of course.
As membership grows, hospitals empty, surgeries’ wait times disappear because of this conservative list of diseases that VitD protects against:
Diseases that Vitamin D protects against:
Below is a long, yet still conservative list, beginning with the most important of all, because it is one that also involves generations to come…
Source: VITAMIN D3 AND THE GREAT BIOLOGY RESET by Prof David Coussmaker Anderson with Dr David Stuart Grimes. 2023. ISBN: 979-12-210-3569-8
Printed by Industria Grafica Umbra Srl – Todi (PG)
So there you are, and I’ll be happy with just a one-time payment of £5,000,000 for the idea.
A big factor has to be the number of elderly people forced to stay in hospital because there isn’t suitable community care or a care home space available for them.
How about we scrap the NHS with effect from the end of one financial year, with employees only being entitled to the minimum statutory redundancy payments. NHS assets are sold off and the proceeds used to reduce the public debt
The money saved is then used to reduce taxes and increase pensions/benefits in the following and subsequent financial years, and people are expected to fund their own insurance/treatment.
Yep, there’d be a difficult transitional period, but the current arrangements involved the NHS effectively shutting down because the bone-idle and thick-as-pigshit employees were scared of a nasty case of the sniffles.
Socialised medicine means you cannot have Mercedes. ——-You will probably have to just accept a second hand Polo.
I fully agree with you.
Further issues are that people can end up with the wrong Specialism and Specialists are so narrow in their field that any overview of the total patient is lost.
I think having good generalists in charge, with Specialists input may get the best outcome for patients.
And don’t get me started on protocolised medicine.
An insurance based system will not work in the UK, because UK insurance companies do not know how to treat customers, and are fundamentally out to take your money and give nothing back.
The NHS needs to be disbanded and UK healthcare replaced by a privatized system, as here in Germany, with mandated insurance schemes.
There is a big difference between the NHS and private hospitals: a private hospital wants to keep patients alive as long as possible, otherwise they have no income! The NHS attaches a ‘Do Not Resuscitate’ notice to your bed!
Many reasons why productivity is down. In hospitals – not enough beds and limits on operating theatre sessions; also bed blocking by the elderly because there are not enough care home places to discharge them to. In general practice – too many time-consuming targets; lack of working flexibility. In both – rigid appointment times waste time; if you have 15 minute appointments but the problem takes 5, then 10 minutes is lost (and, of course, if the problem is complex there is no slack for you to spend half an hour with the patient).
There are two generalist remnants – elderly medicine and rheumatology – where multisystem problems are so common that it would be dangerous not to be. Both call themselves the last bastion of general medicine.
For more detail see my book “Mad Medicine: Myths, Maxims and Mayhem in the National Health Service” (2019).
A lot of issues could be solved if citizens did not expect to live forever, and clinicians did not believe themselves capable of achieving that aim.