by Dr Jonathan Snow
Many times during this pandemic we have been told that we must sacrifice our civil liberties, jobs, mental health and children’s education. Why? Because excess infections will lead to surge demand on the NHS that cannot flex capacity, leading to patients being denied the care they need.
Back in March the public and society was rightly sympathetic – there was very little time to plan for such a situation. But come Christmas, we are told that the NHS is still unable to cope with similar levels of demand, despite having had some nine months to make plans for a fairly predictable eventuality. Please don’t misunderstand me here – this is not in any way a critique of the fantastic clinicians and hospital workers who work tirelessly caring for patients at the coalface. Blame for the current situation has rightly been directed at the Government, but also, and rather unfortunately, at the public for not following the rules. But surely NHS and hospital leaders have some responsibility for not planning for this current wave – why are difficult questions not being directed at them? Of course, it isn’t possible to train more ICU nurses in nine months – ICU nursing is a highly specialised form of nursing that takes years to complete. But it is very possible to train other hospital nurses, whose departments will be largely underutilised in a pandemic situation, to ably support ICU nurses so that they can safely manage three or four times more patients than they usually would. Nine months is also a long time to secure additional intensive care hardware such as dialysis machines and ventilators. If this had happened, acute care and ICU capacity could have been flexed considerably this winter.
But perhaps a more fundamental question needs to be asked. The British people will pay a heavy price for lockdown in terms of non-Covid lives lost, mental health, relationships, livelihoods, children’s education and government borrowing that will be paid by us and our children for generations. When lockdowns have been imposed in part due to the NHS’s inability to cope – why are we being asked to sacrifice so much to prop up a failing institution? The question therefore follows – is the NHS in its current form fit for purpose? As someone who has been in UK healthcare and the NHS for 20 years I have seen at first hand that NHS is frequently unable to deliver basic 21st century healthcare in normal times. Cancer care performs poorly in this country and services cannot cope with modern chronic diseases such as type 2 diabetes and obesity where excellent available therapies are frequently not offered or provided. Every winter routine surgery is cancelled as hospitals do not have enough beds due to accommodation of the very predictable respiratory illnesses that come through A+E. And we are all accustomed and worryingly apathetic towards the plethora of NHS services with long waiting lists that would be unthinkable in other countries – this is rationing of medical services although often not stated as such.
Underfunding is an easy way to attribute blame for much of the above. This is likely part of the explanation – the UK spends less than many other developed countries in terms of GDP per capita. But to explain the NHS’s problems in this way would be to draw conclusions on the cause for the stuttering engine without opening the bonnet. With fixed costs for services and labour, along with structure and bureaucracy that do not incentivise excellence or productivity, many problems exist that stifle world-class healthcare. “I call it the NHSSR” a close-to-retirement NHS consultant colleague said to me several years ago. As a national public monopoly that has service rationing and long waits to access, there are some obvious similarities. And that is without the numerous committees that can plague productive decision-making and stifle innovation.
There is no doubt that the NHS was an institution appropriate for its time, shortly after the end of second world war. The population was smaller and people frequently did not live long enough to have chronic diseases. People used to die from heart attacks where they now survive and commonly encounter medical complications from surviving such an event. Modern medicine, to some degree, is a victim of its own success.
But is the NHS, a centralised single payer system, organised and managed in a way that can deliver world-class healthcare to all of its citizens all the time? We are used to being able to access world class services in other sectors – why do we accept something different in healthcare? For many, something as simple as getting a GP appointment in normal times can be extremely challenging. At the moment in the UK, a religion exists around “our NHS” that clouds and prevents criticism. It would be tantamount to political suicide for any politician to criticise the institution. Any criticism usually is responded to by claims that “we don’t want the US system”. This is true, but healthcare organisation on this planet is not a binary decision of either a socialized NHS model on the one hand or the US system on the other.
Looking at healthcare systems internationally, it doesn’t have to be this way. Other funding models can provide a free-at-the-point-of-use system with universal access. In Australia, there is a healthy mix of public and private providers, plus a competitive market for health insurance. There are tax incentives for members of the public to take private health insurance, as policy makers know that these individuals will use private clinics and hospitals and not the public system. This offloads the public sector and allows it to work better. Having worked there, I know that patient care in the public sector is generally better than in the NHS, as is the productivity of hospitals and morale of doctors and nurses. Medicine and nursing are highly valued careers in Australia. Consultants are able to have a good mix of clinical, non-clinical and private work that is vital for a long and energised career. This is not the case in the NHS where in recent years new consultants have had their non-clinical work cut and clinical commitments maximised. In some specialties new NHS consultants are being asked to do junior doctor night shifts to cover shortfalls, due to the fact that junior doctors are increasingly disillusioned with the profession and deferring, going abroad or dropping out. It is not just junior doctors that are leaving the NHS but also many consultants, particularly surgeons, departing the bureaucracy and poor management to go full-time private. Low morale and cynicism about the profession are sadly rife, and that was before the current pandemic.
There are also challenges in nursing. Many hospital wards are hampered by shortages of nurses and other allied health professionals. Chronic underpay, overwork and poor morale has led to nurses leaving the NHS to work ‘Bank’ or locum shifts, in an attempt to escape low pay and regain some control over their lives. This has led to a downward spiral of low staffing levels, poor morale, and more nurses leaving. It is no wonder that bright young graduates do not seek careers in nursing the way they used to in the past, or still do in Australia and other countries. This is perhaps one of the current NHS’s biggest tragedies.
The pandemic has challenged healthcare systems and society in ways that would have seemed unimaginable 12 months ago. But can we use this as an opportunity to reimagine how healthcare in this country can be organised and delivered? I do not have all the answers, but in order to move forward, as a society we must start by recognising the reality of our current health system and asking the right questions about how “our NHS” is structured, funded and delivered.
Dr Jonathan Snow (not his real name) is a critical care doctor and pharmaceutical physician.