Can Anything Save the NHS?

The Daily Sceptic’s in-house doctor – formerly employed by the NHS, now in private practice – has written a guest post about a recent Policy Exchange report on how the NHS should manage its huge waiting list. He isn’t impressed.

Last week, the think tank Policy Exchange published a report entitled: “A wait on your mind – a realistic proposal for tackling the elective backlog.”

I’m very grateful to the authors, because I love a good chuckle, and this banal document had me laughing out loud at several points. There is so much in it, I barely know where to start – this article can only scratch the surface. It commits the cardinal sin of most NHS ‘strategy documents’ effectively being a wish list for a healthcare utopia – oblivious to the obvious fact that in a world of limited resources, one cannot be strong everywhere.

Readers may not be aware of how or why such reports are constructed. As with all medical/scientific publishing, it’s important to understand the process of production to uncover the real purpose and message. I have contributed to several similar documents over the years. The starting point is normally a specific agenda that the report’s funders wish to push – this isn’t always obvious, although an informed audience can read between the lines. I note that this report was “supported by research grants provided by Ramsay Health Care UK, Smith + Nephew and the Independent Healthcare Provider Network (IHPN)”. Readers can probably figure out the agenda for themselves.

The ‘evidence’ for the report is generally acquired by selecting a compliant group of ‘experts’ that can be relied on to provide the correct opinions. The experts are gathered together with plenty of tea and biscuits – or a couple of cases of wine for a more revealing discussion.

Once the experts have sounded off from their particular perspectives, the writers craft the comments into a narrative. The language is usually verbose in style containing pages of pointless verbiage calculated to dress up the work as deeply researched and referenced. On closer inspection many of the ‘references’ are linked to other opinion pieces that conveniently chime with the predetermined purpose. Reliable ‘elder statesmen’ write a preface and a forward to create an illusion of gravitas and authority. Various other lesser figures in prominent medico-political positions are co-opted for endorsements.

The report is then touted around decision makers and passed off as a representation of current thinking. Successful documents provide decision makers with intellectual cover for controversial changes they want to make anyway. In some ways it’s a bit like employing management consultants – they are paid to tell policy makers what they want to hear, and to take the blame if the decision goes sour.

So, what’s the meat sandwiched between the glossy covers? The key message is contained in the very first paragraph of the blurb on the website:

The waiting list for elective treatment in the NHS in England has reached an unprecedented level. It is likely to become the defining NHS issue as we approach the next general election.

Effectively, this is a threat to politicians – Give us what we want or suffer the consequences at the ballot box. It will come as no surprise to readers that they want a lot more taxpayer’s money.

How big is the threat?

the total number of people waiting will grow substantially over the next 12 months, as a proportion of the 7.5 million people who did not seek treatment during the pandemic are referred by general practice.

Readers will note the language: “people who did not seek treatmen” – the fault lies with the public who did not come forward, not with the NHS.

Exaggerating the size of the problem has two advantages. Firstly, it threatens politicians even more – the implication being that failure to hand over more cash will make the problem worse. The elected representatives will get the blame, because the voters can judge them – whereas the NHS managers (who are really responsible for the problem) are not accountable to the electorate. Secondly, by inflating the numbers, the amount of money extorted can also be inflated.

And how is the extra money to be spent? Here is the first of several belly laughs:

New Care Coordinators should support patients facing long waits in pain for elective treatment.

Outstanding suggestion – we definitely need more managers to apologise to patients for the poor performance of the NHS – an excellent use of taxpayer’s money. To be fair, it is consistent with recent management of the system.

Here is another gem:

a massive expansion of the imaging workforce to staff the new diagnostic capacity – with an additional 2,000 radiologists and 4,000 radiographers required.

A 2018 report by GE Healthcare estimated there were 3,360 consultant radiologists working in the NHS. Policy Exchange is suggesting that we immediately find another 2,000 fully trained X-ray doctors, but are silent on where they are to be found. Down the back of the sofa? Hiding in garden sheds maybe?

Ironically, the report also says that “The NHS must adopt an innovation-mindset across the elective pathway”, yet makes no mention of existing technology relevant to radiology, such as companies using telemedicine to have scans reported by radiologists in other countries with high quality specialists (such as Australia), or use of AI to report routine images such as screening mammograms, where machine learning has already been shown to be more reliable than a human eye in picking up minor abnormalities on vast numbers of scans.

Why might that be? Is it possible that U.K. radiology doesn’t want competition from doctors in other countries? Or maybe they take a Luddite approach to new technology that might displace them from lucrative employment? The reader may very well think that – I could not possibly comment.

The next one is an absolute belter:

The NHS must become relentless in increasing productivity and patient throughput in treatment.

And how is this to be achieved?

the Referral to treatment (RTT) target should remain, given its importance for maintaining public confidence in the NHS.However, this should become a ‘split’ 18-week standard to encourage swifter diagnosis within eight weeks. The current operational policy standard should be replaced over time with a series of fines for ICSs who are unable to give patients a diagnosis/treatment decision within eight weeks of initial referral.

Fantastic – we don’t need another target, but a ‘target within a target’. Leaving aside the fact that we can’t even hit the first target in normal times, we will now put even greater pressure on the people actually doing the work and punish them when they fail to meet it. Genius. Why didn’t I think of that?

As far as actually getting more elective operations done, there is a sensible suggestion in this report – the establishment of ‘surgical hubs’ which are specific treatment centres that only do routine operations. Surgical factories, for want of a better term.

The report glosses over the inconvenient fact that this is not a new idea. Surgeons have been keen on it for decades and there are highly successful existing facilities doing exactly this – one example being SWLEOC orthopaedic clinic at Epsom (referenced in the report – it opened in 2004). The balkanised NHS management has opposed replication of these highly efficient models for years – too many vested interests in keeping remunerative elective surgery under the control of individual hospital trusts and keeping control of the surgeons. Getting this model up at pace and scale might reduce the size of the problem by increasing efficiency, but my experience of NHS management suggests it is unlikely to be delivered no matter how many reports are written or how much cash thrown at it. Curiously, the report recommends a similar system run by Ramsay Healthcare. I’m sure the fact that Ramsay funded the writing of the report had nothing to do with the recommendation, nor with the recommended 20% uplift of remuneration for areas with the longest waits.

My main criticism of this report relates to the ‘elephant in the room’ addressed obliquely and indirectly – the workforce problem. This is a complex issue comprising legacy issues predating COVID. Simply put for the benefit of readers, we don’t have enough properly qualified and experienced staff to manage the workload. Further, the best performing and most experienced people are leaving the NHS far faster than they can be replaced – and the replacements are not like for like.

Lest readers write me off as an archetypal old man disparaging the younger generation, let me elaborate. The EU working time directive was implemented from 2009 in respect of higher medical and surgical training, capping the average working week at 48 hrs from the previous 80 hrs for junior and many senior doctors. Combined with a reduction in the length of training, this has reduced the experience of new consultant appointees to about a third of that experienced by the cohort trained in the 1990s and substantially reduced the number of hours newly appointed consultants are expected to work compared with their immediate predecessors. This matters because in clinical medicine, experience is incredibly important and directly affects productivity. Simply put, a fully experienced doctor will process more cases per unit of time than an inexperienced one.

Further, the Royal College of Physicians recently published a survey suggesting that over half of current trainee doctors intend to work part time. So, although we have increased the number of doctors, the number of whole-time equivalents is falling.

As to why doctors are retiring early from the NHS, Policy Exchange think tank suggests it is to do with the lifetime allowance on pension pots. This may be a factor, but I doubt it is the principal reason. I can only speak from my own experience. I left the NHS in my early 50s for two main reasons. The first, overwhelmingly important reason was that I was totally pissed off with being pushed around by managerial mediocrities who had zero understanding or interest in the realities of clinical practice. The second reason was that I had a better option – the market for my skill set outside the NHS was and remains buoyant. That’s not the case for all specialties, but as the NHS continues to fail, the demand for treatment outside the system is likely to rise. Therefore senior doctors will have an incentive to withdraw from the service at an early stage, intensifying the productivity gap.

Of course, it is easy to mock reports for their facile solutions to complex problems, so, having said all that, what is my solution? Well, I’m afraid I don’t have one. My opinion is that the NHS is a failing system that is incapable of matching the outcomes and efficiencies of mixed healthcare economies in other developed countries. It’s been so for years and the inherent systemic flaws have just been exposed and exacerbated by Covid. If the aftermath of this debacle and the chaos yet to come convince the public that serious structural change is required, eventually we may end up with something better, but this report won’t provide it.

The publication is really aimed at extracting lucrative government funded contracts for existing private companies to exploit the opportunities presented by a political crisis. It is not about turning a monolithic monopolistic state provider into a mature mixed economy with multiple providers competing on price and quality – quite the reverse in fact. It effectively says that existing private providers are welcome but more regulations should be introduced to discourage new entrants into the market. The authors are quite happy for the NHS to continue to fail as long as the overflow contracts keep coming.

Plus ça change, plus c’est la même chose