In recent days the failing NHS has been in the news again. Senior figures in the medical firmament have given evidence to a parliamentary select committee about the workforce crisis. A hard-hitting documentary on ITV exposes the ‘reality’ in A and E departments. David Oliver (President Elect of the Royal College of Physicians) writes in the Financial Times about the existential crisis facing our beloved NHS.
Readers will be wearily familiar with the choreography. The curious timing and alignment of views for example. The consistent line that everything would be marvellous, and nothing would hurt, if the evil Tories would just hand over even more taxpayers cash to the wonderful NHS.
I should say at the outset I entirely endorse the view that the NHS is failing. It’s been failing for years – the current inflection point is an acceleration in the pace and breadth of failure – not a change in the direction of travel.
The Daily Sceptic team have asked me to contribute some thoughts on the factors behind the mantra that it’s all about a funding deficit. Before getting into this subject, I should issue a trigger warning – some readers may disagree with me. Some may be very upset by my opinion. Some may want to ‘call me out’ as a regressive dinosaur unsuitable to be a practising doctor. Some may want to professionally cancel me or revoke my licence to practice. Some may think I am an evil person and should be burned at the stake in the town square.
I write partly in jest. The readership of the DS is (or should be) committed to freedom of expression. Sadly, the medical profession is not so keen. I cite the example of Merion Thomas, an eminent and highly respected cancer surgeon – hounded by an outrage mob and censured by his own Hospital management for highlighting in the press the shortcomings of primary care in the U.K. That was over a decade ago, when society still pretended to tolerate dissent. Being consistently ‘orthogonal to the orthodoxy’ (hat tip Sunetra Gupta), I can’t afford professional cancellation, hence retention of the invisibility cloak.
In a way, the use of the word ‘workforce’ sums up the problem. It’s a lazy managerial term for the disparate professional groups working in the medical or paramedical fields. It is redolent of the paradigm shift from professional control of the NHS to managerial hegemony which has been an inexorable trend over my 33 years in clinical medicine – and there lies much of the problem.
Let’s start with workforce demographics. A recent article published in the Daily Telegraph made the plausible claim that three out of four GPs now work part time.
Might there be an association between childbirth and female professionals working part time?
As 55% of the registered GP workforce are female, could this have something to do with the problem?
Is it possible that most female doctors are second wage earners, so have the choice to work part time? Could it be the case that fewer female doctors go into arduous and stressful specialties such as surgery, because intense work at nights and weekends is deleterious to family commitments? Might this have been predictable when over 60% of the current medical school intake are female? (When I entered medical school in 1983, 30% of students were female.) Weren’t these possibilities written about in the medical press?
Lest anyone misinterpret my view, I am not suggesting in any way that female doctors are inferior in quality or professional esteem to their male counterparts, just that they make different choices about working patterns for entirely rational reasons, and that this demographic shift was predictable and indeed predicted. Increasingly, their male colleagues are making the same choices, for reasons I will expand on.
The recently elected President of the Royal College of Physicians writing in the British Medical Journal has described those of us raising such questions as “ill informed, ill conceived, ill willed, outrageous, and discriminatory”.
It is simply impossible to have a rational discussion in public on this point, so I’m not going to bother trying. I simply observe that in 1987 there were 68,777 doctors on the medical register in England for a population of 47.3 million One doctor for 688 people.
In the whole of the UK in 2022 the figures are 350,000 doctors for 67.44 million – one doctor for 192 people.
The medical workforce demographic no longer meets the demand. This is not due to having an inadequate number of doctors – it is a consequence of how those doctors choose to work and how they have been trained. My cohort of doctors in our mid to late 50s are predominantly male and coming up to retirement – so this problem will get a lot worse, before it gets better. Which leads me to my next point.
Consider professional training. Two decades ago, a trend towards ‘problem based learning’ in medical education arose in direct challenge to the traditional medical school curriculum. A central tenet of PBL was that doctors ‘didn’t need to know’ the really hard science stuff in order to be efficient clinicians. If a doctor was a sufficiently empathetic and compassionate communicator the medicine would just magically sort itself out. Unfortunately, this is not true. Learning medicine is hard work. It is absolutely necessary that a doctor comprehends the basic sciences of anatomy, physiology, biochemistry and pathology. Such familiarity requires long hours spent sitting on a hard chair in a quiet room preparing for intellectually rigorous examinations with no adjustments made for those who fail to reach the required standard. Problem based learning is not a shortcut to excellence – it’s a direct line to clinical failure.
Higher training in the medical specialties has also changed. My cohort of trainees spent approximately 30,000 clinical contact hours in formal training posts over 10 to 12 years. We did an apprentice style training, comprising a huge amount of ‘service work’ – clinics, operating lists, resident on call, work at nights/weekends and so on, where we had to be physically present on the wards for days at a time.
Current higher professional training takes approximately 8,000 to 10,000 clinical hours, typically spread over eight years. We are told this is more educationally productive. It is certainly easier and less arduous for the trainee, but it’s less obvious that new style training produces specialists on a par with prior periods.
Measurable professional productivity in the NHS was on a downward trend before Covid, and has continued to deteriorate sharply since. Spectator data analysts have noted that European Health systems have recovered faster from Covid than the U.K. Why might that be? The authors of the Bennett Institute report ascribe the decline in productivity to lack of ‘investment’ by the Government. Oddly, they avoid discussion in relation to quality of workforce training and restrictive practices. I wonder why?
Next, I turn to the real elephant in the room – that which no one can speak of. The patients.
It is absolutely correct that the patient cohort are older and sicker than in prior decades. Why does this matter? More complex patients require more medical time. It makes each clinic harder work and more stressful for the doctor. Added to this stress is the increased tendency for patients to complain. Complaints take up huge amounts of administrative time to respond to and form part of the yearly appraisal and five yearly revalidation process for doctors. Simply put, if too many patients complain, a doctor can have their licence to practice revoked.
Readers may take the view that such a system is prudent and reasonable. After all, poorly performing doctors should be weeded out of the profession. There is much to commend that argument.
Regrettably, in practice, the complaints system creates a situation whereby clinical doctors are responsible for things over which they have no control. This is extremely stressful. As a direct consequence, some doctors avoid patient contact. They retire early. They shift their job descriptions to include more non-clinical activities – for example going into clinical management roles, medical education or research. They drop NHS sessions and work privately, where there is a higher degree of control over clinical decision making and where patient interaction is directly incentivised.
The simple truth is that the majority of clinical medicine is unrelentingly hard work and quite often boringly repetitive. Doctors are often faced with clinical problems they cannot solve and subject to complaint or abuse from dissatisfied patients and relatives. Further, there is no prospect of advancing one’s professional status by grunting through endless clinics on the front line. What honours and awards there are in medicine invariably go to those sitting on committees – not to the clinical workers.
But there’s more!
An NHS doctor gets paid the same for doing a timetable filled with non-clinical work as for doing a full clinical schedule. Faced with the opportunity of doing a less stressful job for the same money, doctors make a rational choice. To quote Charlie Munger (Warren Buffet’s business partner) “show me the incentive, I’ll show you the outcome”. If NHS management wanted to incentivise doctors to spend more time treating patients, they could start by addressing relative remuneration rates for clinical vs non-clinical activity and scrap increasingly onerous and intimidating regulatory requirements.
Readers may well ask, if what I have written is true, or even partly true, why are none of these matters being addressed? Again, this is a complex question. At the heart of it is the impossibility of open disclosure and discussion. When senior medical figures denounce discordant opinion as morally unacceptable or motivated by malice, there is no possibility of resolution. Politicisation of medicine inhibits open analysis of operational problems. In addition, there is the embarrassing possibility that many of the current incumbents in medical leadership positions have been complicit in generating the problems we now face. It’s a lot easier to blame the evil Tories than address intractable self- generated structural inadequacy.
There is no medical system on the planet that combines perfect clinical outcomes with perfect patient satisfaction. I think we need to stop treating access to medical care as a ‘human right’ provided by the state. Moving towards a system where medicine functions as an appropriately regulated professional service industry, where the onus of maintaining health rests with the individual rather than the Government, would eventually lead to better results. Available data comparing different healthcare systems supports this view. A European/Antipodean style mixed health economy with a variety of social insurance schemes and safety netting for the impoverished would be preferable to the quasi-monopolistic current system – it could hardly be worse. Such suggestions are anathema to the apparatchiks and commissars of our NHS. They react to such suggestions by vilifying and demonising doctors advancing meaningful reform, and by deliberately inculcating terror in the public about alternative models of care. Regular readers of the DS over the last two-an a-half years may spot a pattern of behaviour.
The NHS is socialism in practice. Nice idea. Never works.
That’s why its failing.
The author is a former NHS consultant now in private practice. He contributes regular pieces to the Daily Sceptic and is often referred to as our in-hour doctor.