It’s not every day that the National Audit Office publishes a comedic masterpiece, but the bean counters of Whitehall should be congratulated for their recent report on managing NHS backlogs and waiting times (published November 17th 2022).

The sparse and laconic prose contains gems of humour that had me laughing out loud – and that’s not often said in reference to a document written by accountants.

One doesn’t have to be able to read between the lines to figure out what the national spending watchdog really thinks of the performance of our ‘wonderful NHS’ – sarcasm leaps off the page.

The Daily Sceptic staff have asked me to comment on the story behind the story – why, despite record levels of cash being shovelled into the Department of Health, despite record numbers of registered doctors, despite all the reports, plans and PR hoopla, the NHS is still not performing to the same levels as 2019.

I plan to do this in two parts. Today I will analyse several recently published papers on NHS matters. In a later piece I will consider factors preventing meaningful reform to the health service in the U.K.

Let’s have a look at the National Audit Office (NAO) report referred to above. I’m going to quote extensively from this document because it speaks for itself. Frankly, I couldn’t do better than the authors in exposing what is (or isn’t) going on.

On the first page, there is a list of figures showing that the NHS recovery plan calls for an activity target of 129% in 2024 relative to 2019. However, 26 out of the 42 primary care bodies have published their own projections showing they will fail to meet this target – and that’s likely to be best case scenario. I’d be amazed if any integrated care group gets anywhere near the central planning assumption, given that on the next page, the NAO states:

At the start of the COVID-19 pandemic, the NHS in England had not met its elective waiting time performance standard for four years, nor its full set of eight operational standards for cancer services for six years.

The report goes on to say:

NHSE’s elective recovery programme partly relies on initiatives which have potential but for which there is so far limited evidence of effectiveness.

And further:

In May 2022, elective activity for all ‘high volume, low complexity’ procedures was at only 85% of pre-pandemic levels.

It gets better:

NHSE has estimated that, in 2021, the NHS was around 16% less productive than before the pandemic… It believes that reduced productivity has continued in 2022-23.

You don’t say.

And the best bit:

It is DHSC’s job to hold NHSE to account for NHS performance, but some key metrics for measuring the recovery are hard to understand and could be applied inconsistently.

In other words, because of the bizarre and complicated way the NHS collates the statistics, they may be fiddling the numbers. Well, I’m shocked – never seen that before.

The NAO goes on to recommend the NHS sharpens up its act in relation to transparency and disclosure. These paragraphs are written in astonishingly direct language for an official document – the implications are clear.

The following 40 pages demolish the NHS ‘recovery plan’, exposing it as a utopian charade based on unrealistic assumptions.

I think this is the best line:

NHSE has opted not to produce a fully-costed version of its recovery plan, showing what it will spend on each of the programmes over three years. Consequently, we have not been able to give costs for the programmes on a consistent basis. It is not yet clear whether their cost will be equal to or greater or less than the overall recovery funding of £14 billion.

So, NHS England has been bunged £14 billion of extra taxpayers’ money, but is unable or unwilling to tell the national auditor what it’s going to be spent on. Can this be for real?

I could go on, but there are so many acerbic observations in this document I’d run out of space. I strongly encourage readers to have a look for themselves to discover how their increased taxes are being spent.

I next look at the Parliamentary Select Committee on Health and Social Care report on NHS workforce published July 25th 2022 and then the General Medical Council workforce report from earlier this month.

The Parliamentary Committee (chaired by Jeremy Hunt) concluded that the NHS has a major workforce crisis (who knew?) and this crisis is because the Government has not done enough ‘workforce planning’. I’m not arguing with the first point, which is self-evident, but the notion that the problem is due to inadequate Government planning is frankly ludicrous.

I commented on the real reasons for shortages of fully functional doctors in the NHS in a post earlier this year – spoiler alert: it has nothing to do with Government planning defects and everything to do with demographic change in the workforce, reduction in intensity of postgraduate training and onerous and coercive over-regulation. That’s before one even considers the idiocy of tax rules directly penalising the most productive senior clinicians, leading directly to early retirements.

The parliamentary report correctly identifies many NHS staff are suffering from ‘burnout’ and low morale. The politicians go on to recommend increasing the number of medical school places – without saying how that is to be done or who will teach the extra students; shortening postgraduate medical training still further – even though this is one of the reasons why NHS productivity continues to fall; and allowing everyone to work flexibly – which makes planning on-call rotas in emergency specialties virtually impossible. In other words, the Select Committee thinks all NHS employees should be able to work how they want, when they feel like it and be paid more. Unfortunately, the practice of medicine (including nursing) really doesn’t work like that – patients get ill 24/7, so doctors and nurses must be available out of hours and at weekends and bank holidays, irrespective of their ‘work life balance’. That really shouldn’t come as a surprise to new medical graduates.

The GMC workforce report is revealing. Headline points include:

  1. Two thirds of new medical graduates are female.
  2. 50% of new doctors joining the workforce in 2021 were from overseas.
  3. The rate of early retirement amongst the senior medical cohort has increased. 70% of these doctors are male and mostly work full time.
  4. Foreign doctors have a high tendency to leave the U.K. because working in the NHS system is difficult.

The report notes that new joiners outnumber leavers on the medical register, but fails to link this with the obvious fact that female doctors gravitate towards working part time in non-acute specialities. The GMC report is helpful in term of providing demography of doctors on the medical register, but that does not necessarily mean all these individuals are working in the NHS (or even working at all – one can remain on the register even having ceased clinical practice). So even though we have many more doctors on the register, we have fewer full-time effectives. Hence lower productivity despite larger numbers – a conundrum which frequently puzzles commentators in the media.

All of these reports and plans have a salient commonality – lots of warm words about making staff feel valued and making working life at the coal face of medical practice a more genial experience for doctors. I have to say, I see zero evidence of those aspirations being delivered.

Repressive and coercive regulation imposed in the name of ‘patient safety’ continually increases. Not a month goes by without some new unnecessary box ticking or form filling requirement being imposed on U.K. doctors. I sometimes think medical regulators are attempting to prevent doctors from providing medical care at all. Clearly the safest way of working as a doctor is not to see any patients. If one doesn’t see any patients, one can’t make an error of judgement, have a post-operative complication or be subject to complaint. I wonder what the National Audit Office might make of that?

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