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Wes Streeting, the presumptive health secretary (Hugh Hastings/Getty Images)
Any culture, society or nation is ultimately judged on how it protects its citizens, and how it treats and cares for its most vulnerable. And on this standard, the Conservatives have failed. Over the past 14 years, their contempt has spread from the corridors of power to the corridors of the powerless: hospital corridors where patients can spend up to two days waiting to be seen, where patients openly defecate in front of staff, where, in the worst imaginable cases, patients die from neglect.
Two years ago, I wrote here that the NHS was at breaking point. That point has now been breached. Every day in my own A&E department, I see colleagues — support staff, nurses, doctors, senior managers — in tears. In many respects, it’s encouraging: at least they still care. It’s when they stop crying that I know another person has given up on the system.
The bottlenecks are there for all to see: at one end of the funnel, thanks to breakdowns in primary healthcare provision, too many people access our overwhelmed emergency services. You’re now more likely to see an ambulance queuing outside a hospital than on your street. Inside, meanwhile, would-be patients are forced to wait in bloated emergency rooms, slumped on the floor. That’s because the other end of the funnel is clogged up, too. Bed blocking means patients are stuck in a holding pattern further up the system. Unless these conditions are resolved, a seamless transition from home to ambulance to A&E to a specialist ward is a pipe dream. No one can move forward; no one can move on.
Watching Channel 4’s Undercover A&E earlier this week, what left me slack-jawed was the surprise, rather than disgust, that a consultant displayed when he learned that a patient presenting with a suspected stroke had not been properly examined after being left in a waiting room for 24 hours. If you’re a consultant with an acute specialty, in a leadership role, and you’re not aware of such problems on your watch, then you’re part of the problem.
Especially when none of these horrors is anything new. In 2018, the Government placed Shrewsbury and Telford Hospital NHS Trust into “special measures” following concerns about “several challenges where patient care could be at risk”. These challenges included governance, urgent and maternity care and, revealingly, whistleblowing.
[su_unherd_related fttitle="More from this author" author="Dr Emma Jones"]https://unherd.com/2022/08/dont-go-to-ae/[/su_unherd_related]
How did the Conservative government choose to remedy this? By serving up five different health secretaries since the start of 2018, one of whom, Steve Barclay, served two separate terms in office. Not a single one has been able to manage, reform or revitalise the NHS in a manner they can present to the country as a vote-winning achievement. As Dan Poulter, the former Tory MP for Central Suffolk and North Ipswich, said after defecting to Labour ahead of the election: “I found it increasingly difficult to look my NHS colleagues in the eye, my patients in the eye, and my constituents in the eye with good conscience.”
And yet, while the case against the Tories is damning — years of neglect, underfunding and contempt — I’m far from convinced that Labour can do any better, or is interested in trying. Shadow health secretary Wes Streeting sounds like he’s got it in for doctors already. “You can’t just keep on pouring ever-increasing amounts of money into a leaky bucket,” he said recently. “It’s not right to keep on asking people on low-to-middle incomes to pay high taxes when they’re struggling… and it’s not right that they don’t get much for the money they are putting in.” As far as my colleagues and I are concerned, his message wasn’t hard to glean: NHS doctors are lazy and overpaid. And it seems few in the party are willing to correct him.
[su_pullquote]"While the case against the Tories is damning, I’m far from convinced that Labour can do any better."[/su_pullquote]
Since refusing to back Streeting’s call for private sector intervention, Dr Rosena Allin-Khan, former shadow mental health minister, has been M.I.A. regarding Labour’s health policy. Elsewhere, at least 30 doctors of assorted political hues are standing as candidates next Thursday. Not that you’d know it. Since the election was called, there has hardly been any discussion about the “national treasure” that is the NHS; they’d rather bury the subject until afterwards for fear of being unable to deliver on manifesto promises. Every party’s pledges to boost NHS spending seem fanciful at best, while it remains unclear how these promised funds will be allocated to each department. But such detail doesn’t seem important, especially when you can — as Labour does — simply promise to “cut NHS waiting times” and “double the number of cancer scanners”.
It's not my business to advise or suggest who to vote for, not least because, when it comes to sorting out the NHS, it will inevitably be a pyrrhic victory. But assuming the polls are right, and some force majeure doesn’t intervene, my fear is that, come the morning of 5 July, Mr Streeting will be my boss, empowered by a “supermajority” that will compel him to do… well, not very much.
Junior doctors will press on with their industrial action; the clogged emergency departments will continue to overflow; social care will continue to be ignored; and the private hospitals will carry on cherry-picking uncomplicated patients and leaving under-resourced inner-city hospitals to pick up the slack. To his credit, Keir Starmer has repeatedly made clear that the NHS is not for sale — but who, let’s be honest, would want to buy it?
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SubscribeIs the writer suggesting that the glorious one-size-fits-all creation of Nye Bevan at the dawn of the world is broken?
I don’t believe it. And neither do the experts.
So, Dr Emma Jones, what do you suggest?
Having provided us with a link to an article you wrote for Unherd in 2022, reading the Comments might’ve told you that your opinion wasn’t exactly useful to the debate. There’s nothing in this article that suggests you’ve learnt anything in the intervening time period.
Further, this claim you make, quoting the likely next Health Secretary Wes Streeting:
…is a perfect example of lazy thinking on your part, even if you’re not physically lazy – which no-one actually thinks anyway.
You cite a Consultant specialising in Stroke Care who wasn’t completely au fait with the waiting times in A&E for stroke admissions, and claim that he’s part of the problem. Might it be worth finding a mirror to look into yourself?
When Ben Whishaw did Paddington with the Queen, I wonder if he asked Her Maj if she had seen This Is Going To Hurt.
Quick answer: more doctors, less patients. Recruit and train more doctors; pay them well; reduce the massive inflow of migrants who are soaking up the low-cost housing, education, and medical resources of this country. Build manufacturing in Britain until “Made in the UK” becomes a thing again. Help British families grow, prosper, and thrive. Let British pride lead the way.
Generally yes.
But what is this “low cost” housing, education and medical care of which you speak ? None of these things are low cost in the UK (though they may often be low quality).
Exactly. They used to exist, before the flood of illegal economic migrants soaked up all the available supply.
Twaddle. No evidence illegal migrants the problem. As it is most of them are younger and have less health needs.
Now as regards legal migration, the NHS has relied on them for years because we’ve never wanted to train enough of our own. Chances are if you need care you’ll be treated by a legal migrant, or children of. Think you should be mindful of that.
Absolute rubbish. Immigration brings many problems, but if anything, the NHS is utterly dependent on it for staffing and would have collapsed completely without a long time ago. The twin evils of an aging population, and one ever more prone to chronic lifestyle disease rather than cheap sudden deaths account for the bulk of the problem. A secondary contribution is that medical inflation, like defence, outstrips GDP growth, so that you need a growing proportion of income spent on it just to maintain the same service anyway.
Have a look at the evolution of health spend as a percentage of GDP since its foundation. This is a problem which has been with us since the beginning when it was thought that the NHS would actually save money in the long term (haha). The only difference now is that, just like the rest of the welfare state, we have run out of plasters to stick over it.
There is no real reason why medical cost inflation should exceed general inflation. This – raising medical productivity and reducing costs – is a first order problem we should be addressing with urgency. You cannot go on indefinitely increasing medical costs in real terms. And certainly not when your tax base (working age population as a percentage of the total) is shrinking. Or when the level of economically inactive working age people is so high and continues to rise.
Yet I see no sign of any political party even recognising this as a primary issue.
Go and give blood and compare the level of equipment used to 40 years ago. It is of course true that technology should help labour productivity, but medical advances often work in the other direction. We do as well focus very expensively on prolonging life at any cost (within the confines of NICE and unofficial rationing of treatment) as opposed to quality. The problem with saving people from problems which would have killed them a generation ago is that they are now going to use you again.
in defence, the Economist famously had a piece pointing out that the rate of inflation in the cost of manned aircraft would mean that even the US would only be able to afford one of the latest generation in 2060 or so, to be shared between the different services.
One reason why immigrants are propping up the NHS is because Britain not only doesn’t fund nurses or doctors to train, it actually charges them – including, in the cases of student nurses, when they are actually working.
If some student nurses assist you on your next trip to hospital, they are actually paying for the privilege of doing so.
Charging medics to learn started with the Blair government in 1998 and the level of charge has regularly increased since then.
This is not to make a case against immigration per se – evidently it is needed and wanted in some sectors – but in the NHS the consequences of charging (penalising) students to train as (especially) nurses should not be a cause of celebration.
It was another Labour Government / Trade Union stitch up, with the Tory / Lib Dem, then Tory, Governments apparently oblivious of the situation:
[In 2008] BMA meeting: Doctors vote to limit number of medical students
https://www.bmj.com/content/337/bmj.a748
And not all nurses need a degree, though a path to more expertise through education should be available.
to clarify, in Scotland, student nurses don’t pay tuition fees and receive bursaries. also no strikes of doctors. not suggesting there aren’t any staff shortages or challenges
Samuel Ross referred to ‘illegal economic migrants’ – not the sort that end up employed in the NHS, who are presumably legal, but the sort that end up sucking £££ out of housing and health budgets.
Illegal migrants don’t have access to welfare benefits, social housing or healthcare. They tend to be predominantly young healthy people who disappear into the black economy so they don’t attract the attention of the authorities. So we have no accurate way of knowing how many migrants there are. .
Asylum seekers do have access to state support, but their numbers are tiny as compared with legal migrants entering the UK on work or study visas.
And of course no government has seen fit to bring in ID cards for everyone, and ensure there are sufficient staff to monitor who is coming in and out of the UK – which would at least give us more accurate stats on the true state of affairs. No wonder every government has failed to restrict immigration – because policy is built on lies and guesswork..
Low cost to the people using the services.
Yep something in that. How many years to train sufficient doctors and nurses so we can be self sufficient? Any idea?
Let me help – 3 years for a nurse, at least 5 for a doctor, usually longer to become suitably experienced. So even if we finally start to train enough now – and we’d need an explosion in funded training places – it’s some way down the line because we’ve been so short term-ist for so long. Thus the political challenge – do you switch off the migration that health services need now or wait until your long term plan starts to deliver? Dilemma isn’t it.
And as regards lack of a Long term plan, remember who’s been in power last 14years.
I’ve worked for NHS clients (and in pretty well every other branch of government) since the 90s and seen it all close up. It’s not a party political problem. The truth is that the British state, unlike the ruthless enarchy in France, for example, is not capable of running a system like the NHS. Too much failing upwards and bureaucratic empire building and no penalties for incompetence. ‘We don’t do blame’, they say. Time you did.
I suspect that an essential first step would be to accept your point that the British system as currently structured is unable to manage let alone reform the NHS. A good first step would be to carve out the NHS from the usual short termism of a Treasury / politician led Whitehall. Give it a BBC style system. Managerial autonomy with a separate dedicated health tax (perhaps a repurposed NI). Add some objective benchmarking with other health systems.
Much of the current downward spiral reflects a failure to train and retain enough doctors due supposedly to Treasury opposition to long term manpower planning because it made short term cost control harder. Another factor has been the failure to create a strong enough IT function which is a necessary precondition for improving productivity.
Obviously these would only be first steps. They might make reform possible but it would still require an outstanding team to sort out the NHS on a 10-15 year basis to make it a reality. At present, however, it is very hard to see any hope of the NHS being reformed successfully under current arrangements.
Much agree with AC. We need to sort the workforce planning. Debilitates so much. Arguably also too much credence last 30yrs been put on what the provider/commissioner split might deliver and the role of competition/internal market. There is no real market for emergency care which is well over 50% of the total. The private sector will cherry pick the most profitable stuff – generally lower complexity surgery and consultations so only ever offers a partial solution.
Fact is every developed nation has a dilemma about health policy and funding right now. Aging population adds to this. Much talk is made of need for reform, but v little detail (and Labour currently guilty of this too). I suspect though no magic bullet exists. The UK NHS model is actually v efficient at constraining macro-costs – salaried not ‘fee for service’ based (which generates over treatment costs), how we handle drug procurement because we negotiate on a national level etc. But whether we have all the incentives perfect self evidently not the case.
Give it a BBC style system.
And have it run by the same Oxbridge mafia that have given us every other domestic and foreign policy disaster of the past thirty years? God forbid.
The French, Swiss, Germans and Italians all have vastly better systems. Let’s admit defeat and emulate them.
The French, Swiss, Germans and Italians all have vastly better systems. Let’s admit defeat and emulate them.
Absolutely, but that is a generational undertaking requiring political b***s of steel and a long-term mandate to govern. I don’t see either of those on the horizon.
No one, in the past, has demanded it, and been backed up. It’s been ‘isn’t the NHS wonderful’, without a question mark.
And there lies the paradox. This delusional obsession with protecting “our NHS”, a system that is manifestly failing to provide an adequate standard of healthcare, is one of the great propaganda successes of all time.
Your suggestions make sense – but they still require money, not least to invest in more training places and build more effective IT systems. Money is the stumbling block because nobody seems to want to pay higher taxes to fund it. So we face the continued decline of the NHS whilst those who can will go private. Eventually we will end up with the same situation as is now the case with dentistry – prohibitive costs and an NHS that provides only an emergency service.
It appears that people are reluctant to pay extra taxes especially when such taxes are not hypothecated to health care, but they may be willing to pay more in compulsory health insurance premiums (with commensurate decrease in other taxes).
I agree that compulsory health insurance premiums might be the way forward – but how could insurers be made to take on people like me : aged 70+ and awaiting open heart surgery – without us being charged an exorbitant amount of money or being refused cover at all? The only way forward might be some kind of social insurance scheme which I think some European countries have.
We end up with an average doctor per 1000 of population lower than virtually every developed nation and 25% less than likes of Germany we are going to have problems aren’t we. Docs per 100k a crude metric of course, but the significance of the gap still tells us much.
Now as regards ‘blame’ the blocking of a national training plan is v clearly something politicians empowered to cut through if they wish. There will have been some vested interests seeking supplier shortfall.
There will have been some vested interests seeking supplier shortfall.
Oh come on, you were in the Navy, weren’t you? You know what I’m saying is true:
‘Look at our lovely aircraft carriers’
‘Yes, beautiful … but where are the planes?’
‘Oh … s**t’
It’s not a sinister conspiracy. That’s just childish. It’s a cultural problem within the state.
With the Energy Dept run by people with no STEM knowledge, and ending up with NET Zero policies, I expect it’s the same blind leading the blind elsewhere, including the NHS.
Consultants have seen a c30% drop in real-terms pay since 2008. An undeniable fact which hardly fits that narrative.
So have most others.
Also, very few of us are hitting the pension fund limits and demanding special actions only applicable to our group (and Civil Servants and MPs of course).
I don’t think that is entirely accurate. The BMA (Who don’t exaggerate TOO much) have produced good information on this.
Re Pensions – Doctors of my generation have essentially stopped doing extra work – you can earn an extra £1k, breach the new pensions rules, and incur a £10-12k tax charge – I’m not making this up.
This went on for several years.
Some of those changes have now been reversed, but the effect has been to disincentivise a group of proven workers who are central to medical outputs when there are 7M on the waiting lists.
It’s awful.
But, doctors have been punished for working – my wife is a truly exceptional doctor clinically and in terms of output delivered ( far better than me), and she has had to pay marginal taxes >80%.
With no option of fancy accountants to avoid it (PAYE).
To expose ordinary middle class people to that kills a society and a system (NHS).
Doctors and other senior public servants have been targeted specifically.
Fine, that’s a political choice, but the consequences are that it changes work culture and not in a good way.
Good comment.
Not that much of a dilemma: keep allowing immigrants who come directly to work for the NHS while training up many more of our own. Doesn’t mean we have to keep the borders open for all, hoping that they will drift magically into working in our hospitals.
You should study health outcomes on an international basis and you will see that the NHS has had a very bad comparative record for decades
This is all in the Reform manifesto. Reform also promises to keep up the high-skilled immigration we rely on in the NHS, but to stop the huge numbers of those who come to use it, but not help to pay for it. I know several doctors voting Reform…
However, I fear we’re going to have to tackle the awful moral dilemma of keeping so many extremely old people artificially propped up long term. Eg age limits on things like expensive heart transplants?
Yeah right. Of course Reform can promise the earth – whilst knowing that a FPTP electoral system means they will never be called on to make good on those promises.
Reform are suggesting how the system, could be improved, which is better than the Legacy Parties have ever done.
Suggesting how something could be improved is very far from actually delivering. Reform is run by wealthy people who have their own agenda, most of whom are ex Tories so can’t be trusted. Voting them into power would just mean a rerun of the last 14 years.
You’d better vote for that nice Mr Farage then. You’re precisely his target demographic. Thankfully not only is the voting system against him, but the majority in the UK are not that gullible.
Yet more puerile, emotive rubbish from Emma Jones.
“And yet, while the case against the Tories is damning — years of neglect, underfunding and contempt”
Really ? And I thought NHS funding had consistently risen in real terms over the last 14 years.
But who’s actually responsible for how the money is used ? Well that would be the invisible “Macavity managers” of the NHS.
“Any culture, society or nation is ultimately judged on how it protects its citizens, and how it treats and cares for its most vulnerable. And on this standard, the Conservatives have failed.”
Cited with plenty of emotion, but no real evidence. It’s an election. There’s never been an election I can recall in the past 20 years when the NHS isn’t “in crisis”.
If an organisation reallty is permanently “in crisis”, that usually means there’s something structurally wrong with it.
I don’t know if NHS doctors are “lazy and overpaid”. I very much doubt the “lazy”. And “overpaid” for junior doctors. But when consultants are lobbying for special pension tax breaks that would be denied to non-doctors in similar financial circumstances, I can see a vested interest lobby group at work. And one that is certainly not “underpaid” as far as pension benefits go.
Going further, the NHS appears to be one of those dinosaur organisations that still has seniority (as opposed to skils, competence and achievement) related pay. Whenever we hear about how small NHS pay rises are, the reports neglect the automatic increment that’s added every year to staff simply for still being there. In a similar vein, consultants seem to enjoy far better working hours and pay than junior doctors – some of whom must (statistically) be more competent than more senior doctors.
But these are not management and leadership issues within the NHS, are they ? Repeat after me – “it’s all the government’s fault”.
Just couple points of detail – the incremental pay rises are capped at 5yrs and fairly small. It’s true though that whilst originally more of this was linked to skills acquisition the recruitment and vacancy gaps mean often standards struggle to be maintained. You can have to settle for just having the basics covered or running a unit short staffed with all the consequences that go with that.
As regards ‘management’ – not clear of course who you mean, but Policy is set by the Ministers. The fact UK has not had a long term workforce plan for the NHS is entirely a politician/Treasury matter. The fact discharges are blocked by Social care shortages is again a politician matter as relates to how we all pay for Social care and how it’s provision is incentivised at a time when many more of us need it.
Politically there is a problem all health services suffer from to some degree – we know we need to invest/protect Primary care more – it makes such a difference to how Secondary care then functions – but the moment the latest new treatment or drug potentially available the pressure to fund that instead becomes v difficult to resist.
Is this in any way relevant?
BMJ 2008;337:a748. Delegates at the annual BMA conference voted by a narrow majority to restrict the number of places at medical schools to avoid “overproduction of doctors with limited career opportunities.” They also agreed on a complete ban on opening new medical schools.
Exhibit A. And it’s not just a toothless motion. The profession at all levels in the NHS and academia blocks the expansion of training. The most pernicious is members in our employment in our NHS refusing to provide more work experience places – essential if undergraduate places are to expand. It is a de facto closed shop.
Some of that true NC, but some is carving out time for training undergrads etc compromised by staff shortages. The here and now gets prioritised. It’s the chicken and egg dilemma. Nonetheless need to find a way round this.
Rubbish. I can assure you doctors want to increase work experience places, but these things are controlled by others. I used to get loads of 6th Formers on my ICU rounds and theatre sessions. These were then designated as a mental health risk (I’m not making this up) for people younger than 18 years old! Given that most people apply to medical school early in there upper 6th year, the programme effectively ended. The HR hoops for the slightly older ones completed the cycle. Doctors complained and pointed out how ‘non-progressive’ this was. They were ignored.
Doctors simply don’t have any power or influence in the NHS. To dismiss the views of the brightest individual group of workers in an organisation (medics in the NHS) who have decades of experience is insanity, but that’s what’s happened.
On the point made in other posts about the BMA voting against expanding Med. School.places – keep- up, please. The government continues a significant expansion in numbers of students and is opening several new medical schools- the doctors were ignored.
I don’t think Mr Streeting will be worse than the last dozen Health Secretaries, but he gives me no reason to think he’ll be any better.
Yep.
The nuance is the Workforce planning needs some granularity in type of doctor we need to train/have the most shortages. If you trained to be a Gynaecologist you don’t want to then retrain later to be a GP.
But essentially it’s an attempt to manage supply/demand to the advantage of their members.
“Any culture, society or nation is ultimately judged on how it protects its citizens, and how it treats and cares for its most vulnerable.”
Is it? Who is doing the judging, and how are they judging? And come to think of it, what does protecting citizens mean? Who decides what protection is or what protection I need or want?
If we do decide protection is measured in terms of health and wellbeing, then farming, energy, sanitation, refuse collection, education, industry, transportation… all collectively make a greater individual contribution to health and wellbeing than healthcare. You could build an NHS in Somaliland and life expectancy would barely shift without the aforementioned necessities.
Politicians may not be talking enough about the NHS in the eyes of a striking doctor, but in a general election there are 100s of competing issues, all of which are necessities to voters. Haven’t doctors for years wanted the NHS not to be a political football? Well here we are: the main parties aren’t kicking the NHS ball. The NHS is now far better funded than the OECD average (UK 11.3% of GDP vs 9.2% average), and has an independent executive team and regionalised tiers of medic-led management to deliver healthcare. Whose fault is it now if it still delivers far below OECD average outcomes and falling productivity?
The anecdotes of doctors such as this author point to a professional group unwilling to take managerial responsibility for themselves and their organisations. When doctors as an entire unionised group complain about “the management” and demand *more* political intervention, they’re conceding that they themselves are not effective leaders and managers. When one reviews the curriculum of medical schools in the UK, one is struck by the shallow coverage of management and leadership. Healthcare is a complex system and yet its senior professionals aren’t equipped or willing to lead and manage.
I can’t help but notice that the anglophone healthcare systems where British doctors quitting the NHS have departed for years are now all experiencing similar deterioration as the NHS. Canada, Australia: these are very different systems yet are now experiencing problems more traditionally associated with the UK NHS. In contrast, the wealthy Asia-Pacific healthcare systems with much greater language and educational barriers for emigrating British doctors go from strength to strength.
Being a good professional isn’t just about personal technical skill, it is about leading people, shaping change, and managing challenges. Are UK doctors good professionals when they – like this article – are all too ready to stamp their feet and snipe but offer zero constructive solutions, and still demand more money?
Doctors who are prepared to say difficult things to the hierarchy are targeted. You complaints about the appalling standard of leadership by doctors, whilst accurate, misses the point entirely.
As usual this is a statistic and detailed analysis-free rant from Dr Emma Jones. Of course a generalist politician Health Secretary of any party is not going to be capable during their brief tenure of the job to analyse and devise solutions to the many problems of the NHS as far as those working in the NHS is concerned their job is simply to fight for ever more money to be extracted from the diminishing population not working for the NHS to keep it going.
Unfortunately those working within the higher levels of the NHS seem intellectually incapable of suggesting workable suggestions to be adopted by the politicians that will deliver a better service. Of course it is possible that suggestions are forthcoming but are impossible to adopt because of the entrenched special interests and ideological capture of those working within the service like Dr Emma Jones who rejects any solution that doesn’t involve more money being extracted from the non-NHS sector of the economy. The author makes no analysis of the effect of immigration on the service or of alterations in working and non-working patterns and lifestyle choices impacting the service.
Unherd has to work with the writers it has but there must be others within the NHS or outside it capable of providing more interesting commentary on the NHSs than this author. Can Unherd not seek them out given the consensus that the current NHS is not working and is a significant national problem.
I kind of agree that Dr Jones article doesn’t provide any great illumination on what we might do differently. She also practices in A&E which does not mean she’ll be well sighted on what may be happening in all other specialties. That said I feel for any colleagues working in A&E these days. It’s hellish and nowhere better do we see how the public realm in the UK has been degraded.
But as regards key Policy choices, these are for politicians and some options exist that would probably reduce NHS unit costs in due course. The most obvious is train sufficient doctors and nurses ourselves. France and Germany have long term workforce plans for health sector with proper ‘needs’ assessment and direct link to educational places and funding. We’ve had it blocked by Treasury and politicians for too long, and the result is not only huge gaps, reliance on more immigration, but pay inflation simply via supply/demand mismatch. So we don’t actually save anything from not having a long term plan.
No politician, or thinking member of the public, can ignore social care either. It’s deficiencies and delays backwashes daily into the NHS making the NHS less efficient than it could be. The decision to avoid things like the Dilnot recommendations, because of fear too many of us will abreact, something that has to be faced sooner than later.
Doctors made A&E the mess it is. The GP contracts doctors fought for decimated out of hours care. Restrictive practices doctors continue to insist on mean other non-medical providers (commonly used in superior healthcare systems) cannot step in. The result is everyone needing out of hours care is dumped into A&E, the least effective, most reactive, most costly way of treating patients.
The salient facts are these: the NHS is now far better funded than the OECD average (11.3% of GDP vs 9.2%, 2022/2023) but delivers patient outcomes far below the OECD average, it has an independent executive, and devolved local management tiers. It really is badly managed. The senior professionals in the organisation, the doctors, are incapable or providing leadership and management and instead wash their hands of the problems and demand others sort it out. And this mess is now spreading to other healthcare systems where UK doctors are emigrating, suggesting the problem is UK doctors, not the politics.
Agree with gist of the point about out of hours GP services – albeit with an aging GP workforce and shortages rebuffing this was going to be challenging.
More fundamentally your OECD figs are just wrong. We’re well below the average. I don’t know where you got those figs. Interested in the reference if you have it.
No big organisation could contend it has perfect management. But interested in an example or two you see?
You simply have no idea how the NHS works. Doctors have next to zero power to lead. That is only for the Management class. Who can never fail.
Your complaints about doctors (I have plenty myself) are low-information in the extreme.
DoI: I’m an NHS consultant in and acute speciality, professor in same and ex Clinical Director.
I watched power being drained from actual doctors in real-time. I’d say it was complete about 10 years ago.
In the UK, it is at most 5 years between general elections, but it takes up to 7 years to educate and train a new doctor. Thus a health minister knows he/she will not reap rewards, before the next election, from funding more places in medical schools. The solution is either to extend the period between general elections to 7 years or to shorten the training period of doctors to 5 years (God help us.)
To be fair, Labour are the only party with any chance of reforming the NHS. It’s their child after all.
This is one of those conundrums that requires cross party agreement. A clear “let’s do something for the entire electorate!” moment.
I can make a start for them. Bin the DEI managers and depts. if you’ve been in the NHS you’ll notice the one thing it doesn’t lack is diversity in its workforce.
I disagree with you first point. Labour have never in my lifetime made any serious efforts to reform the NHS. I can recall the early Thatcher years when she went about reofrming public services like the NHS. Labour literally had no policies to offer on reform or improvements at that time. Little has changed.
What a reform you see elsewhere PB keen we adopted? Genuine question.
Labour have fought against all attempts to reform the NHS for the last 14 years. According to them any attempt at reform has been to privatise and not to improve.
I tend to agree though that Labour are the only ones who could attempt any major reform (or replacement) but the rest of the HoC would need to agree, or at least not oppose.
Do you really think Labour will ‘bin the DEI managers and depts’, when its leader doesn’t know the difference between a man and a woman?
And then he did know! Did he go on an advanced medical course, or was it the results of a focus group that changed his mind?
It’d be nice not to see the comments pruned to save the author’s blushes. It’s not like the surviving comments are anything but well reasoned criticism. I myself wanted to put some data on the bones about exactly how well funded the NHS is now, contrast the complaints about the NHS being a political football with the bizarre demand that this election spends more time kicking said football, and draw parallels with other global healthcare systems facing similar problems that are – coincidentally – also heavily staffed with UK educated medics. But no, another Jones article I can’t actually comment on except tangentially.
Give up now Emma. Come out to Australia, preferably the bush where the bureaucrats are out of sight, if not always out of your hair. ( We call them the “fluffy people “). Expecting things to improve on the NHS is ridiculous. The population is aging, medicine is improving so people are living longer with their obesity related chronic disease, and more and more minor social, personal and identity issues are expensively medicalised. Everyone wants to live to 100 then expire painlessly in their own beds. Incredibly for the first time in history this is not an unrealistic expectation. But all it does is create a culture of complaint when that doesn’t happen. So come out to the wide brown land, learn to chop skin cancers out of Celtic skin, Lance abscesses and pull fractures into place without anaesthetic etc and rediscover the fun. And take out private health insurance like we all sensibly do to take the pressure off the public system.
A strange article indeed. A tale told by, I won’t say who, full of sound and fury, signifying – well I don’t know what.
All I can clearly glean from all this foam is that poor Mr Streeting is obviously first in line for a public stoning from the blob when our new health tribunes take up their offices in the Devils Acre.
Repetition does not weaken the fact that the NHS is mismanaged.
Mr Streeting says he will reform rather than throw ever increasing £ at NHS. This will take time: up to 10 years rather than 5.
In fairness to WS, his comments as quoted do not ‘blame the doctors’. Many doctors have given up in frustration. As such it can be hard to find a specialist who will help you as a ‘Private patient’.
The possible good news: that, if there is will by Labour, it can improve matters; but fighting the resistance of the administrators & bureaucracy.
As a simple starting point GP practices should work 24/7, get paid on delivery of customer services rather than a fixed fee per patient. Anyone should be allowed to open a GP practice anywhere (suitably staffed) and offer whatever medical activity their skill set is capable of upto and including major surgery. They can attract patients from wherever they want. Paid on outcomes.
I went to a minor injury clinic recently to have a temporary dressing replaced after removing a skin cancer and prior to major reconstruction. The response “we don’t do that here” even though the place was empty. I went to the GP practice as advised and told “one week” to wait to replace a temporary dressing. I refused to go and after an hour and a lot of long faces got to see the nurse. She took longer to photograph the wound than replaced the dressing. What a load of rubbish, but we’ve become conditioned to absolutely useless NHS.
I’ve been watching the quite excellent (and often very amusing) Gresham College lectures on finance by Raghavendra Rao over the past few months. One of them deals with asymmetric markets – situations where one party to a transaction has more information or expertise than the other.
This seems relevant to the NHS in at least two ways.
Firstly, the obvious aymmetry between patients and medical staff where it is hard to question the authority of the experts. Even when they are sometimes wrong. And the medical experts can exploit this situation to avoid committing themselves or giving opinions or professional judgements when they wish to avoid doing so. I find this incredibly frustrating – and in fact, unprofessional.
More significantly, there’s an asymmetry between the job security and tenure of the politician who the public believe (mistakenly) run the NHS and the professional managers who actually do. Say what you like about the politicians, but it’s generally not too difficult to get them fired. But quite the reverse for the cadres within organisations like the NHS or civil service. It is almost impossible to fire someone there.
I think there’s an argument to be made that the fact that NHS managers (indeed also doctors) cannot be fired while politicians can is a fundamental flaw in the current construction of the NHS. And one which gives far too much power and far too little accountability to the staff.
This should be at the top of the Comments list, for all – especially Emma Jones, to read. Hopefully, some will read “newest” first.
No, you wouldn’t sell the NHS. You’d change the funding system so corporate health providers and insurers alike would invest in it. Government would underwrite and redistribute in whatever measure but the British population would become a lot more responsible for funding their healthcare in partnership with their employers and elected representatives. As in Europe, paying to see your GP and then claiming something back would be the emblematic gesture to change the British mindset.
On the social care point: I have been involved in (trying to) arrange this for two elderly relatives over the past fifteen years. The price is exorbitant and the quality dire – you get fifteen minutes, three times a day, at best, for patients who cannot dress or wash themselves.
The carers are badly paid – not much more than minimum wage – but the cost to the patient is close to the eqivalent of paying someone on the minimum wage full-time, even though you get only 45 minutes a day.
Next time (and I expect several next times) I am going to employ the carer direct, pay twice their usual rate and get longer hours for a lower total cost. Cuts out the cost of Social Services and the private healthcare company that employs the carers, which is most of what you pay for.
The NHS is not fit for purpose, and has been for decades if it ever was. I worked for the NHS in the early 1980s. I think people forget how awful it was then as well. I remember as a 16 year old employee thinking this is just not right.
The problem is that it’s primary function is to look after the people who work in it and the patients come a poor second. That how the South Staffs scandal happened and do not tell me there were not other health authorities with similar issues.
In 2006 I had occasion to contact the family GP as my wife suddenly relapsed and became critically ill. The local surgery were aware of the seriousness of her condition. I phoned the GP at about 5:15. She said what do you expect me to do I have to go home at 5:30. At about 10 am that evening I had to call the police and she was admitted to hospital and spent the next 3 moths in critical care.
The following day I contacted the surgery to inform them what had happened and probably expressed some views about the quality of the service (or lack thereof) but I said nothing about making a complaint. In 2012 I moved just over 3 miles. When the surgery found out the were quick to point out that I was outside the catchment area and would have to find a new GP. In the same conversation they asked me whether I was prepared to withdraw the complaint I had not known I had made 6 years earlier. The GP was not British. Says it all really doesn’t it.
Separately the NHS were responsible by negligence for the premature deaths of both my mother’s parents. Had any other organisation been responsible for causing death as a result of the same level of negligence there would have bee a HSE investigation and prosecution.
I read the article and below. I don’t see any solution to this situation. We all know the arguments. We’ve been round and round them. So here’s one conclusion: this is a huge opportunity for Labour. Imagine Labour solves the problem. The bottlenecks disappear. Patients get treated immediately. Doctor shortages end. etc. In addition, I bet the solution is not incredibly complex.
What a reward for Labour. The same goes for the budget deficit. Don’t go for tax rises, or do nothing. Go for deep cuts. For instance, end all subsidies to charities- there goes £80 billion; slash all potty quangos. Face the fact that Nigerians dominate in passport office.
The reward for Labour’s grasping nettles is enormous. It’s a once in a lifetime opportunity.
Oh dear, it’s all very sad, and it must be unbelievably frustrating on the front line, though I have to say that the service we get in A&E is not totally disastrous all day every day. I’m just starting chemo, and the cancer diagnosis pathway has been excellent. I had two surgeries each with waiting lists of over 7 years, and I’m happy with that as neither case was critical. Painful but not critical. And despite everyone believing that nobody can ever see a GP, they are averaging 30 million GP appointments. per month, in a population of 67 million.
My main point, though, is that I read a speech at the Labour conference in 2022 when Streeting was saying that he would transform the NHS. He made 10 promises, every single one of which involved spending more. Well there was one that didn’t: we’ll use more AI, as if that were a radical new idea. If he had said he would ensure that all information systems were connected between hospitals, that would have been welcome.
And Labour are single handedly responsible for ensuring that the NHS was funded from general taxation rather than a much better insurance based funding system. So half the population gets its funding paid by the richer half, and that also means that we consider your work free.
So please be assured that we are very grateful for all your hard work but I share your scepticism about Labour’s promises.
“Over the past 14 years, their contempt has spread from the corridors of power to the corridors of the powerless: hospital corridors where patients can spend up to two days waiting to be seen, where patients openly defecate in front of staff, where, in the worst imaginable cases, patients die from neglect.”
That isnt Tory ‘contempt. that is the incompetence and greed of you and your colleagues ‘Emma’. you murdered my father, put my mother through hell, had a good go at murdering my infant son, and nearly finished off the entire nation, demanding that we ‘protect our NHS’. £200Bn per year is spaffed down the bog on you and your cronies. you’re an effing disgrace. I would protect a dog t**d before i protected you. now, go back on strike you greedy, grotesque ineptitude. The only good thing a Labour victory next week will bring is the removal of your effing moronic ‘tory contempt’ excuse.
Why is the NHS pushing high Carbohydrate diets for all? There’re plenty of highly qualified medical practicioners in social media offering different diets for various situations, to alleviate different symptoms? And to the layman, it totally confusing, especially when the NHS response is to offer more pills.
But ‘Safe and Effective’ doesn’t have the same ring to it as it used to. And why is the NHS pushing Statins as a first resort? It’s no use blaming the pharmaceutical companies as their job is keep the NHS managers happy. And they certainly do!
As a resident of Shropshire who is unfortunately reliant on the Shrewsbury &Telford Hospital Trust I can attest that it is has been failing since the 1990s and nothing has changed since in was put into special measures. It doesn’t matter how much money and which shade of Government are in office it makes zero difference to the nationalised industry that is the NHS. The problems started with its creation. It was never budgeted for because there was no way of doing so, hence why restrictions were imposed in 1952 by introducing prescription charges. It has never trained sufficient numbers of staff, hence why we have been importing trained staff from overseas since the 50s. The widening remit of NHS treatments and the medicalisation of an ever expanding list of non-medical problems means that demand always outstrips supply. And then we come to the “free at the point of delivery” service which means it is unvalued by many of the users and a vast number of staff. But hey it’s “Our NHS”.
Soviet style systems Soviet type outcomes
Apart from rehashing the tiring memes about ‘underfunding’ Dr Jones fails or ignores that Ministers don’t actually set policy, that is civil servants in the DoH in discussion with NHS ‘leaders’, Ministers are solely there to sign the cheques (on behalf of the beleaguered tax payer and carry the can.
However, Dr Jones cardinal error is to think that there are problems ‘with’ the NHS when the problem ‘is’ the NHS. Socialism is a doctrine that has never ever worked and yet refuses to die; the NHS is failed socialism in action.
There are countless examples of universal healthcare in comparator countries that manage on about the same funding as the benighted NHS but deliver far better outcomes and, crucially, none are funded the same way (Cuba is the only other country that persists with the NHS funding model) (*).
I favour the New Zealand model where healthcare is insurance based until it becomes acute when the taxpayer steps in; a dear friend had a life threatening condition and the critical. care she has received from the NHS has been exemplary.
The Netherlands used to be funded the same way as the NHS but made the jump and now has stable universale healthcare and, significantly, not a single hospital is owned or run by the state.
Socialism always sounds so great and so kind, however it never, ever works. We associate pre-collapse Russia with endless queues, that is what the NHS now offers for exactly the sae reasons.
When doctors threaten to/actually do up sticks and depart for Australia, has it never crossed the minds of these, supposedly, bright people that they are escaping a socialist system for a free market one, like all those climbing over the Iron Curtain.
(*) For the avoidance of doubt the United States doesn’t fall under this comparison.
You have the New Zealand system wrong. Like the UK for those who can afford it, there is private health insurance. For those who can’t there is only the public system and $60 fees for seeing your local GP.
easing the burden on junior doctors could start with removing tuition fees for British students studying STEM subjects as from the coming academic year. Will an incoming Labour govt be insightful enough to do this? What conditions post qualification would be imposed if they do it? The impact on our young medics will be immediate and in the long term, result in more job satisfaction with better retention rates in the NHS.
Remove the fees so that they can then trot off to Australia without paying anything for their training?
Maybe cancel their fees after working in the NHS for 10 years but otherwise I don’t see why I should pay to train people into an extremely well paid job. I certainly couldn’t afford to work part time and then retire early because my pension fund has reached its upper limits! My GP practice seems to have 2 full timers and several part timers.
that would be one of the imposed conditions…. requirement to work in the state system for 10 years post qualification, but we still need to look at the conditions of service to stop them trotting off anywhere more desirable .
The NHS is truly in a dreadful state – in no small part due to softheaded thinking of hand wringing naive “thinkers” such as the writer this fact free polemic. Full of emotion and without any idea about a workable plan to improve matters. Unherd could surely print much better stuff than this.
An evidence/analysis free rant. Also manages to put the boot into a fellow A&E consultant-very professional.
Given that the overwhelming proportion of civil servants and NHS employees vote Labour, no solution that involves reduction of nonessential personnel will be implemented by a Labour government. It would be like turkeys voting for Christmas.
Well, not exactly MIA.
Dr Rosena has sent a missive out to the voters in the constituency she is standing in as Labour candidate. It was headed: Trust me, I’m a Doctor.
Of course she would be trusted – as a doctor.
She also emphasises – the bold text – that ‘Labour has pledged to bring waiting lists down’.
Emma Jones is so predictable.
“The socialist medical system could work if only we had better central planners”.
She lost me when she said the NHS is “underfunded”. Has she actually looked at any data?
Over-managed yes. Inefficient yes. Trying to do everything for everyone and failing yes. Underfunded – uh, no.
But doctors are lazy and overpaid
I wonder if the population is less willing to hold the NHS with the reverence it is supposed to?
Do we really think about “our NHS” anymore?
I don’t expect economic conditions to improve under a Labour Government, because the necessary radical changes are not proposed.
The facts are that we have 1000’s more doctors and nurses in the NHS with above inflation increases in overall funding. Our per capita spending on health exceeds Australia and many EU countries. But still the NHS has delivery problems, in fact performance is worse than it was in 2018/19.
Emma raises issues about the A&E bottlenecks with ambulance queuing for input and bed waits for output. This is a ‘line of balance’ production management and planning issue.
With respect to Primary Healthcare provision, if memory serves me well, the GP contract 2004 reduced the onus on GPs for out-of-hours and weekend cover. Since then the burden has increasingly fallen on A&E.
One of the KPI measures that has been focused on has been bed occupancy rates and management has been encouraged to increase bed occupancy rates. An easy way to do this is reduce the number of beds and, thus, without changing any other working practices or resources you are probably going to keep them fuller. This appears to have been the case as the number of beds in the NHS has reduced and is lower than most other first world countries. Are we measuring the annual occupancy rate? if so, then, seasonality of demand will impact on bed occupancy. Again, if present bed occupancy is 100% in Q1/4 (winter) but only 60% in Q2/3 (summer) then reducing beds will increase occupancy in the summer whilst winter occpancy remains the same therefore improving annual performance figures.
Emma turns her attention to Health Secretaries and apportions most of the blame for NHS failures on this one individual and the few members of his supporting team. It is ridiculous to hold the Health Secretary personally responsible for the organisational and performance failures of 1.2 million people employed in DHSC, Trusts and GP practices.
And here we come to a core issue. The NHS is one of the last monolithic socialist public sector edifices left standing the the Western World. It is run on the basis of a centralised planning cycle that is forever changing but does little to change the roles, responsibilities and activities of employees. Any major organisational changes will be resisted by the established staff representatives at all levels and the sanctity of the NHS will be leveraged to avoid confronting the truly dire decline in outputs and outcomes since 2019.
Firstly, there is no such thing as “bed blocking” – there are some hospitals that don’t have enough beds to meet demand.
The solution, in a word, is privatisation. Open primary care to any qualified provider with money following patient choices about which practice they go to or maybe the polyclinic as an alternative.
Turn the hospital trusts into community interest companies that must cover their costs with payment for services provided – either by government or by patients themselves. No restrictions on charging – maybe a “public service requirement”.
If a hospital trust goes bust, the facility is taken over by another provider – charity, CIC or (hold tight) American healthcare company.
If profits are made they are distributed to shareholders and management.
Major structural flaws of the NHS – no competition, no real consumer choice, no financial incentives to provide a good service – need to be eliminated.
Emotional claptrap like the article has no place in a serious debate.
Firstly, there is no such thing as “bed blocking” – there are some hospitals that do not have enough beds.
The NHS is structurally flawed and cannot provide a high quality service – no competition, no real choice and no financial incentives to provide a good service.
Privatisation. Freedom at primary care level – end the local monopolies of GPs. Bring in professional, profit motivated management companies to hospitals where the trust cannot deliver.
Emotional claptrap has no place in a serious discussion.
“Any culture, society or nation is ultimately judged on how it protects its citizens, and how it treats and cares for its most vulnerable.” This opening premise is border-line false – or at the very least poorly thought through. The rest of the article huffs and puffs based on the poorly developed premise and (unsurprisingly) ends up with nothing worth concluding.
But there is something useful in the opening sentence: there is a judgement and reckoning on culture society and nation. If the clever doctor understood the nature of that judgement, then she would be better placed to illuminate the way through the farrago which is the NHS.
Interested to read all the comments.
Amanda Pritchard is not mentioned once.
youd be forgiven for thinking there was no one at the head of NHS – only government ministers.
however furiously this subject is debated, surely the entire point of appointing someone to lead the NHS is so that some management can take place.
if Ms Pritchard cannot effect any change, then why is she there?
I believe it costs £170,000 to train a gp but that gp will pay £1.5m and £2m of taxes over their career. It is madness not to invest in as many doctors as possible with that return on investment. And many may go on to found businesses and industries. Have an exam to see who has potential to be a doctor and let them all train- don’t let the BMA and their government stooges constrain supply. And the NHS quality and waiting list problem could be solved in a year or two if the uk followed the Australian system of giving citizens the equivalent of an nhs card that could be used at any practice they chose, with the government picking up the bill at a set rate per procedure. Of course with means testing and private insurance to limit cost. We visited an a&e in Sydney last week and were seen within five minutes and had test results in two hours. Five days later we had a successful operation. High quality care, swiftly delivered, and much innovation creating wealth. Introduced by a Labour government more than 40 years ago. I hope Reform offer it to the electorate because vested interests control the nhs for the suppliers not the citizens. The whole welfare state should pivot to bottom up rather than top down decision making. The country would save a fortune and look after its people as it is supposed to do.
Funny isn’t it. The bottlenecks are there to be seen but not prepared to do anything to sort them. Just blame a politician. There’s a bottleneck right there. Sit back and moan, jobsworth.
“As far as my colleagues and I are concerned, his message wasn’t hard to glean: NHS doctors are lazy and overpaid. And it seems few in the party are willing to correct him.”
That’s not the only interpretation possible here. If we do international comparisons with other advanced nations, the NHS costs about in the middle of the pack, but it’s outcomes are not: they are worse than average. This means that there are billions of pounds worth of efficiency gains that are available, and Wes Streeting is therefore within his rights to speak as he does.
Besides, I doubt that anyone seriously thinks the problem with the NHS is its front-line staff. The NHS, to the extent that it works at all, works because of the dedication of its staff in spite of how badly it is managed, and this is a very common perception so I doubt anyone’s making the conclusion described above.
The nhs is and always was misconcerived when health care was nationalised by the Socialist government of Clement Atlee which could only conceive of a sovietised centally controlled model rather than building upon what was already in place which wasn’t too bad at all. This is esentially what happened on the continent which rejected a 100% state controlled/funded models and as aresult for the most part have far better outcomes where no one goes untreated despite the involvement of “private” healthcare eg much better cancer treatment outcomes and far far shorter waiting lists rather than the scandalous not to mention lethal situation in the UK which no amount of extra funding will ameiorate to any great extent. Unfortunately there are many vested interests involved in the UK’s healthcare system – managers, staff, unions and various quangos which prefer to leave the system as it is even when it is manifestly broken- many with an ideological animus rather than an evidenced based one.