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'They have no one, except for us' (Christopher Furlong/Getty Images)
Last Friday night, a young man walked into my A&E department, mid-hallucination, and started to lash out at a crowd of patients. After being wrestled to the ground by my specialist clinical colleagues and security staff, it didn’t take long to ascertain the problem: he was suffering from long-standing mental health issues exacerbated by serious alcohol and drug abuse.
None of this was particularly shocking. It was hardly the first time a mentally ill patient had attacked another on our watch; nor was the trigger of his psychosis anything but expected.
More surprising (and troubling), however, was the scene I witnessed when I returned to work on Monday morning: the patient was still there, standing in my ward, cursing staff and patients alike. When I asked one of the nurses why nobody had staged an intervention, she explained that the psychiatry team were still assessing his condition, and whether he should be sectioned. And as a result, he had spent two and a half days on the ward causing mayhem.
Eventually, the police carted off the young man to be processed through the criminal justice system. But we’re under no illusion that this will cure him. No doubt he’ll return to us soon: yet another reminder that Britain’s A&E departments are reaping the whirlwind of a disintegrated heath, social care and psychiatric system that lacks joined-up thinking, let alone joined-up action.
Only the week before, I was confronted with the case of an 86-year-old woman who presented with a fracture following a fall at home. Despite her injuries, and being shaken up by the accident, she was as bright as a button. But as her octogenarian husband has dementia, and she is his primary carer, due to safeguarding issues he had to accompany her in the same ambulance to A&E — only to find that there was no room in the emergency department for either of them. They were both left in limbo in a corridor for hours while multiple members of staff and assorted agencies tried to figure out what to do with them. Eventually, they were wheeled into another corridor. Out of sight, and out of mind.
Both cases are typical of people forced to survive on society’s fringes. Whether it’s through deep-seated mental health issues or a debilitating condition such as Alzheimer’s, if you find yourself in a crisis with nowhere else to turn, chances are you’ll wind up in A&E — along with the hundreds of other people. The patients I see often don’t have the money to pay for a carer or book into a hotel for a few nights, or family they can lean on in times of need. They have no one, except for us.
[su_unherd_related fttitle="More from this author" author="Emma Jones"]https://unherd.com/2022/11/the-real-nhs-maternity-scandal/[/su_unherd_related]
For the most part, these people have paid into a system through progressive taxation and National Health contributions — just like the rest of us. But do they get value for money? Or do they end up on a trolley in a crowded corridor until they die from neglect? This is, after all, exactly what happened to 39-year-old Inga Rublite, who was found unconscious, lying under her coat, slumped in a waiting room at the Queen’s Medical Centre (QMC) in Nottingham in January. She died days later of a brain aneurysm.
As Britain’s new health secretary, and as someone who has experienced this A&E anarchy first-hand, one would expect Wes Streeting to make fixing it a priority. In 2021, after being admitted to the A&E department at his local hospital, the King George in Essex, with a kidney stone, a scan revealed a cancerous growth on the same kidney, which was soon removed. “That A&E found my kidney cancer and our NHS saved my life,” he reiterated a few weeks before this year’s election. “Now I'm determined to save our NHS.”
But will he? Put to one side yesterday’s announcement that Labour might scrap the Conservatives’ plan to build or expand 40 NHS hospitals by 2030, how is Streeting faring?
Along with Queen’s Hospital, Romford — which, as the MP for Ilford North, is also on Streeting’s local patch — the King George is run by Barking, Havering, Redbridge University Hospitals Trust (BHRUT). In May, it came out of “financial special measures” after failing to pay suppliers on time, though it recently declared an “internal critical incident” due to an evaporation of bed spaces. Only last week, the trust came under fire for seeing a fivefold increase in patient complaints; a few days earlier, a BBC news crew filmed 17 patients from Queen’s being treated on beds in corridors, a situation the emergency department’s director of nursing called “customary practice”.
Perhaps understandably, BHRUT is seeking £35 million from the Government for an A&E rebuild. As the trust’s chief executive, Matthew Trainer says: “The A&E at Queen’s was built for 300 people a day. In March, the average daily attendance was more than 600.”
[su_unherd_related fttitle="Suggested reading" author="Mary Harrington"]https://unherd.com/2023/07/the-nhs-is-powered-by-cakeism/[/su_unherd_related]
Now, given Streeting’s local connection to the trust, as well as his very slender electoral majority, I wouldn’t be surprised if he finds the cash for the BHRUT. But will other nearby A&Es be so lucky? There are, after all, at least six major hospitals in the Essex and northeast London catchment area surrounding his seat, all of which have high levels of deprivation, demographic change and patient acuity — a combustible mix when it comes to accessing health and social care resources. Just yesterday, it was reported that the BHRUT had the worst A&E waiting times in the UK, with a third of patients having to wait more than 12 hours.
None of this is to say that Streeting doesn’t feel passionately about the NHS, or that doctors aren’t rooting for him. Following a succession of careerist Tory health ministers, many of my colleagues feel reassured that we finally have a health secretary who seems willing to listen to our concerns. But even so, Streeting has a mammoth task ahead of him.
Indeed, look at where the money has been spent in recent months, and it becomes clear that this isn’t a question of competence or commitment — but of whether, given its profligacy, the NHS can be saved at all. A number of integrated care systems have been ordered to hire cost-cutting management consultants, with immediate effect, due to concerns over finances, while earlier this year, NHS England awarded £40 million to a consultancy firm to advise on “strategic and productivity matters”.
[su_pullquote]"This isn’t a question of competence or commitment — but of whether, given its profligacy, the NHS can be saved at all."[/su_pullquote]
Both these developments might seem perfectly reasonable, especially since roughly three-quarters of England's 42 integrated care systems have been unable to set balanced budgets for 2024-25. But we shouldn’t forget that these proposals are being administered by the same NHS England that has repeatedly thrown money at the very same problem — only to watch it go to waste.
Last year, in an effort to improve patient care and data efficiency, NHS England handed a staggering £330 million IT contract — the biggest in its history — to Palantir, an American spy-tech company. Palantir’s connections to the CIA and Ministry of Defence sparked concerns among campaigners about data privacy, but less discussed was the financial risk. Few senior doctors have forgotten the National Programme for IT in the NHS, which was launched in 2002 and supposed to improve services and patient care. It would have been the biggest non-military IT system in the world — but was eventually abandoned after costing more than £10 billion of taxpayer money. (The initial projection was £2.3 billion over three years.)
And yet, debates over the state of the NHS — and A&E in particular — are suffused with collective amnesia, with few willing to say that the honest thing: that the best Streeting can hope for is that Labour is able to secure a second term, beyond which point its reforms might actually take effect. But as things stand, Britain’s A&E departments embody everything that is wrong within the healthcare system, from social care to psychiatric support.
True, Streeting has taken the radical step of effectively dumping the Care Quality Commission, one of New Labour’s last innovations, which was long overdue. On the wards, it’s generally accepted that, as a regulator, it’s been hopeless. Several hospitals haven't been inspected for years, including one which was last reviewed a decade ago.
But simply shutting down an ineffective regulator and hiring expensive consultants to tell us what we already know isn’t “reform”. It’s not even a sticking plaster. Every week, I see patients presenting with medical conditions ordinarily not seen in this hemisphere or century because they’re not being treated until it’s almost too late. They are the broken Britons of broken Britain — and I’m no longer convinced we’ll be able to save them.
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SubscribePut medics in charge of hospitals again and get rid of unnecessary bureaucracy, mission statementa and other froth which is covering up the reality.
Whilst your latter points are valid, putting medical professionals in charge simply takes those trained to treat patients and asks them to ‘administer’ them instead.
What usually happens in this situation is that the medics with either the biggest ego or the least medically competent end up in charge, with resultant in-fighting amongst themselves and a never-ending blame-game of professional rivalry.
If/when they fail, their reputation goes down the pan and their ability to practise is compromised.
This is why GP Practices are failing too, since legislative changes put GPs in charge.
So what’s the answer? I’ve not particularly studied other health systems, but mamy seem to be doing so.much better than us. We should therefore try to replicate the best of them, whilst retaining the NHS ethos. This is to serve all equally, but part of the problem is that patients aren’t seen as the reason for the NHS, rather it’s become a place of a ‘job for life’ with the emphasis on protecting one’s own position.
I suspect the author of this piece, who writes regularly for Unherd on such matters, knows this – but it’s rather too close to home.
Thoughtful post.
Many health systems around the world are struggling, but few, in an advanced country, as badly as our own. We should be looking for a better model, not just patching up the one we have.
Its the ethos of the NHS that matters – we need to find the best way of delivering on that.
Some problems are created by the system itself. Where would consultants private work come from if there were no waiting lists? It is in the interest of consultants to have waiting lists so that people will go private to jump the queue.
Professionals tend to run organisations in their own interests at the expense of those they serve – it even has a name: provider capture. putting them in charge would not help.
The managerial problem is mainly that management in the NHS is impotent – the medical profession is too strong, and management too weak, to allow the service to be managed effectively.
Finally, if you hand over the money first, and then expect the service to be delivered later, you are disempowering users. They are put in the weakest of all bargaining positions. Small surprise they don’t get the service they have already paid for.
Remember it’s only really surgical specialties where private practice an issue. The Author is an A&E Doctor and no private practice opportunity in that field.
As regards better enabling individuals to exert purchasing power – there may be something in this for v specific services, but remember 55%+ of health care delivered is of an urgent/emergency nature and the time to shop around non-existent. Furthermore the balance of knowledge and information v asymmetrical which is why health services heavily regulated or folks get ripped off v easily.
In essence it’s more complicated
It’s more complicated than Emma Jones “patients” – since they aren’t patients until they’re admitted, which isn’t the case in A&E.
I guess she didn’t write the headline, but you’d think Unherd would run it past her. If it did, she’s very careless in allowing it.
Plus, i don’t need to “remember” what you think i’ve forgotten.
They are patients moment triaged in A&E. Most are never admitted. Vast majority of NHS care doesn’t involve admission.
They just aren’t, jw – accept it.
This must be one of the most ridiculous
arguments ever on UnHerd. So many people seem to make their case by redefining to their own convenience perfectly acceptable words (usually political terms) but in this case the well understood word “patient”.
This doesn’t just apply to people being treated in A& E! If you are treated or medically advised by a GP you are a patient.
Most Emergency Departments in the UK have an admission rate that lies between 38 and 44% of all attendees.
Fascinating to see this fact gets a downvote. I thought the point of Unherd is that its readers don’t shy away from facts they don’t like, but draw on them to reach logical conclusions that others might not like.
If you don’t like a fact, refute it with a more relevant or up-to-date one. Quote the source if you want to convince. But merely ‘downvoting’ a fact is like putting your hands over your ears and saying “la la la, I can’t hear you”. Surely we can do better than that.
So, GPs don’t have patients, really?
Of course they do. What’s your point?
You imply that Emergency Departments don’t have patients, which of course they do. A patient is an ill person who is being treated by a clinician whether as an inpatient or an outpatient or whether in hospital or in a general practice surgery. I think you were trying to indicate that Emma Jones, presumably an A&E consultant, could not consider someone with mental illness her patient. Which is wrong. Until any patient is accepted by another speciality, even patiets with mental illness, then the patient remains under the care of the A&E consultant and, indeed, remains the resposibility of that consultant.
no private practice opportunity in that field
Why not? Most people would be happy to pay to see a doctor immediately when in pain if the alternative is 8 hours waiting.
Yes it does work for some minor stuff in much richer areas, but you ain’t shopping around if being rushed to hospital with ?stroke are you. Truth is if you’ve got time to shop around you’re not an emergency – you are more likely ‘worried well’. It’s also not where a trained A&E doctor going to add much value.
Truth is if you’ve got time to shop around you’re not an emergency
I think you know that isn’t true. Many people in extreme pain and with quite serious conditions are often obliged to wait for long periods.
Yes of course most people would
You’re right, but it remains the case that A&E medicine doesn’t operate in the private sector in the UK.
Writing as an A&E consultant: you’re spot on. Thank you. I’m not sure who is giving you the down ticks. What you write is accurate and unobjectionable.
As Britain comes last in outcomes except for Rumania in EU countries, and is among the biggest spenders, I think it’s clear that it is not being mamaged effectively. In Germany the proportion of non medical staff to medical is 10%, not 52%
The whole system is different in Germany. But we agree that what we have in the U.K. just isn’t working.
We spend significantly less than likes of France and Germany – the sort of nations we typically compare ourselves too. They use a social insurance model, but to all intents and purposes that’s just a more hypothecated form of tax funding for health care. They also have better developed social care system though and that does make a difference but folks have to contribute more to it via taxation. Nonetheless they have problems with aging population too.
US just excludes c25million from comprehensive cover and still spends almost double what we do.
Far too crude to put the excuse on the attitude of staff within the system. Nobody could vouch for the attitude and professionalism of every employee. Probably the biggest thing we need to do is invest in social care and reduce how much impact this shortfall has on health services. But this a massive issue and both politicians and ourselves duck it repeatedly.
In terms of “the attitude of staff within the system”, i was one of them, for decades, and spent a great deal of time trying to push past it.
No we dont. We spend around 11+% of GDP this is the same as most European Countries. It’s slightly more than Switzerland.
Our GDP per capita is in the lower range in Europe, therefore the same percentage of GDP does not mean the same in absolute terms, the difference is actually striking; Germany spent $8,010 on health care per capita in 2022, Switzerland – $8,050, Norway – $7,898, Netherlands – 7,357, Austria – $7,275, France – $6,500 etc,
UK – $5,492 (!). Source – Statista
Taking Switzerland – salaries there are generally far higher, so presumably the salaries of medical staff are higher too.
If so, then that accounts for some of the difference. If not then U.K. medical staff are being overpaid relative to the rest of the population.
Nope. In those countries, healthcare spend includes the amounts people themselves choose to pay to top up their cover.
As a nation, we’re not spending enough on our own healthcare. Free things tend not to have their true cost and value appreciated.
Far better to have a system where people can choose to upgrade their cover, using their own money. Choice breeds competition, and competition keeps prices lower. That’s why private healthcare insurance in 2 countries where I’ve lived: Spain and Australia, are significantly cheaper than UK private healthcare. I’m sure USA will be likewise.
Read my earlier post. The funding system in most other European countries is different.
I explained the situation in France.
Source of that WC? I can’t find any source that suggests that
But 11% of a little could be less than, say, 9% of a lot.
Correct. Anyone can Google the oecd medical survey which I think is annual or biannual and you can see the proportion of GDP spent in lots of countries as well as the health outcomes and generally we spend above average and have terrible health outcomes. The NHS does not work.
We are among the top spenders, including France and Germany.
Per capita the key of course AB, and we have an aging population and workforce so what do you think is the right level? Include social care in this as that’s increasingly the game changer.
They use a social insurance model, but to all intents and purposes that’s just a more hypothecated form of tax funding for health care.
The crucial difference, of course, is that the hospitals are, for the most part privately run.
In the past thirty years I’ve worked for clients in every part of the public sector – including extensively in the NHS. Take it from me: the British state is not capable of running an effective health service.
Healthcare is not a natural monopoly like water or railways and is therefore much better run by private businesses and charities. The state may wish to ensure equal access for all citizens regardless of income, but that does not in any way necessitate or justify building a vast and unwieldy bureaucracy run from the centre. In fact, it’s foolish to attempt to do that.
If we knew what is the best way to run a hospital – or any other institution – then it would make sense to run them all in exactly the same way. But we don’t. So it doesn’t. Standardisation levels down, not up. Competition and diversity is the way to improvement.
Am I right in thinking that the Conservative proposal for a national health service after WW II (yes there was one) would have allowed the hospitals to continue to be privately run, by charitable trusts, councils and other existing proprietors. Instead we got the centrally planned behemoth of Mr. Bevin.
France and Germany have split systems, where you can pay more for upgraded care. Higher spend in those countries isn’t just government, taxpayer funded, it’s also people’s own discretionary money – when they choose top up, partly privately delivered treatment.
The health care in France (where I have lived for the last 20 years) is often cited as amongst the best in the world. And indeed, it appears to be that way if one needs specialist treatment quickly. But, it’s paid for. I personally pay nearly 1,000€ per year for private health insurance to cover the cost that the French state will not cover. There are exceptions however. Some people pay a lot more, others less. The level of cover depends on what you pay per month. The French state does not pay for everything, unless one is very poor. So in a way it’s a small form of privately funded health care.
But if we suggested that the UK adopt a similar system, I’m confident that it would induce cries of outrage about ‘privatisation’ and a people’s rebellion.
The NHS is a wonderful health service, and free at point of use. Often for quite complex medical interventions. But is it sustainable to all and sundry?
Clinging to the NHS Ethos would be a mistake. The Best systems in other European countries are insurance based . The Doctor is paid to see you . So to him you are an income . And also in the best systems he is self employed and the hospital is private. So the money is spent on medical treatment. Not culture wars.
No that’s not correct. In the key comparable countries they are employees of the organisations delivering the service funded by social insurance which is essentially a hypothecated tax everyone has to pay.
Now be cautious about ‘fee-for service’ payment systems too – over treatment and alot more diagnostic cost generated. Fancy a colonoscopy you didn’t really need? It’s one of the reasons US system costs so much more yet doesn’t have the population health benefit one would expect.
It’s not really a tax when individuals choose where and on what their healthcare money is spent. Choice is good, competition is good. Monopoly is bad.
We can only chose when the situation is not an emergency. Most healthcare tends to be emergency, esp as you age. And given the increase in dementia who’s doing the choosing for that growing cohort?
How many A&Es do you want in a town to offer you sufficient choice?
Choice has a role, and especially where the patient had sufficient knowledge to make an informed choice. But big limitations in healthcare. You don’t know if what you are being advised is correct do you. Would you trust a Thames water equivalent to make a decision in your best interest about whether you needed a colonoscopy or not? The NHS make mistakes but it’s not compromised by having a set of shareholders and dividends to pay first.
Denmark isn’t insurance based, but more than 2.7 million has an partly employer paid private insurance. Which can mean faster access to a consultant, and mostly minor operations, bad knees and so on. The state paid hospitals takes most of the critical and more complicated illness as cancer. But we have been working a lot to secure that mostly elder patients are being taken care of in their private homes or non hospital institution, so they don’t take up hospital beds.
As a few people have pointed out, in the uk the nhs is the system that we have and we are not going to move to a different one anytime soon.
So how to make the present one more efficient?
1.Plan for the aging boomer generation
2. Implement proper social care systems
3. Focus on preventive healthcare
4. Make free exercise classes and weight loss jabs (paid for) available to the obese, everyone over 28 bmi
5. Charge EVERYONE for missed appointments including benefit claimants
6. Mandatory drug and alcohol abuse programs; no transplants etc for addicts.
So what’s the answer?
The answer is to recognise finally that the British state is an incompetent provider – in contrast to, say, France, the culture of impunity is too prevalent – and that there is no reason at all why healthcare should not be free at the point of demand but not delivered by the government. Same goes for education.
The problem with that is the Providers cream-skim the most profitable and seek to minimise risk to them by having multiple exclusions. Ever read the smallprint in a US private health insurance offer?
I assume you would agree the training of doctors/nurses etc would have to be run nationally and not defaulted to the private sector?
And maybe bear in mind private sector not got a great record either – Thames Water for instance? Who then bears the cost of bale-out? You can’t have a Town’s only hospital close because the private provider made a hash of things.
Oh dear, why do you guys always default to the American example? Go to France or Switzerland and see for your self how much better the service and outcomes are.
I assume you would agree the training of doctors/nurses etc would have to be run nationally and not defaulted to the private sector?
Why?
Thames Water for instance?
Water is a natural monopoly and should clearly come under the purview of the communities the utility serves. No role for central government here either.
Who then bears the cost of bale-out?
No bale-outs are needed because there are lots of providers and surplus capacity. Go to Europe and see for yourself.
I think people in the mass are becoming more than a little tired of being told that the services they pay through the nose for have to be crap because there are no alternatives when anyone can see there are plenty.
No. If private cover is a choice and there’s competition and providers have to have competitive pricing.
The NHS is fleeced on every item they buy.
Do look at other health systems. The results willfascinate you.
So add to the shortage of doctors by taking them out to manage the service which they are not qualified to do. A previous CBI director who looked at the role of a chief executive of a hospital group said it was one of the most complicated jobs he had seen.
Yet elsewhere it is done by a director, a secretary and an accountant
Not on that level, it’s not.
How much of that complication was caused by multiple bureaucratic requirements that had nothing to do with health care — like meeting ridiculous DEI goals?
This is the same idea as the disastrous Lansley reforms.
_Careerist_ Tory health ministers? Oh, please. What’s more to the point is that there were eight Tory health ministers in the years 2010-24. And there were six Labour health ministers over 1997-2010.
In fact, since 1979, only two have served more than five years as health minister: Norman Fowler and Jeremy Hunt. For the rest, it’s a game of pass-the-parcel. It would be helpful if Wes Streeting served a full five years in post. But what are the chances of that?
Totally peripheral to the need for proper reform of the NHS, but charging people for having to use emergency services because they have drunk too much could help to ease the burden on A&E, especially at the weekends.
I’m not talking about alcoholics or the homeless or anything – I’m talking about the people who’ve just been irresponsible on a night out and literally ended up on the tiles. I bet there’s plenty of them, and if your hospitals are stretched then this kind of unnecessary drag on resources should be penalised.
They do that here in Austria – I think the charge is about € 700, enough to hurt and make you think again. Quick breath test in the ambulance or when you check in, and if you’re over a certain limit then you’re on the hook.
So do you do the same to somebody who has broken their leg playing football, as they knew the risk before playing? Do you charge the overweight if they have a heart attack? How many beers is too many in order to get charged? If I have 3 pints am I treated for free, but have a 4th and I face a fine? What happens if I’m leathered but the accident wasn’t actually caused by my being drunk? I’d that one a freebie?
This rule, as far as I know, only applies in cases of alcohol/recreational drug consumption. There’s this thing called “discretion” and the people at the hospital are good at calling the shots and assessing the situation – they’ve seen everything 100 if not 1000 times before. They know who’s been unfortunate and who’s been irresponsible and tied up resources that should have been available to someone else.
Whitey pays.
So two lads have been out drinking and both hurt themselves in the same way. They get taken to the same hospital but see different doctors. The first one gets charged but the second one doesn’t due to the doctors discretion.
I can see that causing issues down the line, the health service would be forever fighting cases to prove the cost was justifiable
What if I’m quite drunk but get attacked at random? Not my fault, I’ve done nothing wrong and otherwise the worst that happens to me is a hangover the next day.
The problem is the extra layer of admin you are adding in sorting out who pays, appeals etc would be burdensome. That is the last thing the NHS needs.
An organisational method would be to have a combined town/city centre A&E, and police operations unit, open in evenings at weekends – run it from the ground floor of the council offices, since they’re not in use at that time. That would then keep the drunks out of the main hospital A&E, except for triaged ambulance cases, and, as most would be walk-in-walk-out, beds would not be required. Ask the users to return to do some cleaning and tidy-up or set-up help as recompense for the assistance they received, or a payment if they can’t do this.
Obviously, this is a guess and probably infeasible. But creative solutions to cut costs, while improving service, by applying imagination are preferable to seeing the continue squabble for money. The NHS needs to be continually experimenting with better ways to deliver that are all of higher quality, faster and cheaper. That is the point of technology and innovation – healthcare should be getting less expensive and better.
I believe Russia has a system like that. But Russian hospitals don’t get into trouble if a drunk dies from a brain bleed while in a drunk tank.
This article gives Labour a free ride. How will scrappingthe 40 new hospitals (not just reducing it to 20 or 10) help? How will giving junior doctors a 22% pay rise help? The CQC may not have been peefect but there isn’t really a plan for what to do next. Giving it to PWC will surely be better but only if the suggestions are followed even if the entire medical profession is howling in outrage. The only glimmer of hope is that Labour might be able to pursue real change – almost any other system would be better.
If you have open house for the world, all the worlds detritus will end up on your floor.
Yet another article by this author which paints the grimmest possible picture of the NHS without offering a single solution. And she seems unwilling or unable to accept that she may be part of the problem
She’s a doctor. She fixes people, not large organisations. No surprise if she has few answers. But still better that she is ringing the alarm bell.
What a very unfair, not to say utterly pointless, observation…
What do you suggest? The solutions are there, but they all ultimately involve change in the way our society treats individual responsibility.
A doctor is powerless to fix multi-generational rubbish education, terrible parenting, schools that are powerless to exert discipline, a decline in personal responsibility and community spirit, readily available cheap recreational drugs, a decline in civil and sexual restraint, opportunistic lawyers and a human rights framework that expects miracles without any suggestion as to how they might be funded.
Don’t blame the messenger for failing to provide a solution for the bad news she bears.
I am with you on most of what you have written in your various comments so far but not on this. Of course some individuals are irresponsible, more than a few probably, – in every society, in all of history! But that doesn’t mean that the NHS cannot do better. Last year throughout 2023 I was witness to my father being taken through the NHS [Scarborough hospital] from A and E (2 and a half days) to a ward (pressure sores in the first week – never had them before) to a succession of wards in which the norm was that staff never made sure he eat or drank, they did not help with feeding or drinking,howrver many times I raised this with staff. So of course he deteriorated and lost loads of weight. He couldn’t speak or move independently by then so couldn’t ask them to get him a drink. During all that time in different wards and with different specialties, it was just obvious that there are simply zero accountability provisions in NHS practices on day to day basis or at all. Charge nurses have no substantive authority over staff; doctors none over global patient care (only over narrowly circumscribed medical decisions) and the patient and/ or their representative less than zero. There are literally no sanctions on staff for patients getting pressure sores, becoming dehydrated, losing weight, falling over. When I let one nurse know the patient in the bed next to my father had had no food she said in a loud voice ‘it’s OK he’s end of life’ – that poor man could hear everything as I’d been talking to him. He died a couple of days later. probably some of the last words he heard. When I raised it with the matron- it was treated as merely unfortunate.
This just comes across that the NHS and A&E are simply badly run. A psychiatry team taking more than 2 days to assess someone leaving him stuck in A&E is an appalling failure of organisation and priorities, nothing to do with money.
But why do I get a sense that there is no senior responsible doctor raging and bullying to get the patients cleared out of A&E? It’s emergency treatment – there is no need to be nice. Throughput is more important than bedside manner.
It’s not bullying that’s needed, just effective leadership and management. Also, in my experience, senior medical staff are pretty thin on the ground at the weekend when A&E usually have a rush on.
It’s surprising how the health system seems to think that people don’t get sick or have accidents on a weekend.
Take two aspirin and call me on Monday.
Rubbish! It’s paracetemol.
Cleared out to where SD? If there is no bed, or placement available? Why do you think some psychiatric patients wait so long, esp kids, and then may be shuttled miles away – because we’ve not the capacity. It is true that sometimes things get normalised and we have to re-sensitise to what is happening but that doesn’t create more places to move patients to. You also assume all psychiatry posts are covered. Of course they aren’t. We haven’t trained enough.
Health policy has been badly run for over a decade, assuming somehow we’d have an aging population and not need a good bit more health and social care, plus a workforce plan to deal with an aging workforce.
This assumes the person needs a bed. It assumes no other help or care is available. It assumes that two days waiting in A&E is acceptable as a fallback solution.
If you have a person who has waited for several hours in A&E, is causing problems and discomfort to other patients then prioritise assessment, don’t let him hang around. Find out who or where he is being cared for. You move him out of A&E to somewhere more appropriate, most probably his home or a relative. And if that doesn’t work, you make space somewhere else, because otherwise you’re left making space in A&E. You call his social worker in the middle of the night if necessary.
Someone has to make things happen, even if that’s uncomfortable. Two days in A&E because ‘resources’ is not an answer. A senior doctor needs to rage and bully and make a solution happen and the NHS needs to support that authority, not accept shrugs and sitting around passively complaining.
This solution assumes that primary care, police or social care have adequate resources, but they do not. And the NHS is chronically under resourced as well, which is why so many of the problems occur. Rearranging and reallocating inadequate resources of staff, facilities and capacity, no matter how ingeniously, cannot solve the problems.
But Brits are just not willing to pay for these things through higher taxes. And arguably never have been
I suspect we are willing, but it’s always undercut by somebody saying it’s not necessary in attempt to gain electoral advantage.
The NHS is not ‘chronically under resourced’. In the last fourteen years it has had massive amounts of taxpayers’ money given to it by order of the nasty Tories it and yet is still performing abysmally. The problem is the funding model and the structure – and in some parts of it, the culture too.
Absolutely right! The Bevan imposed structure was bound to fail eventually. Herbert Morrison, an extremely competent organiser, opposed that model.
Exactly penny
As an on call GP at 6pm I do not have the resources to manage the acutely psychotic patient either. Nothing happens fast in social care because everything is full. Psychiatry is the most under resourced and staffed of all areas in medicine and they’re discharging a lot of patients very early as a result.
Social care is DEFINITELY under resourced.
I also want to say that we provide a lot of amazing but expensive medical care on a daily basis that we didn’t even 15 years ago.
But I too am coming round to the fact we need a different system
But it will cost everyone individually more. This is certain.
I’d look to dutch German and scandi systems. French do some very odd and excessive things medically in my experience of treating patients from france. I’m not in favour of funding medically unnecessary care…
Let’s assume we all agree the waiting times are dreadful for such patients.
So in your example let’s assume the assessment has been done and the patient needs time in a proper psychiatric unit – bear in mind anti-psychotics take time to have effect (sometimes weeks) and this assumes the treatment is merely pharmaceutical. (I think you are a little naive as to what usually happens to such patients and how difficult this is). The lack of capacity to move them to someone more appropriate for their complex care means they languish in A&Es for far too long. We just have insufficient places hence delays
But obviously A&E is the last place this person should be. So the doctors on A&E have to have the ability to hand those people over to places more suitable, and that’s where the battles over resources need to take place. Clearing A&E should be the priority – that means a senior doctor in A&E who can throw his/her weight around and pass cases to places more suitable.
The A&E Doctor reviews and if the patient needs a psychiatric review they refer to the specialist who can come down to A&E and do that. An A&E doctor is not able to do that. Then that professional decides what needs to happen. If it’s patient needs admission to safe place, often the case if patient having a psychotic episode, then the search for a suitable and available placement commences. If there is nowhere available because all the psychiatric hospitals are full the patient waits. The search then gets extended to other parts of the country too.
Where else do you think the patient can wait safely? A&E is massively sub-optimal but there isn’t anywhere else. All reflects failure to provide sufficient national capacity. As we know in any fight over resources psychiatric services get less political traction.
What you’re describing has the A&E Department getting stuck because other parts can fob off the A&E doctor with a ‘sorry mate, can’t be done.’
That’s about organisational power. That’s why it needs a real manager in a doctor who doesn’t accept that, able to make other departments jump to find solutions to clear the emergencies.
I’m a senior A&E consultant. I’d appreciate your advice on how to ‘make other departments jump to find solutions’ because I haven’t discovered how to do this yet.
Having spent 12 years as an Army officer prior to training as a doctor, the concept of forceful leadership hasn’t passed me by. Please let me know how I can do things better.
But there ARE no places. No amount of me huffing and puffing will magically create places for these patients. It’s hugely frustrating – and I’m flattered that you think my powers extend to magicking up non-existent psychiatric or social care beds outside my organisation.
This is why it’s a failure of management. A&E – the most high-pressure, high-stressed part of the NHS is left babysitting cases because the 1.1m rest of the organisation throws up its hands and says sorry no places, that person has to stay in A&E – the most overworked and inappropriate part of the NHS for a long-term case.
So you get the scandal of someone with a mental health problem sitting in A&E for two or more days, gumming up the system and disrupting A&E work.
As an external observer, that’s clearly the cart before the horse. The case needs to be moved to the right department and they need to solve their problems, not the A&E staff. A&E finds solutions like trolleys or makeshift treatment areas, so can other areas. And then those other areas need to battle to solve the resource issues, not leave patients in A&E as their ‘solution’ creating A&E madness.
The reality that you’re sharing is actually those other departments always have more organisational power than A&E, and A&E is always being blocked and left picking up the pieces. That’s totally a management and policy problem. A&E should be about throughput with the authority to make the rest of the organisation jump to take cases of A&E’s hands – with their job being to find a way to resource the problem, not the A&E frontline.
I agree. Saul for PM !
Call the police. They’ll find a bed for him. Not an ideal solution, but leaving him to rant and threaten in the emergency ward is no solution at all.
Police recently made clear they don’t have the resource to stay with such patients in A&Es. Ties up too much Police time. Hence Hospitals training more security staff to try and take over but no way are these as well trained/paid as experienced Police officers. And they can’t restrain to same degree either. It’s a dreadful dilemma.
Issue is solve the problem re: Psychiatric capacity and have enough placement spaces nationally that they can move quickly. But not quick solution.
Jw is exactly correct about the system. Ranting and raving a andne consultant does not magic up capacity elsewhere!!! And yes the police are overstretched and no longer want the acutely mentally unwell. They also cannot administer medication
Over simplistic solutions demonstrate a misunderstanding of the system
Tried that. Police say ‘no’.
What then? Please advise.
Ever tried to call a social worker in the middle of the night? Ever tried to discharge an elderly or mentally unwell patient to reluctant relatives at any time?
It’s a nice idea, but these people can say ‘no’ – and they do, all the time. So what then? Chuck a person threatening to jump off a bridge into the street?
Most won’t jump. One in a thousand will. And when that happens, guess what’s going to be in tomorrow’s headlines; and what’s going to make a coroner serve an order on your hospital.
In today’s political and social climate, families can abdicate all responsibility for their members (providing they’re over 18) with complete impunity. Social services and emergency housing works mostly 9-5. The ONLY service that can’t say no in A&E.
I’ve had a psychiatrist patient waiting for a secure psychiatric bed, for SEVEN DAYS in my Emergency Department. Horrible for the patient and worse for the other patients and my staff. If you can suggest a useful, legal remedy to that situation I’ll be forever in your debt and mighty impressed.
Organisational power problem. Someone is on-call for those services. Someone has the telephone number of the director of that section. Call and escalate. Get the director out of bed if necessary. A&E needs the authority to make other services jump, but is being gaslit by other agencies who want to maintain their 9 to 5s, so A&E does the work they are supposed to be responsible for.
That’s a management and policy problem, which seems to be pretty common for the public sector and wouldn’t be possible for private businesses. In a private setting if there’s no such thing as 9 to 5 for a senior manager. Take the recent Crowdstrike issue – all hands on deck – get it fixed, get it done. A&E needs permission to rage and bully to get things done.
The healthcare system has bern badly run for more than a decade, in fact, during the several decades that I’ve been old enough to know what taxation is and what free means.
Spot on. Who’s giving you down ticks? That was a perfectly reasonable, unobjectionable and accurate comment. Please, folks, park your tribalism at the door and look at the issue objectively. It’s too important to be treated like a cup final.
Dr Emma Jones is no doubt a very nice and caring woman that I would be happy to share horror stories about the NHS with but she doesn’t add any positive analysis so I find the comment Steve Murray made regarding a previous article of hers still pertinent:
“Maybe Emma thinks she’s engaging in a form of “whistleblowing”. Perhaps she’d care to write about her ideas for possible solutions? What she’s doing with these articles is the equivalent of standing at the bedside wailing and gnashing her teeth. I fail to see how that’s helping anyone.”
I do wish Unherd would commission some articles from Consultants or NHS administrators with a little more intellectual heft who might be able to suggest practical solutions that might be adopted as Dr Jones never contains any analytical insight or has anything practical to propose.
This is now entirely normal, even normalised, in U.K. hospitals.
They are even inventing euphemisms for it so that it doesn’t sound so bad – as if it is is normal to be stuck in a corridor.
Meanwhile other staff do their best to offload other patients anywhere they can, regardless of their interests, to free up beds. Substandard care homes, for example.
The atrocious part is that during the hours in the corridor, the broken hip gets harder and harder to repair, due to swelling and displacement.
That’s the one thing I love about your Brits always coming up with charming euphemism and linguistic turns of fate. It’s no longer “people that died because they couldn’t get medical care.” It’s instead “individuals who passed away prior to their scheduled service.” Yes Minister really is the greatest documentary on British Government ever seen.
‘Every week, I see patients presenting with medical conditions ordinarily not seen in this hemisphere or century because they’re not being treated until it’s almost too late. They are the broken Britons of broken Britain’
What are the odds that these are not actually Britons but very recent arrivals & the family thereof? Of course we are seeing a rise in third world diseases in this country. And Labour sees it as our responsibility to bring in as much of the third world as wants to be here.
‘Many migrants to the UK arrive from a country with a high burden of infectious diseases. In the UK, the majority of cases of HIV, tuberculosis, enteric fever and malaria are diagnosed in people who were born abroad.‘ Source: https://www.gov.uk/guidance/assessing-new-patients-from-overseas-migrant-health-guide
Tosh.
NHS and social care relies on migrant workforce and always has. We want to stop that we need to train more of our own. We haven’t done that.
Migrants are typically younger and do not exert the pressure on health services in aggregation anything like the mythology. Plus we haven’t had to pay for all their training.
Illegal migration slightly different, but again they are often younger and less prone to illness. They have to be remarkably resilient to make it here.
The fundamental is an aging population with more co-morbidities – some of that actually being because we’ve improved care for heart disease and stroke etc such that more of us live long enough to become frail and elderly. However that in itself creates costs.
1.2 million immigrants arrived in the UK in 2023. In the same year 100,000 overseas born people entered the health or social care sectors as employees. That is 1 in 12 of all immigrants. I don’t know where the other 1.1 million were employed, if they were employed at all.
The IFS confirm that each human in the JUK costs £17000 a year in state services and infrastructure. Even if immigrants never use the NHS – and they do- they are not covrering their costs which is why GDP per capita is reducing as the population increases.
Why all the downticks for JW? There is no doubt that an ageing population puts more and different strains on the system than in the past. On the other hand it is probably correct that the increase in diseases previously eliminated in UK is due at least in part to immigration levels.
This is a fact-free area of debate and it would be better promoted by reasoned discussion by people who have genuine insight rather than by resort to personal insult. Unherd used to be quite good at this.
Dr EC, you’re jumping to conclusions. Emma Jones does not say that these people are immigrants. You are assuming they are. Of course, they could be. Then again, they may be the indigenous population with diseases like rickets, that we thought we had eradicated decades ago.
The solution to the NHS predicament is simple. In terms of socialised healthcare, those who can afford to pay for ordinary services should do so. Their taxes and individual insurance provisions can then contribute in the greater sense to superior treatment for critical health emergencies.
When emergencies appear in the more public sense, as outline here, then this is wh. But British healthcare should not be a subsidised freebie for the middle class.
Such bureaucracies were largely responsible for the collapse of the Soviet Union, after all. There may be a hardcore of Britons , but they should be marginalised and the British political class should not encourage them.
And if GP/hospital appointments and minor treatment were to be charged, then that would greatly deter immigration by ensuring that families put it much more considered provisions for entering adequately into the healthcare system.
“But British healthcare should not be a subsidised freebie for the middle class.”
Firstly, it isn’t. If you’re on a middle class income, the progressive taxes you pay mean that you’re subsidising everyone who doesn’t pay taxes and most people on low incomes too.
Secondly, there aren’t enough middle class people in the country that removing their “free” healthcare entitlement will fix the NHS – it would barely touch the sides.
It’s time to accept that healthcare that’s free at the point of use to anyone who turns up no matter who they are, whether they pay taxes, or even if they have a legal right to be in this country – this is what doesn’t work.
The common anti-tory rants from people who can’t count obscure the fact that the Tories of the past 14 years have tested to destruction the principle of free healthcare funded from general taxation with an open chequebook. It is one of the reasons the Tories were deservedly booted out of office – fiscal incontinence.
The NHS’s business model – if it can be called that – will bankrupt the Treasury if it is not reformed. Let’s not forget what healthcare – especially emergency healthcare – actually is: it’s something that will very often stop you dying of an accident or a disease that you have no hope of dealing with yourself even if you know, theoretically, what needs to be done to save yourself. It’s not like B&Q which will sell you the stuff you need to renovate your own house instead of paying a builder to do it.
What’s broken about Britain is the ludicrous belief that something so extraordinarily precious ought to be free. It’s not free, can never be free, and pretending it’s free is costing us a fortune, not to mention the fact that the medical staff fronting the operation often get treated by a feckless public as if they’re minimum wage fast food workers and not the dedicated, hard-working and very highly skilled specialists that they in fact are.
Usually at this point some utter clown says something utterly cretinous by referring to the American healthcare model, and it wouldn’t surprise me if someone replies in exactly that way because their fatuous sense of indignation prevents them reading all of this comment. I do not recommend the US model, it is the #1 thing about the USA that seriously questions whether it is actually a civilised country at all. Europe, Japan, Singapore etc all contain healthcare systems and associated funding models that comprehensively outclass the idiotic mess that the NHS represents, and we are multiple decades overdue reforms along the lines that such examples readily provide.
And yet in 60 years of using the US health care system I’ve never experienced anything like what is routinely described here. Nor do I know anyone who has.
I do not dispute this. The failures in US healthcare emerge differently to how they emerge in the UK, in the form of scandalous examples where families are bankrupted by uninsured healthcare costs and many people’s conditions are exacerbated by a reluctance to incur medical fees.
The quality of US healthcare for people properly insured is excellent, on many metrics it is the best in the world. But it isn’t perfect and it is understandably not a model that Britain would ever willingly adopt.
Ok so the logical conclusion of your missive is the poorer folks won’t get help as can’t pay for it.
What happens then? Think through the consequences. Maybe some will adopt healthier lifestyle perhaps, some save more etc. But poverty long known to exacerbate ill-health.
Even in US they have Medicare and Medicaid as public safety net.
But regardless you have to deal with political realities. Folks ain’t voting to change the free at point of service principle anytime soo, so the Policy responses have to be elsewhere in how we pay for it.
“Ok so the histrionic and predictably-irrational non-conclusion of your missive is the poorer folks won’t get help as can’t pay for it.”
There, fixed that for you.
Did you get to the point in my comment where I predicted that some clown would probably start talking about the US healthcare system? You didn’t mention it by name, true, you just left the name out and advanced exactly the same daft argument that you would have done if you had named it.
You don’t escape the clown shoes that easily. Now pour a bucket of custard into your oversized trousers.
Bit odd that response JR, can’t quite make out what point you are making?
What you didn’t answer is what happens to a society when a large proportion can’t access emergency healthcare. Peace and love doesn’t break out does it.
I didn’t answer your question for the simple reason that it is not a legitimate challenge to my first comment: it is a red herring, and one that ought to have been obvious to you before you asked it.
Folks ain’t voting to change the free at point of service principle anytime soon
Nobody wants to change ‘the free at point of service principle’. We just don’t want the public sector running the thing because you’re no good at it. Why is that so hard to take on board?
That’s a legit theoretical position HB, but unfortunately the private sector not interested in providing comprehensive healthcare for all and never has been. They can’t work within the sum of money given to the NHS for the required service.
Name a Private hospital with an A&E in UK, or a private insurance plan without a series of exclusions as just a start?
the private sector not interested in providing comprehensive healthcare for all and never has been.
Any evidence for this? Probably not – there usually isn’t.
Just go and try to purchase comprehensive cover from any private provider. You won’t find it.
The fivemain problems with the NHS, in my opinion, are:
1) It is free at the point of use – this means that the service is not valued by most of the people accessing it. Hence we see people going to their GP , or increasingly A&E because they cannot get a GP appointment, for ailments which could be dealt with at home, or via a trip to the pharmacy.As a child (born after the creation of the NHS but to parents who were adults before its inception) it was normal for almost everything to be treated at home. A trip to the doctor was not an automatic response to an illness, or injury.
2) The free at the point of delivery – I am not certain that the staff value the service due to the lack of financial responsibility at the frontline. Having had to deal with a number of elderly and/or very sick family members over the last few years, in different locations, it is clear that no one ever takes account of what has previously been prescribed to a patient and will happily go ahead and issue repeat prescriptions even when a medication is no longer needed/used. As this happened within a number of different health trusts I can assume it is widespread.
3) The NHS being both the procurer and deliverer of service means the is no requirement for it to improve its service. Imposing targets such as eating times are ineffective as it is easy to manage the date. Also it requires copies amounts of people to collect and produce such data. And as we the end user have no real choice about using the service, the NHS staff continue to get paid regardless. And the system of having GPs paid for the number of patients on their list (regardless of if they ever see the patient) is mad.
4) The structure and size of the NHS makes it unwieldy – There are 215 NHS Trusts (including 10 Ambulance Trusts) in England alone. There is also NHS England, NHS Digital, NHS Procurement etc. All of these have CEO’s, Directors, Boards of Trustees, all of which insures huge costs in terms of salaries and administration.
5) Hospital structures are inflexible and outdated- although hospitals, by their nature are a 24/7 service they are not actually run on that basis. Yes, there doctors and nurses on duty 24/7 but many of the ancillary services are not. Hence, patients end up waiting to be discharged because the OT, or Physio or SALT, for example are often staffed by a series of part-time staff so there are continuous breaks in delivery, particularly on weekend and bank holidays. Oddly, the rota system for doctors and nurses, which still seems to operate on a 12 hour shift system is one of the reasons why so many leave.
I no longer believe that increasing the NHS budget or “reform” will make any difference. We need to look at the much better systems on offer elsewhere. France/Germany/Belgium all offer much better systems. There needs to be a reform of funding, moving to an insurance based (with Government top-ups where necessary) system.
And most importantly, the delivery system needs to be changed, again the continental systems seem to work much better. Patients get a choice about hospitals, which means the hospitals have to perform, with the State covering emergency and acute services.
I think we heard yesterday Lab Govt going to insist use of expensive management consultancies be drastically reduced. No bad thing, although there are occasions when they can add value, too often they do the classic ‘take your watch and tell you the time with it’.
14 years of failure to invest in the NHS, and crucially Social care too, was always going to lead to these sort of consequences as the population and workforce ages. The example of an elderly couple cited by the Author is not especially new, but the volume of similar presentations has markedly increased as our population has aged. We just haven’t readied ourselves for this inevitability by strengthening Social Care.
The Author describes the problem with under-sized departments for current demand. Because of the staffing crisis in primary care redirecting more back there isn’t that viable right now. Whilst not everything is benevolent in the way GPs run their practices this is an aging workforce not able to stem the tide in an aging population that presents with multiple co-morbidities. The failure to have a national workforce plan, and to block it for so long, really rebounding on us now.
I’m sure some wastage and unnecessary bureaucracy can be trimmed, but it will not amount to the saving needed to address the fundamentals. The problem described is also not entirely unique to UK. Dealing with the consequences of folks living longer but with more co-morbidities is challenging all systems.
High levels of ‘Demographic change’; is that a euphemism for immigration?
Watch your mouth, sir!
What is an A&E department?
Accident and Emergency.
An Emergency Department. A&E is the popular term, but it stopped being the correct one in about 2010.
The failings are not with the system. The failings sit almost entirely with the medical profession
Perhaps you could be a bit more specific and list those failings.
If you overcrowd hens or animals they fight and kill each other.
Britain (England particularly) is very overcrowded for its services and facilities.
It is possible to have higher densities (Like Singapore) if you have highly law abiding socially responsible people with draconian effective enforcement. The UK has neither.
So the first step has to be stop importing more people. The idea that more people improve GDP is economically illiterate nonsense. It reduces GDP per capita, destroys social structures and overwhelms services.
Too much common sense. It couldn’t possibly be accepted by the new incumbents!
An Airline company looked at the NHS . Their finding was that if they ran the airline in the same manner as the NHS they would have a plane crash most weeks.
The airline analogy only goes so far. Nobody’s going to die if they miss a flight. People can choose to fly or not with no health consequence. If the plane is full, nobody forces extra passengers onto it. A flight won’t take off without a copilot, and the worst that will happen is a bit of inconvenience. Every passenger is more profit for the airline.
And so on. Apples and pears.
So it turns out that shutting down the economy, destroying small business, locking people up in their homes, and putting huge numbers of people out of work wasn’t, actually, a choice between “saving lives” and “the economy”. It turns out it was a choice between a destructive blind moral panic and the longer term health of the people.
Let no-one, ever, forget what the government of this country – goaded on by the so-called “Opposition” of the day, including the member for Ilford North – did to the people in 2020-22 simply because they were just too cowardly, arrogant, dim-witted, frightened, self-interested, corrupted or captured to do anything else.
Let it never, ever, happen again.
You reap what you sow.
Never forget that in 2008 the BMA voted to oppose the creation of extra medical school places, in order to maintain the “career prospects” of existing doctors.
That was terrible. They wouldn’t do that now.
Could be edited down to the much shorter, “Nationalized health care doesn’t work and never has.”
‘Our’ NHS. Envy of the world dontcha know!
The author, who is clearly at least ‘sympathetic’ to Labour, may well be right about a succession of ‘careerist’ Tories in the last few years but why does she think Streeting and Labour will be any different? Streeting has made some positive sounding and encouraging remarks about reform but he’s given no indication that he is willing to be radical and change the current funding and structural models. That would be many steps too far for his party and, I suspect, for the author. The problem with the NHS is not the nasty Tory scum but the fact that Streeting’s party and many in the medical professions refuse to countenance real change.
I’ve often asked the question: If someone shows up on a winter night at the emergency room suffering from depression, hypothermia, and malnutrition, and the doctor prescribes a permanent regime of food, shelter, and clothing, who is going to pay for this?
Ultimately the taxpayer. More immediately, the hospital and then, perhaps days later, the council through their social care budget.
“high levels of ….demographic change.” This is the problem in a nutshell. The NHS was never intended to service the entire third world, especially those who have arrived illegally.
And yet socialized medicine is the nostrum that the Democrats are trying to foist on the United States. Yes, I know some countries manage it quite well, but the Anglosphere seems to have totally lost the plot.
If the British professional middle classes were not so complacent and permissive about the dangers of marijuana to mental health, and supported the enforcement of existing laws against its possession, at least one part of the problem described here would be greatly reduced.
funding : see https://www.reformscotland.com/nhs2048/the-equity-and-efficiency-of-a-free-nhs-cam-donaldson/ for some data on other countries and their spend, and the some pros and cons of alternative funding mechanisms.
the population is getting older, frailer, with more comorbidities and thereby greater demand on all parts of the system. Mental health resources in particular, especially trained people, are in desperate short supply when demand is increasing .
There has been no long-term plan to address the issues – joining up social and health care, public health initiatives (particularly addressing obesity/unhealthy life style choices) . And with no long-term plan and nobody looking system-wide at the issues, whatever additional money has been grudgingly made available over the last decade just goes on firefighting the latest bad-publicity -generating issues, instead of putting resources where it can be most effective.
And we cant fund everything each pressure-group wants to prioritise, so it needs a grown up conversation about where the money should go and the more difficult conversation about where its not going to go .
Is that a joke, BHRUT, sounds like Beirut. Possibly reminiscent of the Beirut during the civil war in Lebanon.
What Wes Streeting Reforms?
It seems strange that conventional wisdom dictates that all we need is a change of health minister or more funding to improve the NHS, as if it were the England football team.
Surely history, multiple ministers (who can’t all have been incompetent) and gazillions of pounds have tested this universally acknowledged “truth” to destruction? Perhaps the problem is the NHS itself?
The “cost-cutting management consultants” go in and rapidly identify how significant costs can be made. They try to teach the managers the basic principles of cost efficiency, but within a year or so the Trust is failing again and the consultants are back.
Apart from A & E most health issues arise from our own behavior. & can be sorted by ourselves . For instance 1/6th of the NHS budget is spent on treating diabetes. Yet type 2 is easily resolved by a change of diet. In addition around 1/3 of chronic illness is due to iatrogenic mistakes. A policy of treating people with fewer drugs and a change in lifestyle would help. My parents both GPs would not renew a prescription without seeing the patient otherwise how do you know it is working? Finally the idea that you have to spend billions on a vaccine to all and sundry to cure a heavy cold is just daft. Oh and by the way as a business consultant myself I can see the ridiculous procedures introduced at great expense via firms like McKinsey & Co – these are too numerous to mention,
The main problem with the NHS is that it is not a health service but a sickness service, and mostly driven by the industry that benefits very well from the illness of people. (recognised in many articles in the MBJ).
Is we were to develop a health service that make people healthy which usually involve giving people agency and making then more resilient, A&E will soon be able to cope with those who does need the help.
But a health service that provides health and resilience needs to be part of a national system that puts health (and wellbeing , they are closely linked) at the forefront in its policies (in stead of just thinking about growth which has become a near to meaningless concept when it comes to making a succesful society.)
But such language is difficult, the concepts are different of what we are familiar with, it does not fit in spreadsheets (see Hillary Cottam in her book /research Radical), and people think politicians are fluffy when these things are discussed…. so A&E will continue to struggle as it the symptom of the society that is struggling: we get what we ask for…
Unfortunately, it is only going to get worse, much worse.
The ‘State’ needs to divest itself of the NHS … it has proved to itself that it is incapable of running such a monolith.
It is time for the medical profession to call for this change loudly and clearly.
Again and again the same stuff – several things that people dispute are true. Firstly, NHS budgets have risen above inflation at a frankly ludicrous rate for a very long time. Secondly, we have a ageing and unhealthy population that has many fat useless wasters. Thirdly, we have invited the poor huddled masses of the world to our shores and many of them bring with them disease, a lack of sanitary standards, and take from the system without ever contributing. Fourthly, the NHS wastes an absolute ton of money on crap IT, rubbish procurement, and paying over the odds for agency staff. Fifthly, there are far too many managers, many of whom exist only to distract front line staff from their jobs. Sixthly, social care and the criminal justice system is underfunded.
Solutions?
1. Stop importing the third world.
2. Sack everyone in the NHS with a role that includes the words “Lead”, “Diversity”, or “Inclusion”.
3. Refuse treatment to anyone who doesn’t speak English. Stop translating leaflets into 100 languages. Stop spending money on interpreters, if people want them they can pay for them themselves.
4. Train our own medical staff by the thousands and stop stealing them from other countries.
5. End the nonsense of procurement rules. They don’t stop corruption, they create it. Reward financial staff with a % cut of savings made on procurement and put harsh penalties in place for corruption.
6. Invest in more police and more prisons, but instantly deport any non-UK national involved in any crime.
7. Allow privatised medical provision, but end double jobbing, consultants either work for the NHS or private. If too many leave to go private, you train more, and that will depress private sector wages and reduce leavers.
Hard but necessary choices.
Will Wes do any of this? More chance of Lord Lucan riding into Great Ormond Street on Shergar.
Spot on.
Canada’s healthcare system is by all accounts as bad or worse than the NHS, meaning many of the major problems of the NHS are not peculiar to it. That fact should be considered in puzzling the origins of the NHS failures.
“ the best Streeting can hope for is that Labour is able to secure a second term, beyond which point its reforms might actually take effect”
>> what reforms are you talking about? And what makes you think they will fix the delivery of NHS services such that it meets all future demands?
“It would have been the biggest non-military IT system in the world — but was eventually abandoned after costing more than £10 billion of taxpayer money. (The initial projection was £2.3 billion over three years.)”
An absolute fracking disgrace.
£10 billion on a failed IT system.
Holy crap, no wonder the NHS is in a mess. How can an IT system cost £10 billion?!
But Doctor, don’t you know there’s a greater priority for developing the 5th generation fighter aircraft? As well as, according to the senior military types, preparing Britain for war ‘in three year’s time’.
There are over 50,000 GPs in the UK who are literally, glorified PAs to consultants. The treat almost nothing. They practice, literally, no medicine at all. Either make them do actual work, like stitching up patients, treating burns, minor operations or get rid of them and replace them with GPT 4o and a booking system.
In 1948 healthcare was run by consultants and matrons who had seen combat in WW1 and WW2. They had a sense of duty and had coped with the stress of combat. Matron and nurses trained in the top teaching hospitals had been had been commissioned officers and were the daughters of officers. Matron could hire and fire porters, cooks, cleaners and laundary staff. Matron had a clerk to run the stores who answered to her. Shop stewards of un and semi skilled staff did not like taking orders from upper middle nurses who had been commissioned officers so management was brought in. Matrons lost the power of hire and fire. By the 1970s matrons reported to managers who had deputies and clerks.
Wes Streeting stated the obvious when he said “our NHS” was “broken”.
The current model is vastly bureaucratic and wasteful. It’s unsustainable – and far from “free”.
The UK must rationally reach a cross-party consensus on the alternative. There is no need to take an eternity pondering alternatives as good templates exist internationally.
The most plausible model is some form of insurance-based health provision such as exists in France and the Netherlands.
Successfully moving to a new model will take outstanding leadership more than money.
Firstly A&E should not accept patients who are drunk or on drugs. Police stations should have drunk tanks for them to stay until they sober up then decide if they actually need medical treatment.
People who present with a cut finger should be sent away in the first 5 minutes.
But most of this isn’t the NHS’s problem. It’s a social care problem. And as the boomers age it’s just going to get worse. Many of that generation are divorced and alone. It’s not just about money. It’s about devising a system.
Labour needs at least 2 terms to do this. Tories had 14 YEARS and did squat.
Experience of the health care worker from the article:
“Every week, I see patients presenting with medical conditions ordinarily not seen in this hemisphere or century because they’re not being treated until it’s almost too late.”
Those with eyes to see saw this coming a long time ago.
Perhaps it was said best by the Dowager Countess of Grantham –
“For years I’ve watched governments take control of our lives. And their argument is always the same. Fewer costs, greater efficiency. But the result is always the same too. Less control by the people, more control by the State. Until the individual’s own wishes count for nothing.”
Methinks it might be a good thing for Britian that the NHS should fail – utterly and completely.
The A&E at Queen’s was built for 300 people a day. In March, the average daily attendance was more than 600.”
This is the direct consequence of mass migration.