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Targets won't help treatment. (Photo by Ian Forsyth/Getty Images)
You learn to be tough as an NHS doctor. But starting my shift a few days ago, even I was shocked. I spotted a patient, clearly someone with severe mental health issues, stuck on the ward without proper care. I recognised them because I’d treated them myself — not a few hours ago, or even a few days ago, but a week ago. And yet there they were, stranded in A&E, not getting the help they so obviously required. Nor, of course, are they alone. From psychiatry to obesity to the elderly, emergency departments up and down the country are on the brink of collapse.
It’s clear, then, that the system needs reform. But what kind of reform? Wes Streeting seems sure he knows the answer. Last week, as my patient was wallowing on the ward, Streeting announced grand plans to introduce a “league table” for hospitals. Due to be rolled out next April, the Health Secretary is already promising to “name and shame” struggling trusts, with doctors and managers in the firing line too. Yet while Streeting is abrasively promising to “drive the health system to improve” — the truth is that his scheme is fundamentally flawed.
By obsessing over performance indicators, he’s ignoring the deep-seated issues that are actually failing people like my patient. Not scorecards: but funding. Not league tables: but inadequate staffing, and archaic IT systems, and waves of retirement that smash the health service’s institutional memory. Clearly, these problems predate the new Labour government. But in his eagerness to turn life and death into the Premier League, and at the risk of sounding like a member of the bureaucratic blob, Streeting will only boot genuine change aside.
Perhaps Streeting’s most obvious problem is his tone. Unveiling his reforms to the NHS’s 1.5 million workers, he (presumably inadvertently) employed the style of an angry football coach. Yet if his bedside manner is notable only by his absence — his soundbites about “failing trusts” will only alienate the very clinicians tasked with delivering care — the real problem is what hospital league tables imply. Under Streeting’s provisions, any failure to deliver improved outcomes won’t be the fault of the immense structural problems facing the health service. Rather, it’ll be my fault, and the fault of other hard-working doctors and nurses, whose only mistake was treating challenging cases without the resources to cope.
Nor will the Government’s plan simply create tension between hospitals and the public they serve. Rather, Streeting’s confrontational approach will also exacerbate the “us and them” dynamic that already exists between clinicians and managers. The moment a poor-performing hospital slides down the league table, after all, incompetent bosses and careerist trust executives will do what they always do when under the cosh themselves: bully clinicians.
It goes without saying, of course, that quite aside from the toxic environment this inevitably creates, such an approach won’t actually improve care. Rather than focusing on treating their charges thoughtfully and professionally, doctors will instead be pushed to simply hit targets: all for the sake of the sainted league table. That, in turn, means the quality of patient care will decline. Let me give you a few examples. Surgical waiting times may drop, for instance, but only because crucial procedures are delayed or denied. At the same time, patients with severe mental health issues may be shunted through A&E, their care ignored in the scramble to meet discharge targets.
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SubscribeI’m not a Brit and can’t address the problems of the UK health service in particular, but I suspect a key component to reducing the stress on health services in all developed countries is to recognize we cannot provide limitless services to the very old.
We have reached the point where medicine can maintain the life (or perhaps “the existence” is a more accurate term) of even extremely elderly patients with complex medical problems. One day, perhaps soon, we’ll have to directly address the question of whether economically developed societies should devote so much resources to the very old.
Perhaps my comment sounds harsh and unfeeling. I myself am quite old and (apparently!) getting older. I don’t expect society to subsidize my existence at limitless cost.
Zeke Emmanuel, the brother of Democrat fixer Rahm Emmanuel, is a US medico who has said something along the lines of when he turns 75 he will refuse any medication prescribed merely to combat his natural decline in quality of life. It will be interesting to see what happens when he eventually cracks 75 – he’s mid 60s now. Active watching brief.
I think you’ve hit the nail on the head there. A major problem with the NHS (and many healthcare systems) is that they’ve simply become too successful.
Modern medicine can now keep people alive for much longer than we could previously, however the downside to this is that you then have large numbers of elderly patients needing much more ongoing hospital care than was the case even a generation ago, and many systems are now struggling to cope as a result.
Essentially you’re left with two options. You either ration care for people nearing the end of their life, or you vastly increase capacity and see the healthcare system gobble up an ever increasing amount of the nations budget, which leaves less for other areas such as education, defence, infrastructure etc.
Anything else is merely tinkering around the edges
Or you introduce assisted dying and gradually widen its scope.
For myself, I agree with you. But some people are desperately afraid of dying. What would you do there?
Rationing doesn’t work for people in pain. It’s OK to talk about not giving services to old people but different if your mother/grandmother is in great pain.
And therein lies the problem. My grandfather cost the NHS a fortune while he was around, realistically much more than he ever contributed towards it, and if I could look at dispassionately you could say a large chunk of the money spent on him during the last year or so wasn’t a good use of the budget.
However if they’d have withheld any of the treatment on financial grounds and he’d died earlier I’d have been absolutely disgusted.
It’s all well and good people clamouring for the private sector to get involved but no private company would have spent that money on people like him as they’d be bankrupt within a year.
The point of insurance – private or state – is to spread risk. Obviously it would always be in the interest of insurance companies not to pay out. But then nobody would take out insurance.
Bring back smoking
Don’t worry, we’ll have euthanasia soon. Then we’ll see if old people really don’t want the care on offer (my hunch is that most will).
It is actually the same at the other end. We enable life when it would otherwise not exist; but without the economic basis to support it. Hence Sudan, Ethiopia and any one of many desperately poor countries.
Of which, of course, Covid Hysteria was exhibit A, at a national cost of perhaps a £ trillion. All the mitigations increased (or avoided a reduction in) life expectancy by perhaps 2 months.
Spot on. Aren’t people allowed to die of natural causes at some point, or must they be condemned by heartless, impersonal and officious medicine to a cycle of ever-increasing pain, confusion and debilitation? At some point, someone has to say ‘Enough’. And that shouldn’t be done in the heat of an emergency department in the middle of the night, which is frequently what happens.
If I had a tenner for every 90 year old nursing home resident with unsurvivable pneumonia and dementia so bad that she can’t recognise her children, and a life so miserable that she needs round-the-clock sedation, whom I’ve seen pitch up in an ambulance at 4 am at my busy Emergency Department, sent in by carers terrified of getting it wrong, I’d have been able to retire long ago.
Death comes to us all, and for a very good reason. But because we’ve got a cultural taboo on this inconvenient truth, we postpone it in a brutal, heroic and cruel way that benefits nobody.
There’s something very repetitive about an Emma Jones article. You hardly have to read it. Almost as repetitive as the fact of yet another government coming to power and trying the same old managerial solutions. 30 years ago, as junior doctors, we used to say similar things. After watching patients die in corridors, overcrowded waiting rooms, playing the endless “find a bed” game, finding patients in wet beds, untreated bed sores etc etc, we could have written pretty much the same sort of article. But things, by and large, HAVE changed. We are now giving chemotherapy to people in their 90s [Yes we are!], dying patients have their own single rooms with end of life care plans and all the relatives of their choice around them. Junior doctors don’t work 90 hours in a row. The elderly aren’t sent to nursing homes against their wishes. Autoimmune diseases, cancer, heart disease, strokes have vastly improved outcomes. Waiting, suffering, frustrations, anxieties are inevitable facts of life. There will never be a health system, or any system for that matter, capable of dealing with them.
Monolithic systems always fail. Not sometimes. Not usually. Always.
I am sure Dr Emma Jones is a very nice and caring doctor but she is, as you say, very repetitive and never provides any proper analysis and prescription backed by figures for the ills of the NHS as much as I share her view that setting up league tables will be utterly useless.
One usually gets more practical suggestions reading the comments section.
The thing is doctors are trained in fixing human bodies, not large organisations. And the range of solutions they consider will always be one consistent with their own self interest.
Agreed. I just wish Unherd commissioned an article from someone with a broader and more analytical approach than Emma’s narrow and biased focus. She doesn’t have anything useful to contribute.
Agree. And it’s pretty well reasearched.
All we get is the overmanaged, too much bureaucracy, let us get on with the job, not our fault, everyone else to blame story. What you’d expect from an interest group.
We need some real analysis.
Supposing she’s right? Would she not then be justified in continuing to talk the truth?
I think she’s correct in her analysis. But how would I know?
I member when I was at school in the 1970s, one of our teachers (Mr Gordon) in his late 40s died of kidney failure because of a lack of dialysis machines.
The shortage of dialysis machines was a nationwide issue with the public raising money to fund their local hospitals to purchase them. One of the popular fund raising methods was collecting ring-pulls. As I recall it took 5m to fund the purchase of a single dialysis machine
So are you saying it can’t be improved!
Of course they are not alone – you turned them into multiple people. Was the patient, by any chance, schizophrenic?
Just non-binary probably.
Isn’t everybody non-binary today?
Something else; “My” patient, which is of course, nonsense. She’s using doctor-speak to try to pull wool over our eyes about how “caring” she is. She’s an A&E doctor, and none of those people she treats are hers, even in the sense of when a patient is under the care of an individual Consultant team – that just doesn’t happen in A&E – and she knows it.
Long on rhetoric then, but her only solution is that which puts staff back on a pedestal. NHS staff have just had sigificant pay increases, and now they’re being asked to get on with it.
Yes, there are infrastructure problems. She’s right about IT systems, for instance. The reason? Any IT professional with ambition and higher skills won’t work in the NHS, which ends up with those who can’t hack it (no.pun intended!) in the private sector. There’s no amount of extra pay could induce a top quality IT pro to join the bureaucratic nightmare of our NHS.
There have been multiple projects to improve/rationalise NHS IT systems in the past 20 years. Most of them were outsourced to consultants, at vastly inflated cost (tens of billions in total) and very few tangible results. The private sector has done very well out of NHS managerial incompetence.
I’m an A&E consultant. When I assess and treat a patient, even for a couple of hours, I regard that patient as ‘my’ patient. Mine to take responsibility for. Mine where the buck stops. Mine to give him or her my name if things are going wrong. Mine to be there for and try to make a difference at a very bad point in their life.
I’m not sure there’s a better way of serving a patient. And I’m certain that, were you that patient, you wouldn’t want anything else.
Would you?
The ‘t’ words! Should have to put fifty p in the kitty for every one! Evidently, you don’t have to be a bot to speak and behave as if you’d been programmed.
Ha! Yes. The only reason she could have for pointedly avoiding an anonymous mention of one member of half the population of the whole world, is that she has bathed in the Coolaid. I mean, would it really matter if she dropped the dreaded F or M words.
Don’t be silly. ‘Them’ is used to avoid the clunky ‘him or her’ construct. That’s all.
Are you getting at her for using “they” or commenters who turn every issue into something about “trans”? Both equally irritating.
I thought that passage was grating as well. Maybe she wanted to preserve *their* identity, but still….
What, both of them?
Then use “its.”
Would it not be a simple privacy issue, by simply referring to a patient in those terms rather than revealing their sex?
Not every subject has to be a culture wars whinge
It’s to avoid the ‘him or her’ when referring to a generic patient. A&E consultants are possibly the least politically correct people in the NHS, because they see life uncut.
Don’t be pedantic. That’s probably an effort to anonymise the patient, not a tragic reflection of the zeitgeist.
The system is bust, and we need to look at fundamental change, moving towards other models that provide much better health care; not, I stress the US one, in anticipation of straw man arguments. This will take time, and particular care will need to be taken over the transition from the present system. We need a politician brave enough to make the argument. At one time, I thought Wes Streeting might, but he is now clearly focused on command and control, exacerbating existing problems, rather than moving to a more patient-focused health service.
Which system/other model you suggesting?
Totally agree. And that means putting money into the hands of patients. As it stands, having fully paid for the service via taxation, they then have to approach it like mendicants with not a Penny in their pockets.
Of all the stakeholders in the nhs, the patients are the ones with the least power. They should be the ones with the most. They are the people the service is supposed to be there for!
It can work for elective care, albeit even there knowledge is asymmetrical – the patient does not really know what they need to purchase. Hence regulation and safeguards essential.
As regards emergency care, time to choose rarely presents and more than 50% of NHS work is emergency. Private sector does not run one full A&E anywhere in UK – too much cost risk.
Giving patients choice definitely has a role, but it’s not quite as simple as might be thought and all health systems grapple with this.
We should certainly give consideration to a bismarckian style system carefully designed to ensure health care for all.
Does a gold-standard healthcare system exist? Being a determined monoglot, I am only familiar with the US system and, at a distance, the British system.
I have no knowledge of the systems in the EU or Scandanavia. I presume they have their successes and their failures. The question is, how pleased is the population with the care they get?
Bismarckian systems generally work better. There are different variants, but health care is generally private, funding is provided by insurance, and all are insured, with support for those who can’t afford it or insurance costs based on wages. So the well off pay more.
These meet the principles of the nhs but do it in a different way. In some countries the insurance is provided by cooperatives. Patients have choice of provider, and providers are incentivised to meet patient needs. So it’s a kind of moderated free market system.
Genuine question, as I’ve no experience of those systems, do insurance companies have to keep providing treatment, even for the elderly who would be massive loss makers financially?
If so apart from giving patients a bit more choice where they go how is it vastly different? From what I gather the Germans actually spend more per capita than Britain does on healthcare, and has done for a long time?
I’m not an expert, but this is my understanding:
Coverage is universal, basically with the state setting the rules of the game.
Choice is what drives services to improve or become cheaper. The fact that you have a choice of supermarket may make little difference to you now. But the fact of choice is what makes supermarkets effective, efficient and customer focussed. And he who pays the piper calls the tune.
Cost has to be set against waiting times and quality – and above all healthy outcomes for patients.
Not sure if this is still the case, but in the past insurance companies would send people on spa weekends free – as this reduced the chance of illness and a claim.
There were also downsides. Huge numbers of Germans had unnecessary appendectomies – because hospitals made money on it, and could convince insurance companies it was needed.
That’s the thing no system is foolproof. I imagine once the patient starts getting towards the end the insurance companies would be much more reluctant to fund treatment as it starts losing them money (likewise the doctors would be pushing for ever more ultimately unnecessary treatment as it turns a profit).
I did read that for the decade of around 2010 the Germans were spending treble on increasing the physical infrastructure of the system compared to the UK, so they don’t have the issue of beds becoming blocked and clogging up the entire system.
It would be interesting to see a proper comparison between the two, without all the usual partisan nonsense that clouds the arguments. Cost per capita, wait times, how much has been spent since the turn of the millennium on infrastructure, number of doctors/nurses/admin staff etc
Patrick Martin is correct, admitting that the NHS is a failed model is a start, and having the humility to copy another country makes sense. But choosing which to copy?
Germany is a non starter, as their system consistently costs more than the NHS, so unless we have spare billions we couldn’t copy it. But the majority of countries have cheaper systems, Australia is one example.
Somebody needs to look into this systematically. Perhaps a role for one of the new political parties?
No system is perfect, but some are far better than others. All have downsides. I agree with other commenters – what is needed is careful investigation of other systems.
We also need to understand full costs. If someone is unable to get back to work, or if their quality of life is affected, if they are unable to exercise or if there are downstream care costs – due to long waits, for example – then that too is a cost.
” … incompetent bosses and careerist trust executives will do what they always do when under the cosh themselves: bully clinicians.” Dr Jones hits the problem on the head but offers no solution beyond more money which the government does not have. It is not credible to imply that there is not better practice among some trusts and worse practice amongst others or that better practice cannot be transferred. In the public sector, it is the market that forces better practice on the recalcitrant. In the NHS, there is no market and so another mechanism needs to be found.
As for mental health problems, the solution for many people lies outside the NHS and not in it. For many people, addressing family breakdown, the crisis in the housing market, a failed drug policy and the lockdowns would do more than NHS doctors.
More money into the black hole of NHS expense is the only solution then? Unbelievable that doctors can still say this stuff with a straight face. The whole premise of cutting waiting times leading to some procedures getting delayed was the clincher. This is the whole point of bringing down waiting lists – cut out or delay unnecessary surgeries so that people can get an appointment that isnt 6 months away. Similarly, when she criticises Streeting’s “bedside manner” she doesn’t realise this isn’t a qualification for higher management at a big corporation like an NHS trust. In fact I would say it is disqualifying. That she thinks patient care isn’t already tied to the area you live in (just like schools, shock, horror) shows she is living in a fantasy. At the very least “failing” hospitals should be completely reinvented – new management, staff, name etc. – with those responsible told that they have one more chance or they are out.
It needs rebuilding from the ground up. Down with the NHS.
Surely, the immediate problem is not treatment in A&E but the situation with the disappearance of GPs. We have gone from one extreme to another, from dedicated GPs who would go out to visit the patient in the middle of the night to no GPs at all.
I have visited my local GP about 5 times in the last 10 years. Each time I would arrive at the surgery to find a waiting room with about 30 customers and all seemed to be coughing at the same time. The most unhealthy places in the world. In general the job of the GP was to give advice and reassurance. If they had found anything serious, you would be passed up the ladder onto a waiting list.
But, in the past, the GP would be there to pass you up the ladder as a last resort. It was almost as if he/she was there to dissuade you from wasting NHS time. Today, when you get to see a GP, everything is about passing you up the ladder to avoid their responsibility or to prescribe various medications to keep you quiet. Everyone becomes a major case or a box of tablets. They have even stopped taking blood tests in our surgery and you now have to go to the overworked hospitals for simple tests.
One of my in-laws, in his 60s, has a very poor lifestyle by choice – he is diabetic but takes three sugars in his tea, not to mention a couple of pints every night. He eats too much, going out regularly for big steak meals. He once boasted that every morning he took a cocktail of 21 different medications. Then he had a minor heart attack, followed another minor heart attack. The NHS did the job and now he boasts of being a new man. He is still diabetic and still has three sugars. My point here is that more counselling in the GP surgery with less flamboyant prescription of medication could have made the treatment preventative. The battle for the NHS is to slowly remove the medication by discussion and advice at the front end, in order to protect the hospitals from inundation.
In fact, the NHS has done the opposite. It has removed the discussion at the front end, made prescriptions free (in Wales), and passed all the work up to the hospitals. So A&E is not really A&E at all.
The point of the league tables is to expose the poor management of some hospitals and trusts. Not to victimise the doctors.
In Emma Jones world, she would have us believe that there are no poorly performing trusts or regions and that all the problems are somehow “structural” and due to insufficient funding. Anyone who has any experience of business or large organisations knows this is untrue.
And of course, A&E is once again “on the brink of collapse”. If this were true (and it’s been repeatedly stated as being true for the last 20 or so years), it really would have collapsed.
As for the doctors being the victims in all this – I just don’t buy it. They may be labouring under an oppressive, stifling bureaucracy. But what are they actually doing to improve anything ? Calling for more funding only reinforces the status quo. At some point, the oppressed (if that is what they really are) need to rise up. It took over 40 years in Eastern Europe, but they finally got there.
I note her demand that Streeting should focus on policies that “put the staff first”. Yes, thet’s right. Staff first. No mention of the patients.
Frankly, Emma Jones is yet again whining on, while everything she demands will only make the situation worse. Will she ever take off her ideological blinkers and start looking at reality ?
Which is what you would expect in an organisation prone to provider capture.
The problem is that League tables will simply concentrate effort on what counts in the table at the expense of what is actually equally or more important. It is just another bureaucratic blunt tool.
In my experience most hospitals are not uniformly good or bad. There can be good services and good wards even in generally disfunctional hospitals and and appalling wards in good hospitals. What is needed is that good practices are adopted throughout the system.
Sure. And similarly schools have good and bad teachers. If some people are letting a school or hospital down, then management has the duty (and should have the power) to deal with that. Sacking people if nothing else works.
As as ex-teacher (state schools) Well said!
I’m really tired of medics blaming funding on the problems and being terrified of private sector competition.
Sure, developing a well functioning health care system is really tough and failures often amount to tragedy but nobody has copied us. There is no equivalent of the NHS in the developed world. Stop asking for money.
I have few suggestions to offer; make private health care tax deductible, ring fence a charge to everyone as a NHS contribution and increasing their budgets until they reduce the bureaucracy.
Much that I’d like to blame the DEI bunch, they don’t cost that much, but they point to a public service which does not care how much of other people’s money it spends.
The entitled tone of this article confirms this to my eyes.
Mind, she’s right that league tables are stupid
I can honestly say I have never come across a ‘medic’ (by which I presume you mean doctor) who’s ‘terrified of private sector competition’.
Why should we be? Anything that shares the burden is more than welcome. And the private sector has to get its doctors from somewhere.
It’s easy to criticise – and there’s a great deal worthy of criticism certainly. It’s also easy to come up with ideas to fix things. That’s what opposition MPs do all the time, and talk is cheap when it’s just talk.
Some of your ideas (like making private care tax-deductible) make good sense but wouldn’t fly with the current government – or the last ‘trying much too hard to capture the centre ground’ one. Hypothecated taxes tend not to work, so perhaps not.
Cutting bureaucracy is welcome, but hard to do. The NHS management class is remarkably tenacious and, not having the responsibility of actually treating patients, can allocate a great deal of its resources to justifying its existence and expansion. This isn’t generally a conscious initiative, but underpins a lot of what’s done and results in s great deal of pointless burden on actual doctors, who are then obliged to spend valuable patient time submitting evidence to managers to reassure them that they’re doing their jobs, and to turn all the little boxes on some management spreadsheet green.
As I say, easy to diagnose but very hard to cure. Like cancer…
Thanks, I confess there’s a degree of grumpiness in my response; Emma Jones’s article is very predictable and unhelpful.
So, some of my own are unhelpful and I’m grateful for your clarity. The problem of health care is very difficult one to solve but my frustration is that those working in the NHS seem to only imagine that we carry on much as we are just with more money.
We’re at a stage in this nation we’re the state is taking more resources than anytime since WW2 so I wish those responsible for taking some of that money would show a little circumspection.
You may take some comfort to learn that many of us NHS foot soldiers are horrified on a daily basis at the waste, inefficiency and sluggishness of this huge, unwieldy system. My NHS trust isn’t a unified hospital. It’s about 35 separate silos, with those in each silo working hard to optimise the environment within that silo regardless of the cost to anybody else. The overall result is a hugely ineffective and divided organisation.
The problem lies with poor leadership at many levels. Very poor political leadership, hide-bound national and regional leadership and weak Trust leadership. This is compounded by a regulatory framework that’s been designed for an optimally-resourced NHS rather than the one we have.
It often takes a war to unwind the ratchet-wheel of over-regulation. Nobody wants to put their name to undoing a rule that might theoretically improve patient safety in a well resourced organisation but probably damages it when added to the burden of all the other regulations in a poorly resourced one. Because if you undo a rule and a named patient dies, it’s all your fault – even if hundreds of un-named patients benefit in some way that is less easily measured.
Thanks for your insights. What should the doctors ‘actually do to improve things?’
As an A&E consultant who’s tried and failed to do this for over a decade, I’m genuinely interested – without irony- in your suggestions. I’m neither proud nor defensive, but genuinely in search of something that might work.
You are quite unlike Emma Jones.
Sorry, I have few suggestions but allowing private healthcare to be tax deductible would be one
I agree. But Labour would sooner everyone suffered rather than be seen to help people to go private, even if that benefitted everyone. It’s a classic case of ideology getting in the way of something useful.
What’s an A&E consultant?
Accident & Emergency.
Consultant; what’s that?
The most senior medical position in the NHS (apart from Professor). At any general hospital, each specialty (surgery, medicine, orthopaedics, etc.) will have several Consultant “firms” with junior doctors attached to them, from training grades upwards to Registrar/Senior Registrar.
What are the “consultant firms”?
I don’t know. Never heard the term in relation to hospitals. Would guess that it is a word specific to the NHS, a jargon word.
It’s “profession-speak” so each Consultant and his/her team are ‘on a par’ with their colleagues in other professions, i.e. legal firms; also an indication of their independence as practitioners.
Do you mean they’re contracted?
It’s hard to know whether you are being deliberately obtuse.
Thanks for your help.
Gave up when I read that the first thing to do was apparently to put the “Staff first”. There’s the problem straight away. The first thing to do is to get your head around putting the Patient frst.
Do Drs and the BMA bully Physician Associates?
No. They don’t.
I had a patient seen by “a doctor at the hospital “ actually seen by a PA and suggestion was treatment with ibuprofen and some milk, patient was aged 88.
No. Grateful for all the help we can get.
League tables have ended up making every public service they’re applied to worse, because organisations inevitably pursue league table rankings rather than genuinely desirable outcomes. It’s almost incredible that Wes Streeting, like a broken record, is still going on in this vein and expecting different results. If this is his big idea for NHS reform God help us all.
Why don’t the league table rankings reflect “genuinely desirable outcomes”? Yours ins’t an argument against rankings, but an argument against rankings that rank the wrong things.
Additionally, we should be able to trust professionals not to throw patients under the bus as a means of fiddling the books!
The de-institutionalisation of severely unwell mental health patients in the 1970s has impacted the health adversely of millions of patients and cost billions of pounds. Its effects can be seen everywhere from jails to centre city streets to EDs. It may be necessary to spend more money building and staffing hospitals for the chronically mentally ill but to improve matters. Waiting lists in ED is one that comes to mind.
The very fact that Mr Streeting is championing the use of a league table system to grade hospital performance and to provide a means by which he, or his successor(s), are given the ammunition to ‘name and shame’ poor performing NHS Trusts speaks only of the paucity of real ideas he seems to have for what it is that the NHS really needs to do, or have done to it, if an improvement in the quality of service which it is able to provide is to be achieved.
The most likely outcome of such a crass system, it seems to me, will be that the worst performing Trusts will get worse still – staff leaving; cuts to funding; plummeting morale among those staff who remain loyal, etc. – and the best performing Trusts will benefit – a larger pool of potential staff to recruit from; increased funding; higher morale amongst a happier staff; better patient outcomes.
So, based upon the performance of the Labour government thus far Mr Streetings plan would seem to be very much ‘a la mode’ in that it would cause and entrench a two-tier system of health care which would dovetail nicely with the direction of travel of both policing and the judiciary.
The thing which worries me whenever I set foot in an NHS building these days is the level to which it appears that an ideological capture of the institution has quietly taken place. Rainbows; Pride flags; notices promoting diversity and inclusion; notices informing us all that NHS staff must be treated with ‘respect’ at all times when it seems to me that the word they should have used is ‘courtesy’. I have always thought that respect is something which needs to be earned and is not due to everyone regardless of character or ability. None of these things may make the service worse but they are all indications of an internal political bias and influence which, in my opinion, most definitely should not be playing a part in the underlying ethos, and operation, of the NHS.
It may be simplistic, not to mention horribly expensive and long-winded, but I think that the first step along the road to understanding the difficulties, and possibly the failings, of the NHS as currently constituted would be a far-reaching and comprehensive audit of each and every NHS Trust. At least then we would all have access to the information detailing exactly how, and how effectively, every pound of the in excess of £210 Billion pounds of taxpayer’s money which disappears annually into the ‘black hole’ of the NHS is being spent. That wouldn’t be a bad starting point would it?
As someone who works in the NHS myself as a clinician, I have to say that I think this article is only partly right.
Firstly, there has never been a serious plan for community transformation backed up by new money in the required amount.
Care in the community along with virtual wards was a wheeze to get people out of hospital and address bed blocking.
If it had been properly thought out and costed it could work; but it never was.
Secondly, the decision usually made by clinicians are now being made by managers according to their budget plans. This is ridiculous and there are far too many manager types in the NHS. I was in a teams meeting where Wes Streeting and Amanda Pritchard spelt out the ten year plan last week.
It was full of managerial speak such as lean operating and doing more with less, cutting waste and living within our means. A great way to do that would be to cut management in half. There are two hospitals near me whose ceilings are held up by supports. No money for that, but billions found to fund overseas green projects and pay rises for strikers.
Thirdly, with the health service being run as the international health service, there will never be enough money to keep it afloat as long as anyone from around the world can access it for free by jumping in a boat and claiming asylum.
Good grief, it takes up nearly one third of the national budget as it is.
I have seen some fantastic work done in the NHS which proves to me that when clinicians are allowed to choose their own priorities and make decisions, lives are saved.
Unlike my colleague who wrote the article, I don’t believe one of the prime directives of the NHS is to stop people from becoming ill through lifestyle choices. I would certainly advise them how to stay well after a particular illness, but it’s their life after all. If they have paid into the system, they have a right to treatment without judgement.
Money given to the NHS should be for patient care only and that includes staffing and the infrastructure.
I am still waiting for someone to say we can’t afford another manager, instead of we can’t afford more clinical staff.
I think I’ll be waiting a long time.
Where to start with this rant? Firstly how come other countries have better outcomes for less or similar amounts of funding? So no, I don’t think more funding is the answer. Second, how come last time targets were used they improved outcomes? Seems to me league tables are just another way of pushing improvement.
Of course Dr Emma Jones ignores the fact that no other country has a similar system of healthcare. What we need is drastic reform otherwise yes, we will get a two tier system as she predicts. What else are people meant to do when the national health service fails? Though when and how private emergency care will happen I don’t know, but I suspect it will come.
We spend over 12% gdp on health. Same or more than other European countries with far better systems. None of them are state monopolies. Most of them are privately provided everyone has insurance and it works far far better .
Stop pleading for more money and change the system
Many use some variant of the bismarckian system. And it seems to work. And no it’s not like America.
Presumably doctors will be leaving Britain on the same boats as farmers and rich people 😉
If Streeting is upsetting the incumbants in the health service, at least that’s a sign that something might change! It won’t be easy – there’s an awful lot of vested interest there – but at least there’s the intent.
I never understand how anyone could seriously defend the central premise of the NHS (“free at the point of service”). There’s incredible, resource-allocating (and therefore system-altering, and therefore life-saving) value to the price mechanism. Without pricing you have no idea if what you are getting is worth what you are paying, nor if you actually want the thing you say you want. Of course everyone says they want another day of life… but are they willing to pay what it costs – in farsightedness, in denying themselves at 30, 40 and 50 – to get it? People should get the medical care they want, provided they really want it. And we can tell if they really want it… through pricing. Should indifferent coffee drinkers be entitled to the finest quality coffee? How can I tell if I care about the finest quality coffee? More profound introspection? No… pricing.
So in other words poor are left to die in a ditch due to not being able to afford the medicine they need to stay alive?
Are you happy for children to die young because their parents aren’t wealthy enough to find the treatment needed to save them?
Classic! I love it! Thank you for your absurd response – this perfectly captures why the NHS will continue to fail. There are, you see, only two options: “Either the NHS continues on, with no connection between the services provided and the costs incurred, or kids die.”
Uh… actually it is your approach that is killing people, reducing services while increasing costs, bleeding the system ounce by ounce of its competencies and capabilities. It is the willful denial of reality that kills people. And reality – unavoidable at all times and all places – is that the market is the best way to ensure goods and services are allocated so as to maximize the satisfaction of people’s preferences.
(PS. Though it hardly needs saying, since trolls on the internet will pretend otherwise, I point out there are many ways to ensure the poor receive healthcare without ignoring pricing mechanisms. Health care vouchers and/or UBI are the most obvious options. Decide: how much do we want govt to spend on healthcare? Take that number and divide it among all your citizens; literally send each of them a check. You will very quickly discover that many people don’t actually want the healthcare we claim they want. Wait – there are bad parents? Fair enough but the solution to bad parenting is not bad economics, bad regulation and bad government.)
I’ve worked in health care for almost 10 years now after a career in RN. I certainly recognise alot of what this Author conveys. However her analysis of why such problems persist and what we might do differently I always feel lack some insight.
Firstly League Tables – I agree they can distort and actually compound a problem. Who applies for the job to a club in relegation danger etc? But I also know Streeting fighting a battle with the Treasury about VFM and the complex issue of how one judges productivity. He has to demonstrate he’s doing something to hit those less productive. The Tables will be as good as the metric used. The Author may not like it but we all need to level up, as far as poss, to the best in class.
She’s right of course though on ‘look after the staff and patient care benefits’. Lots of evidence happier, less stressed staff deliver better outcomes. That’s a theme for many industries. But she could probably explain that thinking a bit more as otherwise looks like we’ve got the wrong focus.
With an aging population, and aging workforce, there is no simple solution. We spend less than some comparable countries, and certainly our Estate is further behind, so you do get a bit what you pay for. But that’s not the whole story either. The latest whizzo treatment constantly drags funding off other basics and there is a whole industry of Drug companies, Businesses, Pressure Groups, Charities etc that play into a very difficult rationing environment.
She’s right about Social Care too. Her A&E will increasing be full of patients who can’t get back home or came in the first place because of deficiencies in social care. Disappointed Lab not moved sooner on this but it’s going to take a cross party consensus and that is not easy.
Good comment.
But that can mean staff pushed to do the kind of job they can be proud of. Staff who are inadequately managed, and get to perform poorly with no one caring, are often unhappy.
Actually, there are managers who voluntarily step up to take over ailing companies or football clubs in relegation danger. And specialise in turnarounds.
But they’re only going to do that if they have the freedom to do what needs to be done and don’t have their hands tied behind their backs. And can get buy in from the players or staff to make the necessary changes.
And this is precisely why you don’t see this in the NHS. Anyone who wants to make the necessary changes both has their hands tied and is resisted by a chort of vested interests who don’t want to change.
You might have met some of these people in the RN (certainly during wartime). Extremely unlikely in the NHS or any government role where it’s all about “following the process”.
Until there’s cultural change, nothing will improve.
The issue about joining a team in danger of relegation isn’t just about managers. It becomes v evident the best clinical staff avoid jobs at those places too. That creates a vicious self perpetuating cycle where those places become constantly short staffed and the jobs avoided even more. And of course one can’t easily just close a hospital serving a community where the alternative is miles away. Some consolidation makes sense but there are some geographical limits too. It’s one reason standard ‘market’ principles breakdown quickly.
Nonetheless what would be an example you think of what a manager might want to do they are stopped from doing if in charge of a hospital?
This isn’t really about management. Turnarounds are an ultimate test of leadership. The missing quality in the NHS.
Point #1: Fire incompetent staff and slackers. Almost impossible in the public sector. But has to be done. These people destroy morale in a team or organisation. Take out the first 1/3 of them. See if the others get the message and shape up. If not, rinse and repeat.
Point #2: Reassign and restructure staff so that people best fit the roles rather than allowing the seniority-defined statis to continue.
Point #3: Actively engage with ideas from younger staff and promote these faster where useful.
Point #4: Get cost saving and process improvement ideas from the staff (NOT top-down) and start executing on these. Savings to be retained and reinvested in the operation and not confiscated by HQ.
Point #5: Ignore all directives and pressure from government, top down bureaucrats and trade unions who are only serving their own interests.
Point #6: Engage actively with patients and local community to explain what you are doing and why.
It is absolutely essential in a turnaround situation that those dragging the team down are out the door immediately. You cannot run a turnaround on low morale. Ask yourself why NHS morale is low and they’re at the back of the queue in recruiting British born workers. Then do something about it.
“I spotted a patient, clearly someone with severe mental health issues … I recognised them … they were, stranded in A&E, not getting the help they so obviously required. Nor, of course, are they alone.” [emphasis mine]
I detest the use of ‘they’, ‘them’, ‘their’, etc. as a neutral (i.e. asexual) pronoun for a single person. Dr Emma’s adherence to the modern orthodoxy here is a prime example! Am I the only one irritated by this 21st Century mangling of English?
It’s to avoid saying ‘him or her’ (which sounds clunky) each time, not some sop to Wokespeak.
The alternative is to call everyone ‘him’ all the time, or ‘her’ all the time. Which might work if it were a gynaecology ward or a prostate clinic, but not more generally.
Fair comment!
League tables, with well designed criteria, are essentially a means of signalling to customers the quality of the service they are being provided. Without some such mechanism it is extremely difficult for patients to know this – at least until a horror story emerges years later.
It can work if patients are given a choice to take their custom elsewhere, or if hospitals are handed over to organisations which can run them better. Some may improve as a result of being “shamed” so long as there is a price to pay if they fail to do so. In some, a dysfunctional culture will be so embedded that anything short of draconian measures will simply have no effect.
So it’s a start. But more is needed to make it work.
The NHS is fundamentally flawed. It needs to be completely reformed from top down. If that means more private care then so be it.
I had thought that maybe Streeting was going to achieve the beginnings of reform, but alas, it is not to be. He’s fallen back on the old solutions, League tables which never worked before. The problem is too big for a politician to solve. We need some form of commission drawing together medics and others in the know to plan an extensive reform over the next years. The decision must not be n the hands of politicians.
Couldn’t you just as justly use this term to describe NHS consultants who do private work, the source of which is those in NHS waiting lists with enough money to go private?
And if private provision is paid for by the state, and especially if it proves more efficient, isn’t that a good way of helping patients?
And might genuine competition in providing serves not force NHS provision to improve?
I thought this, taken from a Guardian article was quite telling:
Contrary to the medical perspective, it is likely the impotence of nhs managers that is the problem.
https://www.theguardian.com/healthcare-network/2017/mar/21/managers-clinicians-working-relationship-nhs
My observation of NHS hospitals in my area is that they are obviously over manmed and or appalling organised. The nursing staff lounge about much of the time. The majority are mostl obviously overweight.
On a visit to a Private hospital all of the staff were busy and none I saw was overweight.
The NHS appears to be believing their own understaffed propaganda.
Funnily enough whenever I’ve been visiting people in hospital the poor nurses are rushed off their feet. The care was lacking not through any fault on their part but simply the fact there wasn’t enough of them to go around.
There is no good fix for health care. In UK, or USA. over the past 60 plus years we have been bribed into expecting the system can cure all ills. In US we get to pay premiums, deductible, copay, co-insurance, Medicare tax, and income tax to support medicaid. Yet, it’s never enough for a service in high demand from limited providers.
We really must reassess our goals and willingness to take more responsibility, i.e. accept more pain for less service.
Doctors and hospitals 60 years ago bore the cost of patients unable to pay. Their profit is now protected by Medicaid, Medicare, and private insurance. Maybe a decentralized system as before would keep the system from collapsing? Are doctors prepared to be be paid in kind with eggs, and chickens, and produce, as before? Will our woke elites be able to tolerate the renewal of faith based hospitals operating without govt largess?
You’re probably right about league tables making no difference. Each trust is, in effect, a local monopoly and so the idea of competition is irrelevant. However, the answer is not more funding, but rather a narrower range of medical assistance combined with a constant search for alternative, better-value providers. Of course more funding would be lovely, and targeting investment wisely is important, but the biggest hurdles are the need to make NHS employees at all levels recognise that “free at the point of delivery” does not mean free whatever you want, and doesn’t have to be delivered under the banner of this massive NHS blob.
The author says: “Significant, sustainable improvements will instead require a comprehensive, evidence-based approach”. How much more evidence do we need that the NHS, as it is established, will never work; just as collectivised farms, nationalised car plants and shipbuilding never worked. The problem is not in the NHS; it is the NHS. Why does the author imagine no-one in France, Germany, Holland, Italy, Spain, Australia, Canada, Poland, Hungary, Sweden, Denmark, Norway has ever thought to copy it?
It is worrying that this clinician believes that the NHS must have a monopoly in medical care and that failing doctors, nurses and managers should not have their performance monitored nor be held accountable when they fail. Just throwing more money at the NHS can “ bob along” is absurd. A fundamental rethink (ie significant scaling down ) of the “free at point of delivery” mantra is required plus the introduction of new players and real competition – but try telling that to the Socialists now in control ( in the medical profession and Government).
I must admit I am surprised by Streeting. It is something a first-time junior McKinsey consultant might come up with. It is not something I would expect after 14 years of opposition, as a considered solution to the problems of the NHS.
Another medic blaming funding shortages.
Dr Emma what is your salary and pension.
How often do you do private work.
As for private as vultures you are wrong. Going private is the only way to avoid the NHS and get a service.
Shame we don’t get a tax break for pay your own.
A&E has practically no private work in this country. So Emma’s reply will be ‘none’.
The first thing to remember is that it is not a national ‘health’ service, it’s a national treatment service. If its main interest was in health it would tell the obese (not a ‘social ill’ but a lifestyle choice) that they were unhealthily fat, that they should immediately change their eating habits, and vastly reduce their consumption of fast food, fat, sugar, and salt, plus get off their fat R says and get some exercise. A message to be reinforced daily by the ‘public service’ BBC, and any responsible media outlet. Similarly tell smokers that their hair, clothes, and breath stink, their lungs are full of crud, their hearts are failing, they are likely to suffer cancer and debilitating diseases, die young and in pain, and are giving the tobacco industry a couple of grand every year of their disposable income in the process. Three can never be enough funding for a ‘free’ treatment service which indulges the very lifestyle choices which cost it the most.
Please get this whining woman off Unherd. She’s utterly vacuous and boring.
The fundamental flaw in the NHS model is that it has a guaranteed 100% failure rate. All its patients will die.
I can’t help noticing, in many counties, the similarities in failure between education and health. Governments keep throwing money at education with no apparent change. The same with health. Teachers are doing their jobs as are doctors and nurses, some better than others but still within a measurable idea of success. Children are given the opportunity to learn to read and write, patients’ are given treatment to improve their health. In the end I can only think it’s the bureaucrats/administrators that are not performing.
per the point made below- one seldom sees any analysis or objective criticism whatsoever of the so called management of the NHS, and in a public company it is the management who will take all the hits in any crisis. I am a UK citizen in Asia for 40y and maybe I am missing something but the absence of analysis of managerial performance at any level in the many many many writings about the NHS is peculiar. Are they protected by CITES? In the interest of full disclosure my Brother works in one of these untrustworthy trusts.
Stop it with the ‘they’ nonsense! There’s only one of him or her and you obviously know which it is. Stop mangling the language.