The NHS; underfunded but still the envy of the world? Or in need of a complete re-think?
Merry Vole
Shipmate
Various crises have hardly been out of the news recently; ambulance waiting times, emergency departments overwhelmed, unhappy and stressed clinicians etc.
But even so, much of the care provided is brilliant; many treatments are being given that didn't exist a few decades ago. eg:
£2.8 million for gene therapy for an inherited enzyme deficiency, MLD.
But 70% of the cost of the NHS is treating long-term conditions eg cardiovascular disease, diabetes, arthritis, lung conditions etc.
And many of such conditions result from 'lifestyle' issues and are in theory preventable.
But socioeconomic factors play a huge part in health and the disadvantaged have worse health outcomes. And the UK is the second highest for income inequality across the G7 countries.
Faced with inadequate time and resources clinicians learn to cut corners.
One in four UK adults have multiple long term conditions. Many are on multiple medications often with side-effects including the 'anti-cholinergic burden'. Improving on the problem of 'polypharmacy' is very time-consuming -so often just doesn't happen.
If the time doctors and other clinicians spent with their patients was doubled it wouldn't, IMHO, seem too much. Treatment for mental health problems is desperately under-resourced.
There is no limit to what healthcare could be provided; it has been said you can have 2 out of 3 of Affordability, Universality or Quality, but not all three.
I think the NHS will have to reduce the range of treatments offered so that emergencies and obstetrics and paediatrics get the highest quality care. In some ways this is already happening -but 'on the quiet'.
What do shipmates think?
But even so, much of the care provided is brilliant; many treatments are being given that didn't exist a few decades ago. eg:
£2.8 million for gene therapy for an inherited enzyme deficiency, MLD.
But 70% of the cost of the NHS is treating long-term conditions eg cardiovascular disease, diabetes, arthritis, lung conditions etc.
And many of such conditions result from 'lifestyle' issues and are in theory preventable.
But socioeconomic factors play a huge part in health and the disadvantaged have worse health outcomes. And the UK is the second highest for income inequality across the G7 countries.
Faced with inadequate time and resources clinicians learn to cut corners.
One in four UK adults have multiple long term conditions. Many are on multiple medications often with side-effects including the 'anti-cholinergic burden'. Improving on the problem of 'polypharmacy' is very time-consuming -so often just doesn't happen.
If the time doctors and other clinicians spent with their patients was doubled it wouldn't, IMHO, seem too much. Treatment for mental health problems is desperately under-resourced.
There is no limit to what healthcare could be provided; it has been said you can have 2 out of 3 of Affordability, Universality or Quality, but not all three.
I think the NHS will have to reduce the range of treatments offered so that emergencies and obstetrics and paediatrics get the highest quality care. In some ways this is already happening -but 'on the quiet'.
What do shipmates think?
Comments
I'll see if I can move this thread for you!
Thanks!
Maybe I was enjoying being in heaven?!
Nevertheless, I'm sure there's room for improvement in various fields - certainly mental health care is one of them - and it may be that some sort of radical reform is needed to achieve this.
(BTW, might this thread be better off in Purgatory?)
Doublethink, Admin
Good point - as the old adage has it *Prevention is better than Cure*.
However, today his consultant said that both his angina and his diabetes ( which has been well under control for nearly 20 years) ought to have been reviewed by specialists a long time ago.
And there is the disconnect. Difficult at the best of times to access one’s GP( too few doctors in an expanding town) and lack of funding to provide the link to specialist services- until it becomes an emergency.
The NHS does not need reform.
It does not need new efficiencies.
Just give us the resources we need to do the fucking job and stop expecting us to do EVERYTHING on a shoestring.
I am sure as this thread develops, I will write some proper comments and justify my arguments. It is complex and detailed and a nuanced discussion but essentially all talk about "reform" or "modernisation" or whatever is a smokescreen for government failures.
I am just very tired.
And very angry.
And totally and utterly sick of NHS critics who are either profoundly ignorant or deeply disingenuous.
AFZ BSc(Hons) MBChB FRCSEd(Paed.Surg) DCH PhD*
(Normal service to be resumed soon).
*I put this here, not to show off but to point out that I have some knowledge of what I speak...
I hear what you say, and apologise for my somewhat unthinking use of the word *reform*...which, as others have said, is toryspeak for *selling it off*, though that's not how I meant it.
Indeed. Don't worry I knew what you meant. I am not against reform per se but
1. Reform is costly (if you do it right)
2. Reform is disruptive
3. The 'need' for Reform even if in itself not a bad thing, is just a way of pretending that resources is not the problem.
There are things that could and should be done better but right now the NHS needs to be left alone to get on with caring for patients...
AFZ
When I worked in an office which was computerising its accounts system (shortly after the death of the last T. Rex), the firm had the wisdom to invest in running both systems concurrently for a month to ensure that any glitches were identified and dealt with before going live on the computerised system, and to invest in continuing high level support for a period after that to ensure that the new system was fully and safely bedded in.
Lack of social care is a big one - this gets you on both ends. Hospitals are jammed up with patients who don't need all the facilities of a hospital, but do need someone to help them wash, dress, make meals etc. On the other end, people are landing in a big expensive hospital because of a lack of relatively cheap prevention.
This is somewhat less true than it used to be. It's complicated; lots of departments fishing about looking for systems that often do what they do very well, but aren't written with interoperability with other systems in mind. What we don't have is sufficient national level in-house development. That would require massive investment and recruitment. Getting the talent needed on NHS pay scales might also be a challenge; you can struggle to recruit service desk staff, never mind creative and talented developers.
The NHS Spine has been up and running for years though.
If you are having hospital treatment and then move to a different area and hope that your medical notes will be seemlessly transferred to another hospital and another GP surgery you will usually be disappointed.
Separate to this of course is the SCR (Summary Care Record) which is accessible from virtually any NHS organisation as required clinically (eg if you're scraped off the tarmac in Bodmin and your GP is in Darlington)
Yep. GIG Cymru (NHS Wales) is a separate body from NHS England.
Scotland separate again.
I think you can get an idea of what happened by looking at these two graphs (source FT's John Burn-Murdoch):
https://pbs.twimg.com/media/FkoNIRBWYAAw1uu?format=jpg
https://pbs.twimg.com/media/Fkpw_o_XEAASRnv?format=jpg
And yet when I registered with my local medical practice in Scotland they had no trouble (that I know of) getting my notes transferred from England.
This has resulted in an expensive time consuming process to bid to provide care, to decide which body is paying for care and a fragmentation of the delivery of care. Whilst - quite obviously - creating a system in which it is easier for the government to say, oh x is not working we’ll let commissioners buy it in from the private sector. (Which creates even more fragmentation, because the private providers information systems are even less interoperable than other bits of the NHS.)
Quite. It's one of those things that can go very well or very badly.
There may be a few things that could be done better, but that's ducking the issue. It needs more money. If the money comes from government, and government won't fund it adequately, it can't and won't do the job.
It’s a private system with good safety nets. The government controls - by law - the prices the hospitals etc can charge.
My son had a bad knee. He phoned the GP and got an appointment the same day. He needed a X-Ray so was sent down the road. The X-Ray film was sent digitally to a specialist who treated his knee (injections) two hours later. Treatment we can only dream of.
My husband needs an eye op (outpatient) - he was sent a list of five clinics to choose from to make an appointment. Not one of them is offering any appointments. What choice does he have but to go private? He can’t read for more than five minutes.
This.
The German system is very good. However it costs a lot more than the NHS. I would argue that if the NHS had German-level funding it would be amazing. I genuinely mean that because I have spent the past 18 years working in a system that much of the time is able to do amazing things with inadequate resources.
Essentially, the NHS is astoundingly efficient in comparison to world wide healthcare systems. In many ways, the worst of all worlds would be the UK adopting a US-like system. Which seems to many of us is what is the most likely outcome of a switch led by the current government. One of the defences you hear is that we could adopt a system like the French or the German ones or whichever country. This is a dangerous lie because if we switched to say the French system tomorrow, we'd have major issues because the overall costs would be higher. Unless more money came from either the government or the public or both, we'd have worse outcomes...
So, whilst we should talk seriously about system issues, about how to do things better, about maximising outcomes for all, ultimately it comes down to a lack of resources.
That remains the key problem. Everything else pales by comparison.
AFZ
Resources aside (if we can say that), the main issue with the NHS is poor management. I've seen this as a patient and hear it from the 3 misses M's who all work in the NHS in different spheres. One is not a zillion miles from where you did your paediatric - if you're still there you may well have come across her.
It may be that resource lack brings poor management but I'm not so sure tbh. Being really hard I'd say that the NHS runs with administrators and not managers. Certainly no risk taking leaders on the front line. I say that as someone who has worked across public and private sectors helping to embed essential change.
One example: when I lived between wood and water, my GP could book me a appointment with a consultant, book tests and view results.This was around 2008. A letter printed in the surgery, no admin and a choice on a convenient date. Why isn't this rolled out for GP's and all hospital appointments where possible? It's all so paper and bureaucratic.
Lucky you. Mine were completely trashed and they had my dad missing a kidney - which he wasn't. Treatment would have been compromised had we not asked for copies.
In City Finance the Regulators used to require this. I spent many hours parallel runing acquired loan books. Now it's not and you get the Santander and TSB fiascos when systems change. It never happened in the Dark Ages of the 90's.
@alienfromzog , Health companies in the USA already have their foot in the door of the NHS:
https://weownit.org.uk/blog/here-are-gp-practices-taken-over-us-health-insurance-giant-centene
You are both wrong and right.
Wrong in the sense, that resources aside is dangerous. Because any attempt to look to things other than resources as a problem is dangerously distracting from THE BIG PROBLEM.
Right in the sense that the NHS is undermanaged. And to some extent, that's a completely separate question to the number of managers.
Healthcare is both complex and very labour intensive. This makes managing it a very skilled role.
AFZ
P.S. I have worked in lots of places doing paediatric surgery...
In my field, there is an infestation of people who are unable to distinguish between the useful sort of management that supports and enables the "actual work", ensures that all the resources are in the right place at the right time, and so on, and pointless bureaucracy, where people think that producing reams of paperwork is actual work.
It's great that you're concerned about safety - we should all be concerned about safety. But the question you should ask yourself is whether making people spend a week writing arse-wiping procedures before wiping their arse actually improves safety. Did you make things better, or did you just make them slower and more annoying?
I could easily imagine that a similar disease infests healthcare.
If public services are underfunded, managers often have to concentrate on saving money at the expense of other aims. In health and social care, this may mean that managers think every person using the services should be kept out of those services as long as possible and then rushed through as quickly as possible. And this often means the person doesn’t actually get much better, because nobody has spent time on sorting things out, and they come back through the service again and again, and the waiting lists go up and up.
Another common issue: deal with your waiting lists by passing the buck. If you’re in the NHS, tell people social services have to sort them out. If you’re in social services, tell people the NHS have to sort them out. If you think your staff spend too long talking to people, put in an automated system so they have to key a bunch of numbers into a phone to confirm their appointment, or it will automatically be cancelled.
(That’s a genuine example, by the way. A few years ago I was assessing an elderly man with dementia for some adaptations to the house. As I was about to leave, his wife asked about her eye clinic appointment. She was very worried because she knew she would lose the appointment if she didn’t verify it by typing in the numbers, but she couldn’t see to do it properly, her husband was too confused, all her friends were elderly and they had no family in the area. I stayed and sorted it out for her, but it was difficult and I got it wrong the first time. There was no helpline. This was for an eye clinic. I am sure the system was very effectively reducing their waiting list.)
At the same time, I hope that we can all give examples of how the NHS has come up trumps for us, or for someone close to us.
You still have to staff them, and with both GPs retiring at record rates and nurses leaving the profession due to low pay that's not an easy issue to address.
[And both of these tend to have compositional effects; those retiring/leaving tend on average to be more experienced, so you could keep the top line number the same or even increase it by hiring more new doctors and nurses and just about keep treading water because less experienced staff are correspondingly less productive]