Blain’s Morning Porridge – September 30th 2022 – The NHS can be Fixed, but it’s not in the interest of politicians to try
“Physician, heal thyself…”
This morning: How do we fix the UK’s broken National Health Service? Don’t expect much from politicians – fixing the NHS is politically dangerous, might take decades, and is way beyond the time frame of the next election. It’s better to tinker, make some noise and do little. There are many reasons the NHS is effectively broken, but even more reasons to be hopeful it can be fixed – if we can just muster the vision and imagination to make it happen and use tech!
I am not going to rant about Truss and Kwarteng this morning. I am not.. I am not… Instead.. let me clear my head from the chaos in Sterling, pension funds, gilts, UK CDS prices, or how the Chancellor is now going to slash spending on services.
Instead, I shall go off on a tangent. Last week the new government announced its much anticipated plans for the reforming the NHS. What we got was a damp squib – which was quickly buried in the Sterling/Gilts/Everything crisis.
Health Minister Therese Coffey unveiled her “plan” to sort out the NHS. ABCD – Ambulances, Beds, Call Handlers and Dentists… Catchy, but thin. Coffey is a competent politician – she is there to ensure it looks like the problem is being addressed…. but realistically we all know there is no money.
So, this morning…. Time for a rant – how to fix the broken NHS.
At 60 with a dodgy ticker, I am a motivated believer in better health care and delivery. There is a medical revolution underway that could completely transform therapies and outcomes. I fear the UK will miss out unless we dramatically improve the NHS. It’s time for reinvention.
What we all want is an effective and functional health service, delivering the best care when we need it! Even better if it comes at a cost-effective price for the whole economy – one that busted Britain can afford.
Unfortunately, there is zero chance the NHS will be fixed soon. Truss will be too busy clinging on to focus time or money on Health. I don’t actually know what Labour’s plans are – beyond the usual soundbites about more doctors, more nurses and more more. After 12 years of Tory government the UK’s NHS is worse on every single imaginable metric. I’m sure it would be no better under Labour. The pandemic exposed many flaws and exhausted the system.
Fixing the NHS is a political minefield. The Tories would immediately be accused of stealth privatisation. Labour of unsustainable funding pledges. Reforming the internal bureaucracy would be … “difficult”. Cost issues will immediately raise the ire of the health unions.
We love the NHS, but it is the UK’s ultimate sacred cow.
To even consider change is electoral suicide. It can’t be fixed in the course of the 5-year electoral cycle. The result is neglect and pushing the problem down the line. The cracks are papered over with more money, and every year the NHS gets bigger, but worse.
A career in health is a calling. It is shocking hospitals are setting up food banks for staff, and nurses are leaving for better paid jobs in pubs and Amazon.. That’s the reality behind the 132,000 medical staff shortage! 300,000 nurses are threating to join junior doctors striking over pay this winter. The daily reality for NHS staff is one of constant struggle. It’s tough to be motivated dealing with overwork, insensitive bureaucracy, unremitting crisis, low pay, understaffing, appalling conditions, and dissatisfied customers. It’s not much fun being a patient in dystopian hospitals either. No wonder the staff are disillusioned and so many are leaving.
Last week the BBC uncovered shocking figures – 55% of maternity units are underperforming! 7% pose “a high risk of avoidable harm”. It shows how far the NHS is off course as it pays 4 times as much in maternity negligence compensation claims as it pays maternity staff!
We need an NHS reset – as much for the staff as for the patients! Let’s rebuild a free-at-the-point-of-care equitable health service. It can be done – but only if we accept some brutal truths and make tough decisions.
We need a debate around the merits of privatisation or mutualisation of health. Insurance funded health in the US in unequal, has resulted in more expensive care with worse outcomes for most. Germany’s non-profit sickness funds (health insurance) work well, are better funded but don’t break the bank, and critically are out of government financial control.
Reinventing the NHS probably means solutions requiring a large element of privatisation – which will immediately peeve my medical chums. I have no problem taking the health service out of health service control – as long it remains affordable, equitable and NHS staff are properly rewarded and motivated.
Let’s start with what the problems are. The NHS’s main problems are not medical. They are all about the delivery of services. Understand and grasp that its all about delivery – and solutions start to become more obvious.
The UK has been at the forefront of medical technology and treatment for centuries. Whether it was pioneering surgery (we fought more battles than anyone else, thus more motivated to work out how to fix stuff), innovating anaesthetics or discovering antibiotics, and new diagnostic technologies like scanners and vaccines, the UK has a great record and remains at the forefront of medical science. No reason we can’t remain a medical leader!
The problem is getting best medical care to the population. Last week I was chatting to a chum in the US, Dr Roy Schoenberg, CEO of AmWell, the US telemedicine firm. The NHS came up in the conversation….. Half a dozen ideas came flooding out of subsequent discussion. If I was the new UK Health Minister I’d be getting guys like Schoenberg in front of the NHS immediately. I am a Trustee on a UK Medical Charity and know a number of leading consultants – desperately keen to improve the service, and with great ideas on how to do it. But no-one ever asks them.
What are the key issues for the NHS?
The first issue is people. We are massively short of key skills across the whole NHS. Ambulances are held up while beds can’t be cleared of infirm patients because care for elderly is so far down the priority list. It’s a cascading series of internal problems that gives the appearance of sinking the service.
The NHS is approaching its human resources crisis with a predictable list of HR solutions – co-operation, LBQT+ training, diversity awareness, staff support and managerial initiative courses to improve retention levels. Blah! They will keep NHS HR consultants in work for life.
The crux of the problem is leadership. Without strong management who understand and embrace the goals and objectives of health care, and are motivated to deliver these, then it will remain little more than an underperforming bureaucracy.
The second issue is the NHS is a 1940’s institution trying to function in the 2020s. It needs a rejig, acknowledging the history of health care:
In the 1700s health care was a luxury. You got ill and sent a servant to fetch the local quack. As the economy grew doctoring became a business – servicing those able to pay the costs. By the 1900s the UK perceived health as a social good – a healthy, fit population made for better workers and soldiers. By 1948, under the Labour government elected in a post-war landslide, it evolved into free health care for all delivered by the new National Health Service. Vast hospitals and a network of GP’s where you went to be cured.
A new Healthcare paradigm shift?
75 years later… and it’s time for another reinvention. That’s likely to be migrating healthcare to the home and increasing individual responsibility. It can happen if we understand that health is unlike anything else Government provides:
- NHS Health care is a service like no other. It is paternalist. We go to the doctor or hospital, passively expecting to be told what is wrong, and how it will be cured. We trust. We don’t question. We treat medical services in a completely different way to any other service Government provides.
- Medicine is conservative. Doctors and nurses are taught to work based on clear and unquestionable procedure. Do nothing out of order, and don’t experiment. Trust the process and don’t question it. Organisational change move slowly within the NHS.
- The NHS is terrified of modern IT – not by the marvellous medical tech with which we are treated, but in terms of processing information and acting on it. The IT and delivery revolution that utterly changed the rest of the world over the last 25 years has passed it by.
Let’s start with that third point. Tech.
Amazon was founded 28 years ago. It evolved from a bookshop and innovated the internet into a revolution in the way we order, pay for, deliver and receive, everything. It pioneered the new economy. The internet economy has taken over nearly every other sector – travel, finance, entertainment.
Every attempt to innovate NHS IT or database patient information, and to make it accessible to clinicians has underdelivered and broke the budget. Interestingly, although we complained initially about Zoom calls with doctors, it was Covid that showed change was possible. We started carrying our Covid Vax information on apps, alerting us to infection. Imagine if we could do the same with our hearts, cancers, diabetes, etc. Wearables are making it happen.
As I write I am wearing a 24 hour blood pressure recorder, and a small heart monitor bandaged to my chest – recording real time EGC data over 2 weeks on my phone. My consultant will use the data to tell me just how dodgy my dodgy ticker is next week. (No worries – I am indestructible.. ish.)
It’s time the IT revolution accelerated within the NHS. The possibilities are boundless. The technologies largely exist. The issue is how to innovate them. The opportunities to make treatment faster, and more efficient by using AI and machine learning to use anonymised diagnostic data from the NHS is limitless. That data is currently locked in patient records. The possibilities to direct and deliver medical services in the same way as we order books and shoes online are equally exciting, and could utterly change the resource allocation required.
For instance; at present we are treated on the NHS on a limited local resource basis. The local GP identifies a condition, the regional registrar or consultant diagnoses it, the specialist surgeon treats it at the local hospital, and the patient recovers in the speciality ward. Its resource intensive – but does not factor in the possibilities of “load balance” across the whole NHS. If we can continue to improve the IT consultation process – why go into hospital?
Imagine if we use video-conferencing to “pipe” NHS expert consultants across the land. Load balancing demand with provision could alleviate the current skills gaps. The tech already exists.
Assisting people to take responsibility for their conditions could dramatically change health outcomes. Being overweight with a heart condition is not clever – but it’s not my cardio’s role to help me lose weight – that’s some other consultant’s responsibility. I have to go back to the GP and join another queue to see a weight loss specialist, who then has to figure out my whole history. Treat the man, not the symptom. Holistic team based treatments would make a lot of sense. Wearable tech and IT could minimise the likelihood of getting ill – preventative health and medicine.
Data is a critical component of health care. If we were to ensure everyone’s data is kept up to date with regular screening and testing, and use it to predict outcomes, then AI could improve and speed up diagnosis across the population. We can put testing out to delivery or local point of GP service. For instance, I recently got the all-clear on Bowel Cancer after self-testing at home and delivering the sample back to the lab.
Envisage a future where we all go to the GP each year for a full battery of blood tests for all conditions, and the ones your genetics say are likely to be troublesome, with the results immediately analysed by AI and directed to the right medical resources and your phone for follow up – all done over the phone or Zoom at your convenience. The possibilities are immense.
Up at the top I noted that reforming the NHS is a political no-go. It’s too risky.
It could be the ultimate vote winner for the Political Party that makes the effort to plan and deliver it. The single most frequent contact any UK person will have with government will be through the NHS – literally from cradle to grave. Who would not thank a government that could make that better?
(I won’t depress you further with Five Things to Read Today…)
Have a great weekend, and stay well by not reading the papers… they will only depress you… Out of time, and back to the day job.. except that I’m off for further tests today and Monday in a 1960’s hospital where I won’t be able to find a parking space…
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So true Bill, and the sad thing is that the barriers here are not the diagnosing tech (‘AI’ is well advanced and could probably make major breakthroughs within days if only the data was there) but it is around data privacy and fundamentally trust
We can annoymise data and put protections in place so only the NHS and Individual have assess. That should not be beyond our abilities.. but probably is…
Having experienced a few NHS last minute cancellations in our family with all the associated waste of time and expense to the surgical team who are completely dependant on bed availability I have come to the conclusion that the NHS must be fully privatised. The Trusts should be turned into competing companies and run as proper businesses. Nurses should be offered shares and bonuses related to profits. There should be competition for patients. Medical Aid contributions should be made before tax as in many other countries. The NHS is a socialist carbuncle within the envelope of a capitalist economy. It can never work. If GP surgeries can work – the are privately owned in most cases after all – then so can hospitals.
I’ve been in Mental Health (MH) for 35+ years, and the difficulties are compounded in that field in comparison to other areas of the NHS, broadly twice as severe, carrying soils the disease burden AND half the funding…
I’ve worked in a tech incubator for MH , and while there are smart people able to implement tech solutions with great optimism, the easy flow in to partnership and rapid implementation in a meritocratic scaffolding does not exist in any substance, and is piecemeal.
It is only this year, that we have had the first standalone digital treatment, which is appalling. If you’re wondering, it’s Sleepio (for insomnia), and is excellent and will make a huge difference for large numbers of people, potential patients, and clinicians alike.
Even when you try, and I’m thinking of the very capable Google Maps guy who was called in to London, having successfully mapped everything on earth for Google, but could not get one NHS trust’s digital systems communicating as ‘they were too complex’; it’s too easy to be foiled.
Handbrake back on.
The excellent scientific learning cycle, from arduous RCT, publishing, and the usual evidence based practice is rigorous and crucial, but it needs catalysing to be quicker.
The whole-systemflow is fecked, to quote Father Ted.
The senior management teams in trusts need to be systematically facilitated to have a grasp to actively change in the way that you suggest, and not blamed by the centre.
I pray that politicians will get a grip of this, but am not optimistic.
We have General Practitioners (GPs) refusing / unable to look at certain conditions, and they use paramedics and A&E for their assessments, and everyone joins the queue (if they are not sitting in an ambulance) tl the beleaguered open doors of hospitals who should not be acting as a primary care service and where patients (worryingly) are getting increasingly more tetchy.
I have had great, fast and accurate medical treatment recently (once in the service), but we need the flow better managed, from tech advice and management for the masses to take care of their health as best they can, with a clear flow of a functioning primary care service and being able to be admitted where necessary (meaning that pw long term conditions need to be discharged and managed in the community).l, and rehabbed after.
However, with the amount of GPs this week saying that they can’t cope, are likely to leave within 5 years (IIRC), pushing the GP under provision to DOUBLE what it is now, we’re stuffed.
Plenty of senior NHS staff are leaving asap, and we have had a serious staffing crisis brewing for the last 25 years which is largely unaddressed, despite the claims by all politicians.
We need politicians with a trans denominational vision to get a grip of this over several parliaments, but like you, I wouldn’t put money on this happening.
Meanwhile I’ll go sailing, then retire early to reduce the pain of banging heads on walls in what is broadly an altruistic profession, that should not be like this.
See you on the water…
Thanks Jem. I should have asked you for comments on this morning’s porridge before i published, but i did not want to wake you at 5 am.. (I was up for a call on the mid-east which is why its overlong…)
I am thinking of putting a brains trust together on this topic – care to join?
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THanks – really appreciate this.
Completely agree Bill and some very interesting ideas as to how it might look. It does concern me that insurance companies are waiting in the wings, licking their lips. But….you mentioned individuals need to take responsibility….unlikely to happen anytime soon. As humans we’d rather blame someone else, especially it seems in this country. Why do you think people believe in god ?
Spectacularly insightful article.
How do we get politicians to read it (or begin to respond to it)?
Dont know. You can lead a horse to water, but you can’t make him support Arsenal…
Or can you imagine trying to explain something like this to geniuses like LUZTRUSS or KamiKwasi?
To many tests and problem patients and not enough responsibility.
People don’t deserve a gastric by pass or consultation about how to lose weight, its common sense and if you can’t figure that our let Darwin do it for you.
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We love to measure everything, whether it’s the NHS, education or business. You can’t fatten a pig …..
Please give your thoughts/comment on the Wall Street Journal editorial from Sep 28 “What Really Went Wrong In Britain” .
Yep.. its a long story that has been years in the making. Will comment fully later this week.
I don’t mean to be impertinent but I recommend “How to Prevent and Reverse Heart Disease” sorry don’t have author handy. I’m not sure if that is a good title for those who took the jabs. Also recommend “The Cure that Works” by Sean Flynn Also recommend “Confessions of a Medical Heretic” by Mendelsohn, MD
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