Blain’s Morning Porridge, September 2nd 2022 – The UK’s NHS is a political nightmare – but could yet be fixed!
“Physician, heal thyself.”
This morning– The last thing new UK premier Liz Truss will try to do is fix the NHS. Too difficult and an electoral minefield. It will get worse. But, tech and medical advances plus a bit of flair could give us a new NHS fit for purpose and ready for the next century. It will take will and imagination – which is unlikely to be found in the Department of Health or No 10.
A few days ago I warned how the UK could squander its global reputation, give up its status as leading G7 nation, and even see our global soft-power evaporate (with all that would consequentially mean for house prices, tourism and the foreign student business). It could happen if faith in the economy, politics, the bond market and currency collapse. I call the relationship between them the “Virtuous Sovereign Trinity”. If one leg breaks, the whole edifice will totter. If the currency collapses because the world thinks the UK is fundamentally broken, they we won’t be able to fund recovery through the Gilt (UK Bond) market.
Ahead of our “eagerly awaited” new government next week (Sarcasm Alert), I’ve upset a number of quite serious (even important!) Porridge readers with my comments. If I’m “so bloody clever, how do we fix it” demanded one, asking me for specific examples of how the UK can turn around the current decline.
Unfortunately, I am not clever. But I know people who are. This morning, let me go into a controlled rant on one aspect of what’s wrong with the UK.
Let’s start with our failing National Health Service.
The NHS is the biggest employer in Europe. It is out best loved, best trusted but possibly least effective institution in the UK. There are some 53,000 bureaucrats in the Department of Health notionally “managing” it, with innumerable layers of local management – many paid excessively well, while nurses live on a pittance. It is a ravenous devourer of resources.
There are calls to change the funding model – some experts have suggested social insurance schemes, but that just misses the point: unchecked the NHS will quite happily consume every penny of taxes or levies it is given, and still bleat about underfunding. NHS spending accounts for 9.6% of UK GDP – but is actually less per head than France, Germany or the USA!
Fixing the NHS is a political impossibility.
To suggest any kind of change would be the death of any government – triggering outcry from unions, staff and the Great British Public about privatisation by the back-door. As we discovered during the pandemic, the NHS has become an obsessive national cult. All governments are willing to do is tinker with it – meaning it becomes progressively less and less efficient.
Don’t expect the new government to act. Fixing the NHS is the last thing the new Liz Truss government will try in the 2 years she has to present herself as a competent replacement to the last 12 years of Tory Chumocratic incompetency before a UK General election is due in 2024.
Disclosure: I am very familiar with the NHS. I love and hate it. It is caring, kind, but bureaucratic and painful to deal with. I had a heart issue addressed through a corrective operation – on a private health package. Unfortunately, private care was not so hot; they missed an infection, the repair didn’t work, and I had a massive heart attack – at which point the NHS put back together again. I could not have asked more of the NHS – they saved me and keep me alive.
We are all aware of the multiple chronic problems faced by the NHS. These include:
- The NHS is fundamentally an organisation designed for the 1950s, trying to function in a 2020s environment.
- Tinkering over the decades has made it less efficient, managerially top heavy and bureaucratically emburdened.
- The NHS is catastrophically short of doctors and nurses, while largely private Welfare care services are short of 150,000 care workers.
- Doctors earn comparatively well, but nursing and welfare jobs pay well below what workers could earn outside – care is considered a “vocation”, meaning employers historically pay less!
- The rebuild of decaying NHS infrastructure – crumbling hospitals, has been delayed.
- Waiting times for patients have ballooned.
- The bulk of resources, costs, beds and staff time are now consumed by the elderly.
- The lack of nursing home care and community care means elderly patients block chronic care beds in hospitals – and UK bed capacity is very low compared to other G7 nations.
- Accident and Emergency rooms – increasingly concentrated in a small number of large regional hospitals – are swamped – one reason being patients going direct to A&E because they can’t get appointments with Local GPs.
- The UK remains at the forefront of medical research, but lags in terms of technology.
NHS England, has a list comprising 41 pages of priorities to address – everything for Autism to Stop-smoking. When everything is a priority – nothing is.
What the NHS needs is a new over-arching plan to address staff shortages (which means paying them properly), an infrastructure plan to rebuild capacity, and a new national health plan to ensure resources are directed more cleverly – more nursing home and welfare care for the increasing elderly patient demographic, smoother access to minor injuries and ailments at local level (to relieve the A&E impasse) and greater emphasis on preventative care. Kind of obvious – but its not happening.
To analyse the entirety of the NHS’s problems in the 2 hours I give myself to write the porridge each morning is not possible – especially when there may be a new crisis approaching.
Earlier this week I read a frightening article in the FT: The growing evidence that Covid-19 is leaving sicker. The data emerging post Covid highlights how Covid may have significant detrimental consequences for survivors on their long-term health – accelerating the diseases of old-age. The numbers show rising respiratory illness, rising cardiovascular disease, rising strokes, rising dementia and increased brain shrinkage among Covid survivors. There is a very good piece on ZeroHedge – The Mysteries of Long-COVID – which illustrates the US experience. It confirms long Covid health problems are hitting not just the vulnerable, but the ultra-fit as well.
Yesterday, I was relieved of a vast quantity of blood to be tested by my chums in the NHS – they confirmed everything in both articles. There is a wave of post-pandemic critical illnesses sweeping the country. There is, however, little evidence to support the growing urban-myth that it’s been Covid vaccines that have triggered a wave of heart-attacks, although I have two good friends who swear Covid jabs trigged their moments of crisis! Its more likely Covid accelerated their existing conditions.
In the face of the extra long-term pressure Long-Covid will place on the NHS, maybe what the UK needs is a more radical solution to health care… like using technology.
A few years ago my Cardiac Consultant outlined a modern healthcare system – all of which was based on then current Genetic, Diagnostic, Data and Artificial Intelligence tech readily available. (Since then the medical tech, data processing, AI and systems have got even better.) Simply put everyone should have responsibility for all their medical data. He suggested:.
- Everyone becomes the owner and retains responsibility for their Personal Health Data (PHD).
- PHD will be encrypted and stored on your smart phone, and backed up on the NHS.
- Real time data from wearable health tech, genetic and medical tests, is added to the PHD, and interrogated by inbuilt AI to highlight changes and suggest causes.
- Your PHD will include all your genetic traits – including propensities to cancer, heart disease and other illnesses.
- Wearables can add exercise, heartbeat, blood-pressure, ECG and other data to the PHD – with the AI can interrogate.
- PHD data is not shared with outside agencies – like insurance companies.
- Individuals can make the decision to share your data – and be paid for it. I.e, Insurance companies would need to reward customers who give them access and record data.
- Every year, everyone gets a full spectrum blood test – to check for markers of change.
- Unexplained changes are followed up with further investigations – such as MRIs.
None of this is rocket science. You can do it privately already. The key to the system is the AI – rather than patients presenting themselves with symptoms and doctors then spending months trying to diagnose whatever ails them – searching for the needle in the haystack – the AI (which will be constantly learning from 62 million UK users) brings the haystack to the needle! It will be able to direct physicians to the most probable cause – dramatically cutting down time delay, and improving the use of resources, freeing them up for preventative medicine.
Unfortunately, the NHS innovating such a modern system is unlikely.
THey may welcome the multiple new bureaucratic jobs the Department of Health will insist are neccessary to examine it, but the Health nomenaklatura is notoriously anti-tech after multiple failures to innovate NHS databases over the years. During COVID, the Test and Trace tracking system devoured £37 bln (20% of the NHS budget!) to deliver absolutely nothing. (Except a damehood for its leader Dido Harding, who farmed the work out to very grateful consultants who were paid rather well at an average of £1100 per day…) The British Medical Journal was scathing: NHS Test and Trace failed despite eye-watering budget.
But….. What Test and Trace did demonstrate was the ability of the UK to build-out very quickly a full laboratory testing infrastructure. The UK’s response to Covid showed what can be achieved – when the will and urgency is present. The AstraZeneca vaccine, the vaccine programme and the (actually never used) Nightingale emergency hospitals all highlight the fact the UK can deliver when pushed and challenged to do so.
If firms like Meta, Netflix, Apple and Amazon can build the tech to amass details allowing them to predict every aspect of our commercial likes and dislikes, its not inconceivable a smart entrepreneur could build out a PHD service for the UK. It would improve treatment and care, and allow the NHS to refocus on the other aspects:
- The right mix of facilities to treat the demographic (the AI would provide the real-time data to do so)
- The right salary structure to attract staff – making care in the community and nursing high quality roles.
There is nothing that can’t be solved – even the NHS.
Six Things to Read This Morning
Spectator – Trussonomics – A beginners guide.
Thunderer – Average pay for GPs has hit £122,000 + Health Minister brands NHS managers “a distraction”
FT – UK Fuel poverty to hit 12 million homes without immediate action
BBerg – Global Bonds Tumble Into Their First Bear Market in a Generation
WSJ – Hopes for Fed Pivot Have Faded, Snapping Stock Momentum
Out of time, back to the day-job, and have a great weekend. I am off to do a charity-walk round Stonehenge this weekend – and really looking forward to it!
Strategist – Shard Capital
The IA company Palantir (Karp/ Thiel) will fix the NHS problems. Contract announcement due in september…
Lefties are going to love that announcement!
Bill, It may be worse than you realise. To give an example of how stuck in the past the NHS is and how much it clings to outmoded ways of thinking consider mental health. Poor mental health is the biggest health problem we face and sure there’s loads of column inches devoted to it but its empathetic not responsive. Estimates from 2016 estimate it’s total real cost to UK Ltd is of the order of £75bn-£99bn, thats around 6.5% of GDP (think about the UKs productivity gap?). Cancer costs on the same basis are around £14bn. So you would think we are ploughing resources into trying to address this yet cancers research budget is 4 times greater than mental healths’, thats a 32X differential on an impact addicted basis. What are the 50,000 “managers” doing when they permit discrepancies this size to persist?
Bill, As a NHS trained Doc, now working in Canada, the ails of any health care system are common and there is only one solution to be added in, the most important one; Responsibility. Individuals have to be made responsible for their own health, and for deviations from a health care plan, ie pay premiums for smoking, obesity, drinking too much etc. Providers also have to be made responsible by measuring their performance, using good data collection. Our western society operates a “Humpty Dumpty” system of health care, we wait for people to fall off the wall, we don’t do enough prevention to prevent falls. The elderly, of which I am now a reluctant member have even more responsibility to exercise and keep the weight off. As for post Covid, it was always so with any viral illness, we just never collected the data as well as we do so now. Technology can never replace individual responsibility, but it can make care more efficient when properly applied. Read Ivan Illich’s book “Medical Nemesis” to understand the dangers of the Industrial Health care complex and the medicalization of normal life.
From a reader:
I now believe that the “Country” is actually ready for someone to grasp the political “nettle” that is the NHS.
It is a bear trap, I agree, but if you listen to the tales of woe from around the whole system the over-riding message is that it is a busted flush. Even those who work within it accept that. The notable exceptions are all the overpaid box tickers who depend on the inefficiency of the system to keep them in their mostly useless jobs.
Remember the old mantra “always spend your budget on something, anything, or else it will be cut back next year!”. The NHS is a classic example. Improvement in efficiency, delivery and outcomes is always just around the next corner but will require more money to achieve!
Rather like our fondly remembered City, the more HR and Compliance get involved the less the damned thing works and the best people find themselves hemmed in by the ever mounting piles of justificatory garbage they have to deal with and spew forth for nobody to read, understand and fail to act on.
Matron would get the junior nurse to swab the floor and wards were pristine. You now have to call house-keeping to send an “operative” merely to mop the place.
Everybody knew their job and got on with it. No reams of paperwork to satisfy the H&S crowd in case, God forbid, someone got nasty and sued the hospital for malpractice. GP surgeries now employ a team to fill all the rubbish that the “centre” demands so that unpleasant outcomes can be explained away. Medicine is a science that will never be perfect but we must let the doctors and nurses do their jobs without the constant fear of being second-guessed by lawyers and even their own Associations/BMA/GMC etc.. Lawsuits overhang every poor practitioner. Covering backs is never a productive use of scarce resources. Incidentally, do you know a GP doctor who works a 5-day week? The answer is surely “no” and that goes some way to explaining the “shortage” of practitioners and the ludicrous situation in A&E departments.
No Nurses are NOT paid a pittance.
By the standard of the lower wage they do very well. Even by the standards of many graduates (which modern nurses unnecessarily are).
But the trouble is that over half the working population is paid badly.
GDP doubled and median wages are up about 10% in 40 years (up 0% in US).
The huge spread between consultant doctors, new doctors, Nurses and Auxiliary workers is just typical of how the rich got very very richer and the rest stayed unchanged. Never mind the Private sector.
Tax and spend is the only way to make this a fairer country after 40 years of reversing inequality. NHS and Infrastructure really need it.
Thank goodness your not running the NHS or Dept. of Health. That sort of intrusion in to normal lives, let alone all the ill effects of mis-diagnosis, potenial for the data to be stolen, corrupted or misused would i think tip many over the edge. Finally given that the most benefit is to rather older people, would many of them be able to use this stuff. I have friends of 70 years old that don’t use email or a mobile phone.
It might not be perfect – and allowance will need to be made, plus it can be introed slowly to older generations…
What we cant do is do nothing.
Bill, this comment is only related to the start of the article where you talk about reversing our decline. I believe a huge amount could help if we loosened our planning laws. The current system of effectively giving everyone in the country a veto on what gets built where is ludicrous and cripples any ability to produce. An offshore wind farm was blocked because one person complained it spoiled their view. HS2 has been stopped at every turn by planning restrictions. The “green” belts (in reality a series of petrol stations, car parks, and other tarmac monstrosities) stop cities from expanding outwards and planning restrictions stop them from building upwards, causing huge amounts of city dwellers incomes to be sucked up in rent and property values, rather than much more productive ventures. It’ll never get through as every MP relies on their local NIMBYs for votes, but I think allowing the private sector to build would be a good starting point for growth.
And the more affordable housing that would come from building enough homes to meet demand, would help those with lower salaries, such as nurses.
Society starts when two guys sitting around a fire decide one will stay and keep the fire going while the other hunts. And it makes sense. And society and civilization grow. But then a man is elected who “decides” who hunts and who watches the fire. And then he hires his brother in law. And the system grows until there are more people planning than doing the work. And we are there. And then the system collapses, and you start all over. And we are there. There is no fix. They only “fix” it by hiring more government workers to “plan” it. Which makes it worse. This is the long collapse. It was after my time in the US military, but the sandbox kids had a saying. “Embrace the suck”.
The NHS was very much a creature of its time along with the partition of India and Pakistan, the Central Africa Federation, the British Motor Corporation and the ill considered ground nut scheme, when gigantism and ideology ruled. This monolithic organisation, which would herald the New Jerusalem, was created by a Welsh rabble rouser, aided and abetted by a bunch of Oxford schoolboys against the advice of Herbert Morrison, who had practical experience of running the hospital services of the LCC before the war.
The problems we see today were quite visible in the 1950s, when successive Conservative governments adopted an approach of benevolent negligence, which was possible with solid economic growth of 2-3% per annum.
A sane administrator would have created a modest, decentralised system building on the achievements of the 1930s.
The poor state of the NHS isn’t a result of too many managers or, as many suggest, a willful intent by management to waste public funds. It’s the result of the desire of every government we have had to seek short term popularism instead of having a long term strategic plan coupled with the total failure of every party in power since 1948 to manage the public expectations of what the NHS was designed to deliver. The % of headcount designated as ‘management’ in the NHS is below that of any FTSE 100 business and, at the risk of stating the very obvious, without management the financial crisis the NHS now faces would be many orders of magnitude greater because, quite rightly, an NHS managed solely by health care professionals would put the care of patients above and beyond any considerations of the cost of delivering said care.
Should someone in power decide to tackle the issue a good starting point would be to acknowledge that the N in NHS is meaningless and the S should stand for System and not Service. General Practice or Primary Care, the first encounter with the NHS most have, is not part of the NHS. The vast majority of GP’s are private limited companies run for profit who have only one customer – the NHS. Tackle that and you’re a third of the way to sorting the basics. The queues outside every ED at the moment are, as you point out Bill, because seeing a GP is pretty much impossible. Social care is delivered by councils and despite all the soundbites from many Secs of State for Health, and the comedic renaming of the Department of Heath to the Department of Health and Social Care, is run in to the ground and in many areas verging on non-existent. If Granny has nowhere to be discharged to from her (probably unnecessary – see Primary Care) stay in an Acute hospital, be that to her home with a care package or to rehabilitation, then the system grinds to a halt – just what we are currently experiencing. The council social care budgets are not ring fenced and by and large viewed as the first area to have funding cut because we all notice when the bins aren’t emptied but many of us will have little or no experience of social care.
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