Reality in the NHS

Last week I went to an 80th birthday party with a difference. The birthday boy failed to show on account of having died two weeks earlier. The family decided to continue with the arrangements, balloons and all, as rather a jolly wake. The family all agreed was that he would have been there if he hadn’t agreed to yet another round of chemo. It was very disagreeable for him and it killed him.

No one is blaming the doctors and nurses. They are wonderful and have the best of intentions. He made the wrong choice or maybe the system made the wrong choice. A man with a hammer goes around looking for nails to knock in. As Atul Gawande showed in his splendid book, “Being Mortal: Illness, Medicine and What Matters in the End” (2014), specialist medical practitioners look to use their skills. It is what they do. The consequence is an excessive number of over-worked specialists and a shortage of geriatric specialists who can take a holistic view.

That is symptomatic of so many areas in the NHS where savings are not only possible but would benefit the patients. One reality is that the NHS will need more money. If the Prime Minister does provide it then she is acting irresponsibly–because she is doing so without also ensuring real reform. For a start, productivity will decrease.

Lord Warner was a Health Minister during the Blair government and witnessed exactly that. His book, “A Suitable Case for Treatment - The NHS and Reform” (2011), documents what happened when the NHS was given large sums of new money but little improved because it is an unchallenged monopoly: “This monopolistic power shows in the attitude of many NHS staff and their resistance to external providers and reform. While I was a Minister, the health team regularly had meetings with groups of NHS staff, with everyone from porters to consultants, but with no senior managers present. When asked what they would most like me as a Minister to do, they invariably asked me to stop change.”  

Listing the areas of NHS waste would take more space than this Blog allows. Some are massive: such as procurement and the external bureaucracy now committed to it. NHS constraints on surgeons and consultants lowers their productivity relative to their private work. Spending £180m a year on back injections and surgeries the medical community decry as useless. Prescribing over-the-counter medicines which the NHS forbids every few years. Refusing to recycle medical devices, such as crutches, or unopened packets of medicine.

Some are less serious: such as throwing away metal scissors and tweezers after one use. They used to be sterilized in boiling water but scientists have shown that “prions” (Mad Cow disease) are not destroyed by boiling. The grand total of UK cases of Mad Cow disease is two in the last eight years, both likely due to long ago blood transfusions from an asymptomatic patient who'd eaten infected beef–with no known instance of the disease being caused by surgical instruments.

The second reality is that the Department for Health and Social Care and NHS have more reasons to conceal waste than to come clean. Transparency would undermine their case for more money and it would increase the pressure for reform. Ministers can be fobbed off with promises of savings (procurement being a good example) without those savings actually being tracked and delivered. Worst of all, as Lord Warner discovered, transparency would mean change.

The NHS, like all those reaching three score years and ten, embarrassingly pretend everything is and will be as it once was. The reality is that the NHS should adapt. That does not mean accepting the whims of a few politicians as led to the unfortunate 2012 Act. We need creative thinking by well-informed experts. There has only ever been one Royal Commission strategically to review the NHS and that was 40 years ago. Be it a Commission or a more informal Convention, let us have a non-partisan strategic review now. Once the consequential reform has been put in place, then of course the necessary funding can flow.