The NHS has come a long way in the past few years. Not so long ago it was described as our national religion: so revered by the vast majority that we stood on our doorsteps and applauded those who worked for it. Now it is more vilified than lauded. In the past few days it has been described by one of the country’s most distinguished doctors as a lobster trap: easy to get into it, but impossible to get out. Jeremy Hunt promised in his autumn statement to pour another few billion pounds into its coffers but is more cash the answer or does it need fundamental reform?
It was Dr Adrian Boyle, the new president of the Royal College of Emergency Medicine, who came up with that seemingly bizarre lobster trap comparison. He was describing an organisation in which hospital overcrowding and bed blocking are killing hundreds of patients. A crisis in social care has left 13,000 patients stranded on wards, despite them being deemed medically fit to leave. There is a logjam fuelled by long waits for ambulances and even longer waits – often twelve hours or more - in A&E. Last month 44,000 patients had to wait over twelve hours to be seen. The target is four hours and many say even that is far too long. People with genuine problems should have to wait no longer than one hour. Other unnecessary delays to emergency care are estimated to be causing 500 deaths a week.
Dr Boyle expects things to get worse. Hospitals are running at 94.3 per cent capacity. That’s the highest it has ever been and we are not even in winter yet. That, of course, is when the pressure on beds is at its highest. The maximum safe limit at which the doctor-patient ratio is manageable is 85 per cent. And Dr Boyle says it will get worse. As many as one in three hospital beds are occupied by people fit enough to be discharged – and they are suffering because of it.
It's true that the NHS cannot be blamed directly for bed blocking. The root cause of that is a social care system which does not meet the needs of the many people - mostly elderly and infirm – who need to be cared for when they are discharged. The days of convalescent homes are long gone. But critics of the NHS say the crisis is much wider. In England the number waiting for routine hospital treatment has passed the seven million mark.
Defenders of the NHS say if there is a crisis it has been exacerbated by something for which it cannot be held responsible: a national pandemic. The covid crisis meant vast numbers of people had to be admitted to hospital as emergencies and that, in turn, meant having to turn away many who should have been admitted with other serious illnesses. To which the critics say if the NHS was being properly managed the covid crisis would not have happened – or, at least, would have had much less affect. They say the response was hysterical, pandering to popular pressure, rather than well considered. One example often quoted was the way in which a vast amount of private hospital space was commandeered. It cost many millions of pounds a day to staff and was barely, if ever, used. The so-called Nightingale hospitals were built at huge expense even though there were nowhere near enough nurses and doctors to staff them.
The real cost of all this, say the critics, is being borne by those who desperately need treatment but have to wait too long. Half a million additional people have dropped out of the workforce because of long-term illness since 2019. Long Covid is thought to account for a fifth, but many will be struggling with a cancer diagnosis. Last week, a BBC investigation revealed that the number of patients waiting more than the 62-day target time for cancer therapy has reached more than 67,000 in England, Northern Ireland and Scotland. That’s twice as many as it was in 2017-18. The NHS is now near the bottom of the developed nations’ league table of cancer performance even though it has some of the leading researchers. The poorest are hardest hit. Cancer deaths in the most deprived areas are 53 per cent higher than in the richest parts of the country. Overall, the UK came 33rd of 41 developed nations for cancer mortality last year, behind Bulgaria, South Africa and Brazil, according to the OECD.
The list of problems is a long one and, the critics claim, is growing. Staff vacancies are at record levels. Nurses are about to strike and some are refusing to conduct mammograms, smear tests, colonoscopies and skin biopsies. Many doctors are retiring early. And then, of course there is what many see as a crisis in our local GP surgeries. Getting an appointment in person with a doctor Is something we once took for granted. Now, in many parts of the country, it is more a dream rather than a reality.
And all this has come at a vast cost. Last year we spent £277 billion for all healthcare and £229 billion of it went to the NHS. That is 12 per cent of the UK's entire GDP and more than £4,000 for every man, woman and child in England. It's also well above the average of richer countries in the Organisation for Economic Co-Operation and Development (OECD).
Many critics say the root causes of the crisis in the NHS go far deeper than the size of the cash handout or one single epidemic or even the grossly inadequate social care provision. It needs root and branch reform. The most sacred tenets of our state-controlled model of centralised health provision need to be challenged. They ridicule the notion that our NHS is the envy of the world. If that is really the case, they ask, how is it that no other country has copied it? It’s no longer enough, they say to keep pumping ever more money into the system – as Jeremy Hunt did – it’s meaningful reform that is needed and good management.
Ben Zaranko of the Institute for Fiscal Studies, notes that NHS spending in England this year is 12 per cent higher in real terms than in 2019-20. In other words an increase in the NHS budget from £123.7 billion in 2019-20 to £151.8 billion. And that has indeed resulted in clinical staff: “There are 13 per cent more doctors (including 10 per cent more consultants) than in 2019, 11 per cent more nurses and 10 per cent more clinical staff. Yet the NHS is treating fewer people from the waiting list.” And that, he points out, is fewer than it was before the pandemic. Peter Johnson, the NHS cancer chief, has said the problem is not funding so much as “looking after the people who work in the NHS, making sure the organisation is running as efficiently as possible”.
Efficiency may be the holy grail of NHS reform according to many experts. They question whether new technology is being used to its full potential and, indeed, whether we need much more of it. Should we not be training more doctors and nurses – something that would pay for itself because of savings made in hiring vastly expensive agency staff? Why are more senior doctors not working at weekends? Should the NHS not be learning lessons from the infinitely more efficient private sector both in this country and from our European neighbours? Are we making sufficient use of our network of highly trained pharmacists, some of whom know more about their customers than GPs know about their patients? And are different NHS trusts learning from each other? Why is it that nearly 80 per cent of cancer patients are treated within two months in Surrey but only 43 per cent in Mid and South Essex?
According to the Shadow Health Secretary Wes Streeting, who was himself successfully treated for kidney cancer last year, it is market forces that might be able to provide what the NHS so badly needs: more accountability and competition and better outcomes.
Is he right? Do we need to talk seriously about bringing a touch of commercial enterprise and innovation into our sacred, but clearly ailing, NHS? And, if not that… then what?
Are you happy with the service you are getting and if you were running the NHS what would you do?
Let us know.