Fixing the NHS will be difficult but can be done

Rajan Madhok

The NHS has featured prominently in every national election in the last three decades, and will do so, again, next year as Wales goes to polls.

And so it should be, after all the NHS is part of our psyche – people are proud of and love the NHS, and currently it is badly letting them down.

Rightly they are looking to their leaders to sort it out. But, can the politicians solve the problems facing NHS, and how can they?

As I see it, two things are essential in solving any problem: one, to understand the existing reality: what is happening, the challenges and the opportunities; and two, a clear articulation of a vision so that it can then be executed.

What is the reality of the NHS? Here, I will touch, very briefly, on a few of the most topical issues.

Money

Does anyone know how much money will be enough? After all the NHS funding is already a (very) large part of the government expenditure and more for the NHS means less for other sectors like education, social care, housing, policing etc. Pay awards to the staff will soak up additional allocations, leaving little aside for other pressures like the poor infrastructure – physical buildings and IT for example – not to mention the gaps in many services.

Should there not be a responsibility to ensure that existing funds are well-utilised first, why keep pouring more into this leaky bucket? How to raise and spend the funds is another dimension, which need to be discussed, at the right time.

Waiting lists

Waits are inevitable in a public system, but are all waits bad, are some waits more important than others, and how to solve waiting lists in a system which is ‘Supply induced demand’, which means that with scientific and technological advances the more that can be provided more will be demanded?

Can anyone see an ‘end’ to the demands, and if not then how to manage the situation dynamically, requiring a self-regulating and improving system? Will it always mean more money?

The private sector

Yes, there is a role for it, but how to involve this sector? Currently, it seems that profits are outsourced and the risks are in-house. Indiscriminate use, enabling private sector to cherry pick, creates an imbalance – the NHS only makes sense as a whole as some services like for children or elderly are cost centres and elective surgery like hip replacements or cataracts are profit centre, the latter subsidising the former.

Take cataracts as an example, whereby not only is the private sector making a profit, leaving less for the NHS which must provide comprehensive eye care services, and not just cataract surgery including complex care, there is also the knock-on effect on training of future surgeons who do not get enough experience of this common condition.

The workforce

“We will create xxx more doctors and zzz more nurses, or other professions depending on the type of the crisis in the news at the time” is the usual response from the policymakers. But where will these workers come from? From joining medical school to being a consultant can take 14-15 years. The NHS record on workforce planning is very poor – the oversupply of GPs currently or the limited places for Foundation training for medical students exemplify this.

Not to mention the debts incurred by these doctors, and similar situation applies to other professionals, and who will then need proper pay and conditions to make it worthwhile. Better to be a plumber than a doctor is not an uncommon refrain. The NHS has relied heavily on international recruitment, which is getting difficult due to immigration rules, and as many professionals find better opportunities elsewhere, and not just in monetary terms but also working conditions.

Information Technology

The track record of NHS in implementing IT projects is rather poor – nearly twenty-five years after Tony Blair talked about the electronic patient record, and after billions have been spent on it, we are nowhere near a useful working system. In any case, technology always moves faster than practice – by the time IT is deployed in the NHS, it is outdated. This is not unique to the NHS, but is an across-the-board public sector problem. IT does work, but as part of a well-designed system; it is an aid rather than a substitute for good management. We forget the hard lesson: successful deployment is 10% technology and 90% human factors.

Primary and community care, away from hospitals

Except the whole of NHS focus is on hospitals it seems, and that too acute hospitals; when primary and community care are not well developed, not to mention limited mental health or children services. The GPs are struggling to provide even the basics, let alone take over the work from hospitals. Critical to success will be better integration with social care and public health and creation of strong communities, which with the present state of society with debacles around winter fuel payments, PIPs and general costs of living are not going to be easy.

I could go on giving more examples, but they do not add further value, at this stage. I will also be accused of making superficial observations rather than provide deep, insightful details.

Rather, my main point is that things are not that simple and we need to think carefully about the whole system and its component parts, undertake a detailed review, and make well-informed choices.

Thus, for example, should more funding be diverted to public health and primary care, how should money be raised: is co-payment/charges an option, should there be some sort of ‘rationing’ with the NHS providing a basic/essential level of service? These are challenging but essential discussions, and where rather than emotions we need maturity and objectivity. In any case, these are all inter-related issues- you cannot fix one without considering the impact on others.

Sorting waiting lists out by putting more money into the NHS now and through the private sector may be necessary in the short term, but unless done as part of an overall plan will make the NHS worse off.

John Gray, the political philosopher, wrote: “politics is best understood, not as a path to salvation, but as the “art of devising temporary remedies for recurring evils” and that is what we need now – another remedy. The NHS in 1948 was not perfect and major compromises were made; the fact that it has survived for seventy-five years is a miracle, and we should be thankful for it. But it is time now for its successor, a system which reflects the current reality.

Piece meal

Instead, the present policymaking is, sadly, reactive, piece meal, with incompletely thought through changes, and often to manage the news cycle rather than provide clear direction, and there is no vision. And when there are grand plans, their execution is poor. “We are living today in tomorrow’s world with yesterday’s ideas” said a former Yugoslavian Vice President, Milovan Djalas, and that about sums up the problem with the NHS. We are neither able to embrace the future nor let go of the past. But maybe this is deliberate; the sceptics argue that there is a vision, and which is to create chaos and distraction in order to break the NHS up!

Only by systematic analyses can we hope to understand the problems and create the much-needed change for a fit for purpose health and social care system.

How do we move forward then? Let me start by sharing what Dr Bill Kirkup, who led several major NHS inquiries, said in his inquiry on maternity and neonatal services in East Kent, in 2022:

The primary reason for this Report is to set out the truth of what happened, for their sake, and so that maternity services in East Kent can begin to meet the standards expected nationally, for the sake of those to come.

But this alone is not enough. It is too late to pretend that this is just another one-off, isolated failure, a freak event that “will never happen again”. Since the report of the Morecambe Bay Investigation in 2015, maternity services have been the subject of more significant policy initiatives than any other service. Yet, since then, there have been major service failures in Shrewsbury and Telford, in East Kent, and (it seems) in Nottingham. If we do not begin to tackle this differently, there will be more.

For that reason, this Report is somewhat different to the usual when it comes to recommendations. I have not sought to identify detailed changes of policy directed at specific areas of either practice or management. I do not think that making policy on the basis of extreme examples is necessarily the best approach; nor are those who carry out investigations necessarily the best to do it. More significantly, this approach has been tried by almost every investigation in the five decades since the Inquiry into Ely Hospital, Cardiff, in 1967–69, and it does not work. At least, it does not work in preventing the recurrence of remarkably similar sets of problems in other places.

My reason for sharing this is that the usual approach to policy making and management needs a rethink – producing reports with recommendations and Special Measures regimens is not working. We need something different.

Broken

The system is broken completely, not just managerially, but more importantly spiritually – the soul has gone from the NHS. We need to start with restoring it by bringing back compassion, empathy and humanity. Yes, there must be more accountability and management as there are things that can and should be solved now, and patients are being let down. But there is good delegation where the ‘boss’ knows the ground reality, has given clear instructions, and provided the wherewithal, and then there is the NHS. Threats and exhortations to work smarter/harder on their own are not the answer.

The most urgent thing, to me, is to get the workers on board, win their trust and confidence and restore their morale. “We set our hopes on doctors when ill, and our dogs when well.” wrote William Carlos Williams, and I would include all frontline workers. It was shocking to see how these very workers, who kept us safe during the Covid 19 pandemic were treated once it was over- claps for NHS became slaps for nurses with derisory pay awards.

We have lost the much-needed goodwill, and must re-earn it. Yes, I am aware that there are two sides to this issue; in some quarters there is under- and poor-performance and we must address these – not everything can be blamed on shortages, too much demand or lack of resources.

Learned helplessness 

And overall, we need to get away from the prevalent learned helplessness – everyone feels like a victim and helpless. The whole culture of the NHS seems ‘wrong’ in parts, a colleague recently pointed out his frustration with the GIRFT (Getting It Right First Time) initiative – were they just playing around before and doing things wrongly? The language, and thought processes, did not sit well with him.

But this is not new – it took huge effort and money to tackle poor hand hygiene and get people to wash hands, and even basic courtesy like introducing self to patients took a major “My name is ……..” initiative. We need to find ways of professionals being professionals, not requiring this level of hand-holding, prescriptive interventions, and taking personal responsibility.

My own ‘focus groups’ (friends and families) accept that change is essential and are waiting for a clear vision. They are open to new ideas, and those of us of a certain vintage worry about the future generations and want to do their best and be seen as good ancestors. They are also upset with lack of openness and honesty about the situation with the NHS, and do not feel fully engaged – they want to co-produce solutions, and not be critics.

This is an open door for the right leadership to walk through. But remember, both, staff and public, are rather (rightly) cynical and would want to see serious intent and commitment, and results, before they will begin to trust the leaders. There have been too many promises and grand plans in the past.

Accordingly, in my view four things need to happen urgently.

Review

One, a root and branch, comprehensive, review of Waste in the NHS and Social Care- everything should be questioned, asking the 5 Whys (way of getting to the nub of the problem), and designing new ways of working using proper analysis, evidence and imagination. This is what anyone would do in their household; when circumstances change, we look at what we are doing, cut back/adapt. It is not someone else’s money, it is our money being wasted; this mentality will be crucial.

Two, sort out the basics: appointments going missing, patients stuck waiting for discharge due to poor planning, test results – even when tests done and reported on- just sitting there, and so on. Ask the public, or better, look at the patient stories and complaints data and see the common themes and tackle them.

Three, yes, it will take time to create a vision for the future system, but ensure all short-term initiatives are future-proof. Most importantly, let us stop new initiatives, there is already enough knowledge and reports; Wales is good at producing reports is what I hear, but not at execution. I firmly believe that any new announcements should come with a clear road map for how they would be delivered. So, the recent example that Wales would become a Marmot country – after the respected academic Sir Michael Marmot and his emphasis on public health and prevention and move away from hospitals to more primary and community care-  sounds good, but how can this be achieved?

Four, my repeated plea: please, please plan for the coming winter, do not wait till later.

Meticulous

At the start of my training as a junior doctor, a senior consultant told me that the most important thing to do when attending to a patient with sudden cardiac arrest is to take a deep breath and check own pulse- told lightly it was a serious point about being calm in a crisis, and being meticulous and professional. I believe this advice is relevant now- the NHS cannot be changed quickly – it will take persistent effort; just like the old NHS that was hard fought and won over a long period.

My critics will say I am not being practical and will want action now, they talk about strong and articulate leaders who are convinced and confident about what is wrong and already know the answers. I am on the other side, and feel that there are no answers yet, mainly because we have not even asked the right questions and explored alternatives, and leadership is sometimes about humility, accepting that one does not know the answers, and seeking help.

We do not know what the future will bring yet, but we do know what we want, and that is a system that will care for everyone, an effective, safe and efficient system, and a system that gives peace of mind and assurance, and we do not want more of what we are getting now.

Rajan Madhok is a retired Public Health Doctor

This article is written in his personal capacity. More details of his work are available at www.ramareflections.com