I decided many weeks ago that my next blog entry would be on health and the NHS, as this topic remains so close to the heart of the UK’s concerns. From the perspective of this ‘Change of the tide’ blog, it is noteworthy that much teaching about improving one’s personal health went hand in hand with the Evangelical Revival of the eighteenth century. Meanwhile, the main focus of recent press reports and public preoccupation has been on getting yet more money for the NHS rather than looking deeper at what it does with the very large budget it already receives.
I don’t recommend this as a method of gleaning evidence first-hand, but my own health has been so badly affected recently that I composed this blog in hospital, where I was for four weeks. I felt like an undercover reporter and was able to have numerous revealing conversations with staff, patients and their visitors, besides being on the receiving end of substantial treatment myself.
I must start with some great praise for NHS front-line staff. A large majority of them are very good at their job, very hard-working, reflective and a pleasure to be around. The work they do is far more meaningful, satisfying and rewarding than the national news might suggest. The NHS is a world-class health system. Unsurprisingly, there are some things about it that are definitely not world-class, for example the very unrelational powers of bed managers which makes it possible for staff to decouple a patient from his or her ward at will (it happened to me after just a few days in hospital) – and even in the middle of the night. More broadly, I propose that world-class medical standards (and not so much our own over-rehearsed NHS history) should be the main key for benchmarking the NHS and improving it further.
The primary problem of the NHS, in my opinion, is that it functions in silos. Once a patient has successfully landed in one of these – such as a typical hospital ward – nearly every staff member in contact with that patient does a fantastic job. However, if the patient’s needs crosses to other silos, then there can quickly be a clash of priorities to the detriment of the patient’s care.
For example, I was put into hospital to expedite appointments with other specialists. Having got me that far, a junior doctor assigned to me explained that he had to build my case well enough to persuade those specialists to fit me in, as if I might not be sufficiently deserving of their attention. The antidote to this silo mentality is to ‘put the patient first’ at all times, to apply that principle rigorously, evaluate how well it is happening, recognise those who do it best and hold accountable those individuals and units that repeatedly fail to achieve it according to recurring patient feedback. I was given the opportunity to complete a very short written evaluation on leaving the hospital, but the printed wording of it was too bland to elicit effectively any principle concerns of departing patients.
One of the most concerning silos of them all in the NHS is the pharmaceutical industry, whereby NHS pharmacies and pharmaceutical companies have deeply embedded power to sell products and services in increasing quantities. It is not as though the hospital pharmacy is even efficient: the ward staff can order up medication that can take 48 hours to reach its destination upstairs, with no tracking procedure to show what is happening in the meantime. One of the less publicised hindrances to releasing hospital beds concerns the delays caused by the pharmacy in assembling what a departing patient needs to take home. I could have left several hours earlier but for the inefficiency in that part of the departure process, and I had already witnessed the same happening to other patients.
I have found that most doctors I have talked to on the subject are embarrassingly ignorant of dietary matters, as their training and emphasis revolves far more around prescribing medication than asking the patient to consider more natural remedies (e.g. discussing, not just noting, what the patient is eating and then helping to steer his or her diet accordingly). A standard 10-minute GP appointment also gives too little time to get to the roots of mental health problems, so a fresh prescription is an easy option for getting the patient out of the door on time.
My own particular case involved a situation where the head of pharmacy blocked for about 17 days the ‘tertiary’ course of treatment that the specialist doctors wanted to give me. That blocked a bed in the meantime and left me in considerable pain, just because of protocol requirements that oblige the patient to ‘fail’ first at two other courses of treatment. Surely, medical teams should always have the ultimate say about treatments, not a pharmacist who goes nowhere near the patient.
The most principled pharmacist is not a neutral agent when it comes to budgetary matters or as an enforcer of medical standards. Sales of drugs to the NHS went up by 20% between 2010/2011 and 2016/2017, reaching £17bn (according to The Health Foundation). Within those same years, the rate of increase of costs in hospitals was double that in primary care. One notable price hike in that time was for Tamoxifen, the widely used breast cancer drug, which went up from 10p to £1.21 per tablet (BBC, ‘Cancer drug price rise costing NHS millions’, 29.01.2017). This represents a major place in NHS budgets where the financial tail is wagging the dog. Some level of savings could make possible higher wages for nurses and healthcare assistants.
Another area with great scope for savings is the NHS internal market, which costs an estimated £4.7bn annually to administer (Centre for Health and the Public Interest, July 2017). Although I am not against internal markets on principle, an NHS patient has very little opportunity to function as a customer. I experienced no such role while in hospital. The internal market is an elite and expensive system to go on using any longer.
Another key area for attention is nurse training and recruitment. Overstated language requirements have now made it very difficult for a competent foreign nurse to get a job in the UK. I write this as a teacher of English as a Foreign Language, with much experience of teaching for the IELTS language test involved. The requirement of minimum scores of 7.0 in all four sections of this generalised test is too high. Some educated British people, capable of being good nurses, would not reach that score.
Meanwhile, British student nurses have to pay £30,000 to study and qualify in the UK, even though they move during their course from one unpaid placement to another. Student nursing fees should go down corresponding to their valuable contribution on these placements, and the pre-degree training needs to become less full of essays and theory. The four-year nursing apprenticeship, already being piloted, seems a much better option than a degree for many British citizens.
Last of all, I need to mention the disturbingly costly time bomb that is being put under NHS mental health services by the scam that says it is possible to change gender personally just by announcing it to be so. With no disrespect to those with transgender leanings and characteristics, this unscientific and unsustainable idea ignores the rigorous medical criteria for gender dysphoria.
It seems to me that this is the biggest deceit being taken seriously by government since the South Sea Bubble that peaked in 1720. In that scenario, ministers, including the Prime Minister, ended up losing their jobs as the scale of the deceit that they had permitted produced its own destructive consequences. I don’t think the government can afford that level of political collapse to occur as the emptiness of a self-identified gender policy starts leading to legal cases.
Our GPs remain under huge strain. I suggest that every A&E should have a 24-hour GP practice attached to it, so that all cases that are not accidents or emergencies are immediately sent ‘next door’. GPs in general need more support than they are already getting. I propose that this can best be done by encouraging their steady merger into larger practices, without a corresponding loss of geographical reach, in a way that is comparable with what is happening with solicitors’ practices.
My international connections have allowed me to ask people from other nations what is the best aspect of their health system. A group of high-level health administrators from Denmark replied to me without hesitation, “We work together”. A citizen of Finland replied “the baby box”, which is a well-composed starter kit that a mother is sent home with after giving birth in a Finnish hospital (e.g. the box itself can be used as an initial cradle). The Infant Mortality Rate in Finland is nearly half that in the UK. Spanish and Portuguese nursing staff have unanimously replied to me, “the quality of our nurse training”. We have much we can rapidly learn from other nations in this kind of way.
I think that we can yet have much hope about the NHS, but only if its managers are prepared to make some daring improvements quickly. At its lower levels the NHS is providing some fantastic patient care. In the upper levels of management, over-concentration on just some financial constraints has obscured other factors that could enable the system to do considerably more within its current resources.
I will write about the related topic of public health in due course. I plan my next blog to be about education.
Change of the tide 