The plight of the NHS at 75

By Bertie Leigh
Retired medical defence solicitor 

It is not a good time to talk about the plight of the NHS.  The Service is visibly failing to deliver on targets, which were built into the laughably misnamed NHS Constitution almost 20 years ago.  As a result, private medical insurance is booming because sensible people have lost confidence in the alternative.  There seems to be a cadre of journalists who consistently call for it to be replaced by an insurance-based alternative. Now they have been supplemented by Sajid Javid, the last Health Secretary.  Sensible people who have experience of alternatives in Australia, Denmark, the Netherlands and France urge us to embrace these.

The reality is that we have two distinct problems.  The first is the NHS itself: this is a nationalised insurance system, a means of paying for our care at a time when we are healthy.  It is failing to deliver because we have been failing to pay for it properly for 15 years.

The answer to the Daily Telegraph critics is very simple.  Since the Global Financial Crisis of 2008, a succession of Conservative governments have underfinanced the NHS.  To starve any organisation for 15 years of essential resources and then to denounce it for not providing an adequate service is unreasonable.

It is true that the NHS does suffer from periodic political interference and we need a system for insulating it from ill-informed wheezes from above.  But we know that is manageable: in the five years before COVID-19, the modus vivendi between the Department of Health and NHS England, between Simon Stevens and Jeremy Hunt did reduce political interference to a reasonable level.  In reaction to the Lansley disaster, there was no significant legislation for years on end.  That did not mean that there was no radical reorganisation – achieved largely by consensus within the Service – or that the reorganisation that happened was not a radical attempt to restore the old System of Health Accounts, and to resolve the gap between health and social care.  This suggests that the propensity for politicians to meddle is manageable, even without the legislative reform we need to establish a statutory independence.

International comparisons suggest that the NHS delivers more than most alternatives, and could be made to do far better if we were to dismantle the internal market and other unnecessary bureaucratic burdens whose absence was the glory of the model until 30 years ago.  But whatever system we choose, we inevitably have to pay what the Service costs: at the moment we are in the undignified position of complaining about the quality of something we have not paid for. 

The NHS is also the victim of a second problem for which it is not really responsible, although it does sometimes make it worse.  There is a dysfunctional relationship between medicine and society.  We are, by turns, euphorically grateful when things go right and petulantly angry when they do not.  Since things go right when people simply do their job, this gratitude finds no tangible expression towards a staff whose pay has in real terms been frozen since 2006.  When we try, as with the doorstep clapping during the pandemic, the staff are baffled.

By contrast, the anger and the unreasonable demands are volubly expressed.  From individuals, staff have to put up with rudeness and threats of violence as a matter of routine.  From employers and regulators like the General Medical Council, and the Nursing and Midwifery Council, staff have to put up with career-threatening prosecutions that can last for years.  Prosecutions for gross negligence manslaughter cast a fearsome shadow that is disproportionate to their rarity.  Litigation is disproportionately expensive and arduous, managed on the claimant side by lawyers who earn far more than the staff they are criticising.  All of this is experienced as something utterly threatening by the staff.  Much of it is tinged with an appearance of racism, as minorities are grossly over-represented amongst defendants.

If we want to restore productivity, we have to address these things.  We have to recognise that medicine is an activity that can only be delivered by an elite.  We have to foster that elite – undoing the damage we have done to medical training over the last 30 years, granting the staff the space and scope to excel.

This may sound like a tall order, because it depends upon a revised social consensus, a willingness to change our behaviour.  But these changes are deliverable.  Some of the things we want to restore – like continuity of care and continuity of training – we had 25 years ago.  We could easily improve continuity of training at zero cost, if we were to restore the medical firm so that consultants knew their trainees and their abilities.

The whole system should be focused on productivity.  In orthopaedics it is extraordinary that at a time when most surgery involves a very much shorter stay in hospital, we still cannot let our surgeons operate.  It was understandable that the system conspired to stop people operating when a hip replacement would involve a two or three week stay in hospital: now it is usually an overnight stay in hospital, if not a day case. It is absurd that we have such long waiting lists when surgeons are only allowed to operate once a week and trainees cannot get to 1,800 operations in their training career.  The Secretary of State recently denounced consultants for not operating more, as though it were due to laziness, in the same week as the President of the Royal College of Surgeons complained that they were not allowed to do more.  It was as though the system was suffering from chronic constipation and nobody could find the laxative, or a bicycle could not move because its wheels were stuck in a clamp and we had lost the key.

The proposal to abolish or radically change the NHS is a snare and a delusion. If we provide enough money and constructively seek to repair the relationship between society and medicine, we will not need to change NHS structures.  Things will fix themselves and we will revert to the steady process of understated improvement that we took for granted for the first 50 years after 1948.  If we do not and we continue to make unrealistic demands, there is no organisational change that will address our problems.