Saturday, August 14, 2021

WEEKENDER: The Future of Health Care, by Wiggia


This is an advert pre-Covid from one NHS trust trying to sound as though they would actually act on any changes suggested by the public. It is so disingenuous, because nothing ever comes from these surveys. The only item assured of continuance and probably enlargement is the ‘communications team’ that put it together. In the real world the public just want the NHS to do what they are paid for, to protect and treat us, not self-serve.

I have just had a hip replacement at my own expense, with a lead-in time including consultant of 38-40 months. I had to make a decision on the quality of the life I have left. I was fortunate to be able to afford the quicker route or would have ended up in a wheelchair. One has to question after an experience like that the future of health care in this country in its current form.

I have written as have many others before, on the perilous state of the NHS but my short time in a private hospital revealed ever more that professionals in the health care business are not shy any more in sharing their opinions. Not many years ago any criticism would have been greeted with a blank stare or a condescending smile and the words ‘but it is free’.

That last phrase has been a get out of jail card for the NHS for far too long, and latterly so has ‘because of covid’; of course it is not free, we all pay for it in taxes.

The problem - and it becomes ever more obvious - is we have no say in how our money is spent or how the NHS is run and above all we have no choice, something all the other decent health services do have. This you would think would suggest something to those that run this unwieldy monolith.

What has happened since the virus arrived and all else was closed down to combat the virus is horrendous. The waiting lists for care of all sorts is so long now as to be incomprehensible - thirteen million is the current number being spouted - and that is ever growing as despite all the platitudes about getting the lists down they are still increasing as the NHS is still running under Covid restrictions making normal targets and reductions a thing of fantasy.

Covid itself has also become the go-to excuse for doing nothing. Any phone call, and not just to the NHS, will be greeted with the words ‘we are currently receiving high rates of calls because of the virus but hang in there as your call is valuable to us.’ Not really valuable or they would answer the bloody phone; the ‘ because of the virus’ preamble has proved to be a terrific excuse to ignore patients and is continuing to be so.

I am not going to repeat what I think about GP services. They are in many cases non-existent. Our ‘medical centre’ had two people including my wife waiting in a thirty-person area to see a doctor last week and the same nurse area also had two waiting. Despite having a large, mainly unused building, they are not even doing the vaccine jabs; the small pharmacy attached is doing those. There is something very wrong and all this pre-dates the virus; it is almost as though the virus has been used to finally trash what was a health service in decline anyway, this being the most visible aspect.

It is interesting how the NHS is using media such as television to push a vision of how hard they have worked over the last eighteen months and how now they are doing the same to rectify the total basket case the NHS in certain areas has become.

Only this morning (August 11) on BBC breakfast an enthusiastic GP brought in to give advice on whether pregnant women should have the jab went into contortions when asked about how busy they are now. ‘Oh terribly busy, still dealing with virus cases, trying hard to reduce the backlog' etc. I would really like to know where her surgery was: it does not relate to any round here which are still using the virus as an excuse to do virtually nothing and show no signs of upping their game anytime soon. They seem to have found a way of taking the same money for even less work than pre-Covid and that was not a good scenario, in fact it is a disgraceful con of the public purse.

It would be easy to repeat all the endless faults, some of which would probably be criminal in the outside world, that the NHS has managed to perpetuate during and before the virus. The virus merely accentuated the already evident problems, but that has been done to death. If anyone doesn’t get what has been happening to our ‘finest in the world’ health service in recent times they have either not had to deal with it or live in this bubble where the NHS is held in some sort cult status.

Every criticism is normally answered by saying what heroes they were, the pressure they have been under during the virus, they all deserve unlimited pay rises and shopping discounts forever, etc. The truth is very different: front line staff did step up to the plate, did the work and the hours, but they had nothing else to contend with as the rest of the NHS shut down; and how many front line staff out of the 1.3-5 million employed by the NHS were actually involved? A question never answered.

What did become obvious was that those not on the front line, the vast majority, were at home. GPs (my particular bête noir) and doctors are prolific round here as we are not far from the main area hospital; virtually all were at home for months and even on return were not working normal hours. Of course if you shut down a service to deal with one problem that is not a fault of theirs but it does rather dilute the myth about everyone being heroes, not that I can find that word appropriate for people doing the job they are paid for in the first place.

I am just going to give some of the answers I got from health professionals while in a private hospital and before anyone says ‘well they would say that wouldn’t they’ remember virtually all the senior doctors etc. work in the NHS for the majority of their time, or we presume so.

Not many years ago it would be difficult to pry anything from the same people, such was the blind loyalty to the organisation; not so today and not the last time I was in a NHS hospital four years ago, even there it was changing.

The variety of views was interesting as were the solutions, though not so many of those, and in that I concur: in the short term there is no solution. The juggernaut even if willing will take a lot of turning, so what wants changing first? Good question.

The one item above all others that came up in various forms last time I was a patient and also this time is the woeful state of primary care. It was not that many years ago that primary care was given priority in the government's health plans/reform; the minister concerned made much of how this would relieve the strain on hospitals and save money by pre-empting expensive long care conditions. It was also said with ‘conviction’ that everyone should have the choice of doctor and surgery to use.
Bluntly, it was either a lie or the minister was p****** in the wind as no more was heard or done on those two essential fronts, and this is before the GP shortage became a problem.

I will say it again: the GP section of the NHS is in the majority of cases and growing, not fit for purpose. As my anaesthetist said at my pre-op, you now need two GPs to do the work of one because so many are part time.

This of course goes back to the ludicrous ‘you can have what you want’ contract under the Blair government which absolves GPs from out of hours work and weekends. This in turn has slowly loaded A&E with work that GP surgeries should be doing and the hospital workers have voiced this fact for some time, but it increases, with surgeries even trying to offload their work as they did with me four years ago, expecting the hospital to do the regular blood tests needed, after I was discharged; only a stern warning from a very insistent senior nurse that they would be reported achieved a change of mind.

Add in the fact that many older GPs are retiring early because of taxation problems over pensions (we should be so lucky, to have pensions that large) and you have this set up with not enough staff to do the job even if they worked full time (and none of them do, though they still earn even on a three day week - if that is what they really do, we don’t know - up to 130k, a figure not plucked from the air but gleaned from a friend of one such GP.)

There is a way of changing some of that as suggested by the health professionals and others who have put their heads above the parapet: they should not be paid for the number of patients on their books as present and then ignore them, but on each face to face consultation; that just might concentrate their minds as to why they are there in the first place. They are not doing us a favour, they are paid by us to perform a service which currently and for some time they haven’t been.

Whatever the faults in the NHS beyond primary care - GPs - it is currently adding fuel to the fire by its failure to do its job.

We are constantly told the NHS is short-staffed, lack of front line staff is causing problems in carrying out their statutory duties. The official figures show, as I referenced in an earlier piece, that the NHS has had an increase of around 5% per annum for the last two years; no small beer. If they are short-staffed - and figures of doctor-patient ratios show we are as nation behind our western neighbours, as we are with available hospital beds - then one asks the question, how does an organisation which is the fourth largest employer on the planet explain that fact?

The management of the NHS have for years run the organisation for themselves. Even governments are reduced to throwing money at it for it just to stand still or go into reverse. Unless whichever government is in power orders a root and branch reform we will continue to pay for an ever-diminishing service.

I think most thinking people find it obscene to see the NHS still advertising high-paying jobs as diversity officers, advertising and getting involved in what we eat, having input into how parks and playing fields are used, endless advertising on how we can save the NHS, when we who pay for it all (and I have to keep banging on about that as so many believe it really is free, including many who work in it) only want to be able to see a GP at a time that suits us, not them.

In many cities - and again this comes from the horse's mouth - A&E s are swamped with people who have no right to access the health service at all: they are illegal migrants who cannot sign on with a GP as they have no social security number but can rock up with whatever complaint to A&E and be seen free of charge - for them, it is indeed free.

When - rarely - the scale of the international influx that comes here to fleece our NHS is put to health ministers, it is dismissed as an insignificant amount and a small figure is produced. How they can arrive at any figure as these recipients have no papers and are invisible is a mystery, but whatever it is it sucks needed money from those that pay for the service and diminishes the service itself.

Much was heard about how the NHS should be funded and what the NHS should provide. If you cut it all to the nub, the NHS cannot at this moment of time fulfil all its obligations, that is painfully obvious, so going forward what should it be? The consensus opinion was of a slimmed-down NHS providing basic entry level care, emergency cover and a more elementary hospital service. Even with that brief, currently the NHS would struggle, but trying to be all things to all men without drastic change in the way it is funded and run, that is all it can currently manage. It certainly can no longer manage its current portfolio.

Worldwide, health services are struggling; people living longer and new technological advances in health care put ever more pressure on those services. We can all accept that and the population explosion continues, all create problems on top of the day to day running; all the more reason for a total re-think on the way our NHS is run and funded.

That is assuming the way it is run can be changed. Let's have no little trust fiefdoms, no trusts spending on vanity projects, no ploughing on with expensive failures such as the IT project and no unsupervised outsourcing and purchasing, no woke trust boards more concerned with the make up of staff than the treatment of patients and no more world service of any sort; let's dispense with senior managers who would wreck the careers of whistleblowers; and let's reduce overall both the numbers and pay of middle management - not surprisingly a graph that showed the rise of middle management numbers since the inception of the NHS has disappeared, I failed to bookmark it a couple of years back but the increase was staggering.

One thing I didn’t fail to bookmark was the unbelievable amount of money required for negligence claims:

This was something of a cause célèbre for the late blogger and writer Anna Raccoon: not without reason she could see no sense in the ever-rising payments that had to be taken from the care bill. We seem to have gone the American route by being evermore litigious in this area; rightly, poor decisions that affect the life of someone should be compensated, but the sums involved now are eye-watering, enough to sustain a couple of third world countries; there is either gross neglect going on in the NHS or the lawyers are driving a coach and horses through current rulings in the matter; either way, we the public pay and the service is further diminished.

And there is the obscene waste of funds for a problem they never seen to resolve: the locum, a breed of doctor who using market forces bleed the NHS of very large amounts of much needed cash. The same applies to the rise in agency nurses. In both cases the majority were NHS employees before they saw a way of increasing their earnings by margins that could never be achieved by remaining within the organisation; in many cases it has reached obscene levels of pay. It's not easy to blame people for finding a loophole that allows them to do the same work for hugely increased monetary rewards, who wouldn’t do it? But it shows no signs of being rectified.

Funding is probably the sticking point. No government wants to touch the NHS in any way that will harm their perceived handling of the organisation. If you throw money at it, it disappears but for a temporary period makes you look as though you care, and for years that is how it has been. It doesn’t work, the money is never enough, even if all the PFI projects were paid off they would still want more for doing the same; the whole thing has reached level stupid.

You can take two routes on finance in my book. 

The first as above is to reduce the NHS's offering to a more basic but functioning service; the suggestions I heard here are for people to pay extra for any other treatments. I even heard from a surgeon ‘people should give up buying a new car and pay for a procedure instead’ - fine, but what if you cannot access that sort of money? In the current climate the howls about unfairness would be heard the length and breadth of the country, and the exemptions would grossly outnumber those that would be expected to pay, nullifying the whole exercise, in the same way that fewer and fewer people pay council tax and the slack is taken up by those who do; is that fair? In a Marxist society yes, maybe that is what people want, I have no idea any more. I see no future for that route for all those reasons; a minefield of compromise awaits.

No solution is perfect. There has to be a safety net in healthcare but not one that can be permanently abused. The poll tax faced a fate worse than death by having very poor parameters to paying; if it had been introduced with a small charge for the lowest earners it would have succeeded and been a much better system than the current council tax which is now going the same way as the long-gone rates system, forever upwards for the minority who pay it. There was a general feeling that a change has to come. 

The second route is insurance. Few weaned on the NHS wanted to suggest anything really different but a few agreed the most likely and fair way forward was the insurance element. There are two reasons for this: firstly, in other countries, including most of those with a decent health service, it seems largely to work. Nothing is ever going to be perfect but this system in its many guises offers choice and a say in your own treatment, something totally missing from our own.

It also means competition within the insurance area to keep prices competitive, not as now where tendering seems to be done in house and behind closed doors, hence so much waste. Waste is always easy when you are not accountable and the money is someone else's.

In some countries, in a situation such as I have had where the national service cannot deliver, you can get treatment elsewhere and then get a refund of all or part of the price. Why not? You have already paid for their treatment as has everyone else over a lifetime; why should you pay twice when easing the waiting list at the same time for someone else. You are not just helping yourself, but by paying up front you are helping the system. Needless to say that view was not popular though I never heard why. The NHS focuses on the issues of all being equal and the problem of whether you could afford the treatment; they think that however the money was created you are so so fortunate; the upside is lost on them.

So there you have it, my small take on the way forward. No doubt other suggestions can go in the mix, but it all matters not unless a government grows some spine and is prepared to take this sacred cow by the horns and wrestle it to the floor where at the moment it belongs.

To finish, a short Carry on Doctor moment from my short hospital stay: as most people who take pain killers know, cocodamol taken over time causes constipation  and I have been taking it for over six months with results that can be described as decent compared with some.

I had no knowledge that when you go into hospital this fact is acknowledged and a laxative is automatically added to to your medication, which in my case after two days resulted in a rear end crisis.
I told the dispensing nurse my problem and presumed, wrongly, that the laxative had been withdrawn; no, I was still taking it and on the day of discharge (unfortunate word) I got the runs again.
All packed up and waiting for my cab the urge to go again became too strong so I went to the bathroom; with a hip replacement you are not supposed to go to the bathroom without a member of staff being on hand in case of a fall - no they don’t come in with you but are aware and nearby.

I wasn’t going to bother with that procedure as I was on the way home so in I went. Having finished I reached for the toilet roll; this was for reasons unknown fitted facing away and I had already dislodged the roll from the holder several times as I stood up, but this time it was different. It bounced as it hit the floor and kept rolling, leaving an ever growing tail of paper as it made its way to the door. The door has to be left ajar for the same reason, that if you have a fall they have to be able to reach you. It reached the door and carried on rolling through the gap, dragging what remained of the paper tail with it; it went completely out of reach.

Not being exactly Usain Bolt at this moment in time I could not stand up with trousers round ankles and stop the bloody roll with my crutches. I had no choice but to stand, shuffle with aforementioned trousers round ankles through the door until I could drag back the tail of the paper and retrieve the roll and shuffle back with great difficulty to inside the bathroom, all the time believing the nurse would reappear to take me to my cab. No doubt they have all seen it before, but at moments like that one is inclined to say 'why me?' I escaped the ultimate embarrassment by about a minute, too close for comfort in all respects.

Kenneth Williams would have had a word for it all.

And yet in that brief moment of farce that leftover roll of toilet paper summed up the current NHS, as it rolled away out of reach.

As you may be aware, JD of this parish has himself been a custodian recently of the NHS for five weeks. His own experiences will also resonate if he chooses to recant them on here; it all makes very wearisome reading.


Sobers said...

My thoughts are that any changes cannot start with the NHS, its unreformable as things are. Its too big, and the alternative private facilities too small and patchy to take any of the strain. The best one could do is facilitate the growth of the parallel private system, which when it reaches a critical mass would then allow reforms of the NHS to take place.

To that end I would introduce financial measures designed to facilitate people going private. Your idea about making GPs paid by consultation is a great one, and I would open up the market by saying the State will pay for you to see any registered GP anywhere in the country, up to a certain payment limit. No need to be registered with a practice, if you can get an appointment the State will pay. And it would be up to the GP to ensure the person they are consulting with qualifies for NHS treatment, as proof would be required before the State would pay up. Thus providing a massive incentive for GPs to act as NHS gatekeepers - if they don't they don't get paid.

Then I would make private insurance premiums allowable against tax, and I would allow patients to go private with a contribution from the State for certain procedures if the NHS is incapable of providing treatment within certain timescales. Anything that facilitates the private individual to get private healthcare outside the NHS needs to be done.

I might even consider setting up a State owned health insurance company in order to keep the private ones honest. The best socialised healthcare systems seem to work on the principle that the State collects the money via its existing taxation system and pays it out for care, effectively operating as one large insurance pool, but doesn't get involved in the actual healthcare. Thats what we need to be working towards creating, while ignoring the NHS and allowing it to wither away slowly. The process is going to be expensive, because for a while we would be operating 2 healthcare systems, and paying for both, but its the only way I can see we shift from one to the other. Having a State run insurance company would be the basis of such a system, but we need to stimulate private section provision massively first so that when the time comes to switch of the NHS life support system there is something ready to take its place, or at least take on the NHS assets and run them.

The final elephant in the room is female GPs. Since women have come to dominate GP medicine the crisis of availability has gotten worse and worse, because of their propensity to work part time due to family commitments etc. A process exacerbated by the overpayment of GPs which makes part time working still a very comfortable middle class income. I would demand that anyone taking the State's shilling for medical training would have to sign an agreement that they either a) provide X years of full time employment within the NHS (or UK GP practice) or b) pay back the cost of the training plus interest. Rather in the way if you sign up with the Army you can't get out until your tour of duty is over. As a quid pro quo I'd probably reduce the cost to the medical students to virtually zero. You'd get all your training for free, but you'd have to put in (say) at least 20 years work in the NHS to pay it back. This wouldn't preclude women from taking career breaks for children etc, but would mean if they take 15 years out aged 30 for family reasons then aged 45 they've got to work til retirement to make up.

Sackerson said...

@Sobers: love your plans, I think you should contact your MP/ the Govt / whoever.

Sobers said...

One idea that occurs to me would be an extension of the idea of a State owned private insurance firm. Or rather the amalgamation of the tax system and an insurance company. Its often said that people would pay more tax for better healthcare. Well why not put that to the test? Introduce a special healthcare tax but instead of putting the money into the general taxation pot and wasting it on the NHS, why not put it into an insurance pot on each taxpayers behalf? That is to the say your healthcare tax payments would be considered the premiums for a private healthcare policy, that offered benefits above and beyond those available on the NHS. So the taxpayer would have legal rights to healthcare as per their policy, not just whatever the NHS deigned to give them. Such a system could start quite small, with limited additional benefits, but slowly grow them over time. It would be a sort of Trojan horse to introducing non-NHS type healthcare into the UK on a mass scale. It would introduce the masses to the idea of managing their own healthcare, rather than being NHS supplicants, and could be added to by people's own private funds, allowing co-pays. So if you needed a hip replacement the insurance element might pay for the initial consultations and diagnosis, and a proportion of the cost of the op, the balance being paid by the patient. Eventually as the number of people and amount of healthcare covered by this system rose one could start making cuts to NHS funding and moving it across to the insurance based system. It would also introduce the concept of having to prove your entitlement to healthcare, and for medical professionals to having to get prove of entitlement in order to get paid.

Sackerson said...

Or an elective surgery budget - and what's unused you get paid out at State Retirement Age?

Jim in San Marcos said...

Maybe the government could change the rules. Everyone that is born after the year 2004 has to buy private health insurance. It would be a slow way to walk out of it. Government health care doesn't have to show a profit, private health care has to.