The opinions which follow are my own, and are not representative of any organisation.
Any system can be improved, and I agree with some of the comment on A&E targets but, apart from that, wot a load of tosh this report is. Does anyone else who works in the NHS recognise the description (check the link) as even remotely close to getting to the real issues? Let's take key points.
1. "The NHS "became too powerful to criticise." Where exactly does that power reside? Who/what wields power wrt the NHS? Politicians & journalists, I would suggest. The former spend their lives in fear of being doorstepped by journalists who conveniently only tackle one media-selling issue at a time, with the luxury of never having to be accountable for juggling competing and relative priorities. Besides that, in answer to the quote above, there has been no shortage of criticism.
2. "If you criticised the NHS the attitude was 'How dare you?'" Whose attitude? It really credible that this has been a significant obstacle to quality assurance? I suggest that the obstacles have been elsewhere.
3. I'm all for making access as easy as is affordable to the public purse, but really… the Sainsbury's/Tesco argument being trotted out again??!! This is supposed to be a quality-assured service, not a business competing for sales of microwave dinners or smoked salmon. People's lives, and the quality of those lives, are at stake. In any case, if Tesco goes belly-up tomorrow, another will rise to take its place. What will replace a system free to all at the point of need?
4. "Working people need to be able to see their GP in the evening or at the weekend." I have some sympathy with this, but why are "working people" generally not working in the evenings or weekends? Could it be because (i) generally it costs more to employ them to work weekends or evenings and/or (ii) the services they provide are considered non-essential in the evenings or weekends? Last time I checked Drs & nurses are working people too. Many of us already work evenings and weekends for essential acute/emergency care, and have been doing so for decades. (Some of us spent a substantial period of our career working those unsocial hours for 1/3 the "office hours" rate. NB NOT time and a third; one third). Should taxpayers' money be used to fund a more costly service for things which aren't sufficiently acute to require consultation or treatment in the evenings or weekends?
5. "A chillingly defensive culture in which even the most 'alpha-male surgeons' felt frightened to speak out for fear of ending their careers." Is Northern Ireland really that different to England in this respect? I don't recognise this scenario at all.
Thirty years ago junior docs were among the lowest paid staff in the hospital for their out-of-hours work, and frequently worked in excess of 100 hours/week. In addition to the hours the NHS was prepared to pay us to work, we put in additional unpaid, unsociable hours to get the job done. That was what many of us understood to be professional behaviour. However, when it became too extreme, and there weren't enough docs employed to cover the work, some sought to be paid (at 1/3 office hours rate) for the extra unsociable extra hours we were expected to work. I recall sitting with 2 colleagues in a meeting with a senior hospital administrator who told us in no uncertain terms that if we didn't drop the subject, we would suffer when it came to references etc and future employment. We were too naive to realise that administrators didn't write or influence junior doc references. Thankfully the process is now less dangerous for patients in terms of junior doc hours, more just and transparent. That was a result of people speaking out. Journalists assisted in that process. Thankfully I have since had (and continue to have) the privilege of working with some outstanding healthcare managers, and have held several managerial roles myself.
As a Consultant, I have worked with quite a few 'alpha-male' surgeons. I have yet to meet one afraid to speak out on issues of quality or safety out of fear of it ending their career. Indeed many who are not alpha-personality, or male gender, speak out. We have had all sorts of ways to make representation both within our healthcare institutions, and beyond them - regionally and nationally. The issue is actually being taken any notice of! Consultant colleagues describe recurring experiences across multiple specialities of being convened in 'expert groups' whose views are only welcome when they conform to the political ideology being pursued. The minutes (when it suits to take them) of such meetings can bear little relation to the views expressed or expert conclusions reached. Such groups tend to be disbanded if they prove to be 'inconvenient.'
Politicians are in the business of wielding power and influence. They have strategies they wish to pursue. Many of these may genuinely be better for society, but it is hard to separate this from the fact that their life-blood as politicians is success at the next election. They have a fixed term in which to appear to have been responsible for improvement. Some of the issues may be highly complex and there is limited time to educate the public on them and implement change - so there is a tendency to oversimplify and 'sell' their proposed solution. Professionals who disagree with their strategy are a real thorn in their side, and particularly when those professionals are held by society (ie the voters) to be credible and trustworthy experts in the territory which politicians wish to change. The public sector is expensive to run, and there is huge pressure to cut costs. I imagine this is an issue in teaching, as well as in healthcare. If the professionals can be discredited, or the service portrayed as needing overhauled, this plays into the hands of those who can then ride in as "white knights." Be aware of who's claiming who is naughty or nice, who stands to benefit, who might be harmed, and who might be being misled.
Be astute, people. There can be great distortion in the media of what constitutes deficient care. There are also shifting goalposts as knowledge increases. And when the spotlight is turned on one thing, be careful about what might be going on in areas left in the dark.
Clinicians aim to practice evidence-based medicine (when the evidence is there), and may be held accountable for deviations from it or for negligence. Yet politicians, and civil servants less accountable to the public, may make decisions and run with ideologically-based strategies which could cause harm to a great many more people, seemingly with impunity. Government has recently proposed making 'wilful neglect' by healthcare staff in the NHS a criminal offence. If suitable standards against which to measure neglect are applied, I'm all in favour BUT it should also be applied to politicians and civil servants who implement strategies without expert advice or, worse still, ignore expert advice.
Do you think these points I'm making are just a demonstration of the "defensiveness" of the NHS? If so, then the argument isn't that the NHS is defensive, as is alleged, rather it's that health care workers like me who are working within it are being defensive. Well does that actually hold water? I've already alluded to the fact that nurses, doctors, physios, pharmacists, often criticise the service from within, and professional bodies regularly produce new and better clinical standards at which to aim, as knowledge increases - which includes ability to measure in ways not feasible in the past. So healthcare professionals are not defensive of bad practice or poor standards. It's just that they may not agree with those outside the service on what are the biggest issues.
When are we going to have a grown-up discussion about what the taxpayer can afford in terms of public services? By necessity this involves looking at hard at prioritisation (rather than privatisation) and economies of scale. Are varicose veins sufficiently important that they should delay/displace gall bladder ops, or hip or cardiac surgery. Should enormously expensive and proliferating cancer therapies which prolong life for a few weeks/months at dubious quality be funded at the expense of delaying potentially curative surgery or medicine? Should we have lots of little grocery stores scattered across the country - all very nostalgic, and we know that nice Mr Swinson who serves us our cabbage (and we don't want aubergine, fresh mint, or coriander that often) - or should do we want a service which can cover the full range of what we need, which necessitates concentrating resources in a smaller number of larger institutions. Is there any point having a room labelled "A&E" close by if, when you go there after an accident, it turns out that it doesn't have full X-ray & CT scan facilities to determine whether or not you require emergency surgery; or has no on-site capacity to provide emergency blood transfusion, or does not have surgeons who carry out the emergency procedure you might need, and who do it sufficiently often to be competent at it.
"You'd better watch out, you'd better not cry
You'd better not pout, I'm telling you why..."
The NHS is potentially a bottomless pit. Santa Claus might be coming to town in the next 48 hours but the elves don't do interventional radiology, provide full trauma services, full diagnostic work-ups and modern interventions for acute coronary syndromes. And Santa's sleigh isn't big enough to bring them all down every chimney anyway. It's a finite public purse, people. This is a more useful analogy with Tesco/Sainsbury, or indeed Harrods, than the ridiculous one still being advanced by those who delude themselves and others that competition is the best way to run public service.
Does being able to visit the GP when it's a bit more convenient justify what it will do to the need for recruitment of more GPs (or else reduce their availability at other times)? Are they going to ask them to work more hours? Government direction has been to reduce the hours consultants work - many of us have had the experience of being asked to reduce the hours in our job plans. The word on the street is that Government wants changes to contracts which will increase the cover and yet be 'cost neutral.' How does that work?
In 2003, government decided that it wanted a new contract for hospital consultants (implemented 2004). There were many assumptions that consultants were not working hard enough, and that a new contract would be more transparent, and they'd be more accountable. Sure, there were a very small minority who were double-jobbing (doing private work during NHS sessions) or 'consulting' on a boat or golf course somewhere, but the vast majority of consultants were working way beyond (old) contract. It was a concept known as professional behaviour. The bottom line is that more work was being done than government would believe. (They were told). Imaginary stereotypes were too firmly rooted. Since the new contract, consultants' work has been much more closely monitored and work directly related through job planning to pay. So when hospitals planned their work, they ended up needing more planned sessions than government anticipated. Government then complained that they didn't see an increase in productivity associated with the increased cost of the new contract. This of course comes as no surprise to the medical profession who tried to tell ministers that they were previously working beyond contract. Even National Audit Office conclusions have failed to take this into account:
"NHS consultants play a key role in the NHS. Given the size of the pay increase given to consultants under the 2003 contract, it is reasonable to expect Trusts to have made more progress in improving how consultants are managed and realizing the expected benefits of the contract."
"Trusts need to get consultants strongly involved in achieving the trusts' objectives as well as their own clinical goals."
Amyas Morse, head of the National Audit Office, 6 February 2013.
However, the statement above does (inadvertently?) highlight the rub - clinical priorities may be something quite different to "Trust objectives." The two can be in conflict. This is not necessarily the fault of the senior managers of Trusts - they are essentially employed now to deliver the goals set by Ministers/Government Department of Health. And, as I've said, the latter are often at the mercy of political expediency or journalistic distortion.
If a public system is working but underfunded (and ministers either couldn't or wouldn't believe that it was the case), then fixing that underfunding should not be expected to produce an increase in activity (particularly when acute bed numbers are being cut, and working practices and priorities interfered with).
There has been much talk recently of the lack of senior medical input at night in some areas of medicine, and various strategies rolled out including 'Hospital at Night." I do recall, as a junior doc, feeling huge responsibility for keeping my consultants' patients alive through the night. No-one thought it was feasible for consultants to be resident and working hard throughout the night and do a full operating list or busy clinics the next day. I mean, they were old.... Guess what, that's still not a runner, although the current government has suggested that it wants consultants present and working overnight and has announced its changes to pension plans so that they're going to be even older when they're doing it... The latest delusion circulating is that they should be able to do this with no increase in cost - and this is supposed to deliver enhanced patient safety??!! But then politicians have also advanced the notion that, whilst formal consent is required for operations on individual patients when the surgery may benefit them, and for retention of organs or tissues for educational or other legitimate purposes, it may be fair enough merely to presume consent that their organs can be taken when they die, for the benefit of others.
Just like junior docs didn't (and hopefully still don't) want their patients to fall apart overnight, I have no doubt that UK society doesn't want its public healthcare system to fall apart - nor should it be pulled apart or left to the (absent) mercy of market forces or have its priorities distorted by 'financial incentives.' Don't let Government pull apart your NHS, or allow it to fall apart.
"I wish I’d have been a doctor
Maybe I’d have saved some life that had been lost
Maybe I’d have done some good in the world
’Stead of burning every bridge I crossed."
Don't fall apart on me tonight..."
[for illustrative purposes - no copyright infringement intended - unreleased version sourced from here]