Review
The English National Health Service (NHS) appears to be metaphorically shattered; as an institution, and physically with regards to the frontline personnel who have been doing everything they can to make it work, until now. They have reached the summit of their frustrations - not just pay, but extreme staff shortages, long hours, and poor working conditions. All of this is putting patient safety at increased risk. Nurses, paramedics, physios, midwives, and junior doctors, are now acting through strike action to shout at the British Government and NHS leaders that “ENOUGH IS ENOUGH”.
There have been financial ‘sticking plasters’ announced in recent weeks, including the British Prime Minister making £200 million available in an attempt to help alleviate the shortage of beds in English hospitals. Alongside this, the British Government has also been holding crisis talks with NHS leaders and healthcare unions, including the Royal College of Nursing (RCN) and General Medical Council (GMC), in an attempt to address the nursing strikes and threats of Junior Doctors striking. The Prime Minister has stressed that serious conversations are needed to address the ongoing problems arising. ‘Serious’ conversations now? Surely these conversations should have been happening a long time ago – and not just in the UK.
On 5th July 1948, the 1946 NHS Act came into force – the English NHS was born. As outlined in the Act, the role of the first Secretary of Health, Aneurin Bevan MP, was to promote the establishment of a health service to secure and improve the physical and mental health of the population, including the prevention, diagnosis and treatment of illness. This original Act included opticians and dentists, along with local authorities taking responsibility for community services, immunizations, maternity clinics, and community nursing. The most important overarching purpose of the 1946 NHS Act was to ensure that all services would be “free of charge to all”.
This common purpose still stands today (although the majority of the British public now pay for opticians and the majority of dentists are now private practices, with very limited ‘free’ NHS spaces), with the English NHS being part of British culture; an institution that is assisting all citizens to live longer lives; fixing people when they are broken; an organization that the UK is immensely proud and extremely passionate about. However, in reality, it could be argued, that it has become an enemy of its own success.
Looking back to 1990, children in British schools were being educated and alerted to research by social scientists and human geographers who were predicting future populations around the world. They were being shown population pyramids demonstrating the population boom post-war – now known as the Baby Boomer generation. The pyramids showed how there were very few living beyond the age of 70 in the UK and other Western countries, yet there were large numbers of babies being born. These social predictions in the late 1980s and early 1990s were suggesting that by the mid-21st Century, the population pyramids would become inverted – in other words, there would be a decrease in births, with a dramatic increase in an aging population. You can imagine the discussions in the classrooms involving debates around how there would be fewer people working, therefore fewer people paying taxes, with an aging population who would therefore potentially become more reliant on the younger generations to care for them. These population predictions were arguably the early warning signs of a potential social care crisis, as well as a possible healthcare crisis. If this was being researched and predicted over thirty years ago, why has nothing been done – nationally in the UK or globally - to strategically and proactively plan for the healthcare crisis many countries are experiencing today?
To be blunt, there are no straightforward answers or any one person, country, or system to blame – there are just multiple layers of highly complex social, political, and economic issues. This is what makes any attempt to ‘fix’ the English NHS, in fact, any healthcare organization in most countries, verging on impossible.
In the UK, we socially view the NHS as part of the DNA of British culture. It is an organization that is admired around the world for its fairness of ‘free’ treatment to all (‘free’ at the point of delivery – it is funded through everyone paying their National Insurance contributions, in other words, taxes), alongside its research, advancements and innovation in healthcare. But, do the British people expect too much from it? Is it now being taken for granted?
Accident and Emergency (A&E) departments are overwhelmed, with ambulances queuing up for hours in the bays outside, patients being treated in corridors, and apparently in cupboards. There are certainly many who are using A&E for the appropriate reasons, but there are some who have become so disenchanted with getting appointments with (also overwhelmed) General Practitioners (GP) that more often than not, the sick does not know where else to turn for treatment. There is the NHS 111 telephone helpline in the UK that was implemented in 2014 (replacing NHS Direct) to help reduce the demands on A&E, but there is so much negativity and cynicism around this NHS service, along with the unpopular increase in virtual GP appointments, that it has almost had a negative impact and only exasperated the demands on A&E, alongside the increase in winter flu admissions and COVID-19 cases. The British population have lived with the NHS for almost 75 years – it is a way of life, a given that it is always there to ‘fix’ people when they are broken. Most of the population do not know a society in the UK without it. Have the expectations of the British people become too high? Is there a complacency that it is there to ‘fix’ everything healthcare related? Maybe now is the time to re-align expectations here in the UK and consider what healthcare means in the 21st Century for everyone in this overpopulated world. But there is no doubt that this is going to be far easier said than done.
Politically the English NHS is a public service, and it is being used as a political pawn. The political parties in the British Government are constantly arguing over it, insisting they know what is best for it; more money, restructuring, another public inquiry, more money, another committee, another public inquiry, another restructuring, and insistence on more money. And the British media do not help when it comes to the politics of the English NHS. There has been (and there still is) the huge unprecedented issue of COVID-19 which completely put everyone on the back foot, but despite the current Government increasing funding year after year, the English NHS has been struggling for years. There have almost always been waiting lists for routine surgery, targets in A&E that are not being met, despite the constant increases in funding. Looking back at public inquiries conducted in the past, for example, the Francis Report investigating the Mid-Staffordshire debacle between 2005 and 2009, the English NHS has been screaming for appropriate and strategic intervention for decades. The Francis Report was published in 2013 (costing the British taxpayer over £15 million due to being extended twice), listing no end of recommendations for improving the English NHS (too many to list here). More recently there has been the Ockenden report looking into the failures of maternity services across Shrewsbury and Telford NHS Trust. For those who have read both of these reports in detail, they would overwhelmingly agree that not much has changed with regards to the issues around patient safety, leadership and staffing levels, highlighting the desperation across all corners of the English NHS. A huge concern here is why are our political leaders, across all political parties, not implementing the learnings from the past to appropriately adapt the English NHS for the future?
There are many arguments shouted across the despatch boxes in the Houses of Parliament in Westminster, with constant promises of even more money and change needed to meet the excessive demands and pressures the English NHS is under, yet the situation is getting worse – those at the ‘sharp end’ would say it is now beyond a crisis. The so-called knee jerk ‘sticking plasters’ are not working; the metaphorical fires are burning so fiercely they are out of control. Any experienced fire fighter who has tackled a fire that is out of control – a forest fire, for example – will clearly articulate the importance of extinguishing the smouldering roots of the fire. In a real bush fire situation, you can extinguish the flames on the surface, but the embers are still glowing under-ground. There is an assumption that the fire is now out, but as you move onto the next fire, the one behind you flares up again – this is exactly what is happening in the English NHS (and arguably other healthcare systems around the world). The British Government, the ‘blunt end’ assume they have dealt with a problem (for example more money, stricter targets, restructuring), but ultimately, they have not dealt with the root cause of the problem. Why? Maybe it is because it is just too complex, too difficult, and too unpopular. Here in the UK, facing the truth would more than likely mean losing the next general election (and politicians losing out on a lucrative career in politics).
The English NHS is the fifth largest organisation in the world in terms of number of employees. It consists of many facets, bureaucratic processes, brilliant minds and it is hugely expensive to run – it is estimated by the Kings Fund (a UK based Think Tank) that it is costing £180.2 billion this 2022/23 financial year. This is up almost £50 billion over the last 10 years. Are these costs honestly sustainable moving forward? Estimates are putting the costs of running the English NHS in 2024/25 at almost £185 billion. There is no NHS money tree; money is finite. Globally, populations are living in a cost-of-living crisis, based on many reasons which we are all very aware. To keep funding this incredible British institution, there is only so much each tax payer can take when it comes to tax rises. Part of the reality is that there is no money left, unless some very difficult decisions are made – including taking funding from other (arguably equally as important) public services. There are many who work within the English NHS, along with many others, who would argue that it is the people working on the front line who are what makes it brilliant and keep it as effective as it has become globally recognized; however, it is arguably hugely inefficient.
There are layers of bureaucracy, layers of management, layers of complex governance, layers of process, layers of different policies, barriers and red tape, all imposed on the English NHS over the decades, all contributing to what is making it so inefficient. It is a beautiful, yet fragile bubble of brilliance that appears to be about to burst under the multiple pressures it is facing.
It is already a location lottery as to what treatment is being offered by which English NHS Trusts; so many ‘free’ rounds of IVF for a couple in one Trust; pain management rehabilitation in another; a specific cancer drug in another. It is fast becoming a case where doctors (and many nurses even) are having to make some very morally difficult decisions that goes against what they are trained to do – save lives. If there is only so much money in the pot, who gets the treatment?
Almost every healthcare worker in the world is struggling with the pressures of demand, with so many of them having experienced extreme situations during COVID-19, there are many of them now experiencing PTSD and burn out, retiring early or leaving the profession altogether. This is causing a global shortage of healthcare workers – with very few wanting to enter such a demanding profession.
As already mentioned, it is impossible to ‘fix’ the English NHS. It is far too complex. It would potentially take a very long time to dissect it to even think about how to resurrect a small part of it. So, what could be done? There are the suspected conspiracies of the British Government ‘stealthily’ privatising the English NHS: There has been and are pockets of this. This includes paying private hospitals to undertake routine surgery to reduce waiting lists; Virgin Care Services Ltd running some walk-in centres, community hospitals, sexual health clinics and even a hospital; and, Practice Plus Group running hospitals and clinics (urgent care, walk-in centres, surgeries and community diagnostic centres). This concept of privatisation is very unpopular with many of the British people, but it could be argued that it is needed. However, are these organisations charging the British Government even more money? How are the negotiations being undertaken? Who is auditing and ensuring high levels of quality care and patient safety?
If there was an obvious answer, then there would be no need to even be discussing it here. One thing that is needed – not just nationally in the UK, but across many healthcare systems around the world - is an open, honest and very difficult conversation – with many different voices – to address what next for future generations. A collaboration of experts (doctors and nurses, academics, entrepreneurs and business owners) and users (patients and carers), with cross-party political representation, and innovative thinkers. Not another ‘sticking plaster’, not another policy, not another enquiry, not another restructuring to fan another fire. The conversations should be uncomfortable to address some very difficult and uncomfortable questions.
First, what is the purpose of the English NHS for the population’s needs NOW? What is the purpose of the English NHS in 30 years? Alongside the recognition of the purpose, what are the real expectations of what it can deliver within budget? On a global level, we need to be addressing what the public need to do to take personal responsibility for their own health to relieve the pressure on all healthcare services. How can people be better educated, along with future generations, to recognize the agreed purpose of healthcare services in the future? A huge problem in the UK is how to streamline the processes alongside social care and local authorities to ensure things happen innovatively and promptly, reducing bureaucracy and complexities for users. Can the English NHS along with all healthcare organizations keep paying for many of the services that are not linked with actually ‘fixing’ people? Do we need to think about end-of-life care differently? What choice can really be given to the patient/public when it comes to their care? Instead of worrying about pension plans, maybe people should be considering individual death plans, assisting them in choosing to die with dignity. Do healthcare organizations need to be broken down into many smaller more manageable organizations? Is it necessary to have so many managers/administrators? In the UK, do politicians and civil servants actually know how to run such a complex organization? Who should be running it on behalf of the public?
Conclusion
These observations and questions are scary to think about when it comes to such an integral institution of the British culture – personally, nationally, globally. It is being argued here that they are necessary if healthcare services in the UK, and healthcare around the world, are to maintain such high standards of care for as many people as possible; both ethically and morally, fairly and safely. Here in the UK, the National Health Service is precious; it is important that it is revived to ensure the British population have it for another 70 plus years, along with assisting and influencing other global healthcare organisations to learn, improve and grow to keep current and future generations healthy during the second half of the 21st Century.
