We are developing the social individualist meta-context for the future. From the very serious to the extremely frivolous... lets see what is on the mind of the Samizdata people.

Samizdata, derived from Samizdat /n. - a system of clandestine publication of banned literature in the USSR [Russ.,= self-publishing house]

Why is the National Health Service in crisis?

This post was written by my regular correspondent “ARC”, who has several family members working in the NHS. – NS

I’ve been discussing the NHS A&E issue that’s been in the news of late with the medically knowledgeable and NHS-aware members of my family and thought you might be interested in their background information, so have written it up while the conversations are still fairly fresh in my mind. I summarise, then give my own thoughts at the end.

The immediate cause of the NHS A&E issue being such a story in the media at this time (other than the upcoming election, of course) is simply that at Christmas a great many staff take holidays. The resulting shortfall exposes long-term trends in an area under pressure. There is no other immediate cause, as distinct from long-term trends: these problems have been growing for 15 years and more as follows.

1) Flow-though is crucial to A&E: you must get people out the back-end of the process to maintain your rate of input to the front-end. However ever-increasing regulations mean a patient without family cannot be released until a boat-load of checks have been done. This is clogging up the back end. It may be preventing the release of a few who had better not be sent home yet (not much and not often, is the general suspicion) but it is definitely delaying hugely processing the release of all others who could be. All this admin takes time and effort – delaying release and also using up time of staff in non-health work – and costs money.

This effect needs to be understood in the context of the 15-years-older story of the destruction of many non-NHS nursing homes by galloping regulation. These homes were mostly owned and operated by senior ex-NHS nurses and provided low-grade post-operative care. The NHS relied on them as half-way houses to get patients out of NHS hospitals when they no longer needed intensive care but were not yet recovered enough to go home. These nurses did not want to spend time form-filling instead of caring for patients, and for each home there was always one of the 1000+ rules that was particularly hard for that given home to meet without vast expense or complication. So they died one by one. The ‘waiting times have increased’ story of Tony Blair’s early-2000 years – “If the NHS were a patient, she’d be on the critical list” – was caused by this and the resultant bed-blocking more than any other one cause.

A more recent context is over-regulation of local councils’ social services leading to declining throughput, unrealistic expectations for their visit times, etc., and there have also been some social services cuts by said councils. These also have an impact on a hospital’s ability to get people out of the back-end to free up beds for A&E incomers.

2) The new 111 service is sending many more patients to A&E.

2.1) The service’s advice is very risk averse. The people who set up the process were afraid of the consequences of the statistical 1-in-a-million time when anything other than mega-risk-averse advice would see some consequence that would become a major news story blaming them.

2.2) Thanks to the post-1997 reforms, GPs work less hours on-call but the doctors are not just slacking off and doing nothing. The huge growth in regulation means they are in effect putting in as many hours as before, but on form-filling and admin to provide all the info the NHS and other government demand, to ensure they tick every box, etc. The out-of-hours on-call time they used to have is now swallowed by this work. So they are not in fact working less; it is the balance of what they are working on that has changed: less on healthcare, more on admin. Thus 111 must send people to A&E, not an on-call GP (and, of course, fewer on-call GPs mean more people phone 111).

3) Regulation prevents fixing the problem as well as causing it. A Birmingham hospital (Queen Elizabeth in Edgebaston IIRC), said to be very efficient as such things go, tried to create a low-level care unit precisely to solve the problem. Because of the regulations, the attempt had to be abandoned – they just could not tick all the boxes.

4) Back in the early-80s, when my sister (a doctor) did her elective in A&E, she loved it. Now, doctors are avoiding A&E as a speciality because they know how brutal is the pressure there. So the problem is beginning to compound itself.

There is a great deal more one could say, but the above are what my informed relations see as the key immediately-relevant causes. So far my summary. Now some thoughts of my own.

What I observe has most changed in the last two decades in these either left-leaning or were-left-leaning people is firstly their belief that “No party can fix it”. (This I heard from a previously definitely-left individual who would probably still cut her hand off before it voted Tory and whose heart wavered between Labour and [Scots] Nats although her head despises Nats ideas and despairs of Labour.) There is an expectation that no likely government will do anything other than talk of reform while actually causing yet more regulation. Some of this in some of them might be a reluctance to think that the side of politics they’ve loved to hate in the past might be the place to look for an answer (I am reminded of Gore Vidal in 1979, “I feel the despair of coming to think that the Soviet Union may be as despicable as the U.S.” – quoted from memory) but it also reflects their opinion that the Tory-led coalition has failed to reverse any of the above trends, and this opinion I fear is not mere prejudice but has a basis in their experience of the last three years, just as much of the above reflects their experience of the last 15 years.

Secondly, they report a widespread belief within the health service that this time “a bit of money can’t fix it”. There is no expectation of an ocean of money (and – I sense – awareness that the NHS already consumes an ocean of money, so can hardly demand another ocean of money even as a righteous goal, however impossible to arrange).

Lastly, I know that behind all this inefficiency of regulation, there lurks a compounding problem of looming social trends. The number of patients who have no family ready to help is rising. The promise that the state will look after all has led more people to lead lives that make no other arrangements. But these long-term trends are not the reason the NHS operates much worse now than two or three decades ago.

Tweet about this on TwitterShare on FacebookShare on TumblrShare on RedditShare on Google+Share on VKEmail this to someone

30 comments to Why is the National Health Service in crisis?

  • Paul Marks

    The principle of the NHS is that it should be “free” – i.e. financed by taxation.

    I see no chance of this principle being changed – this side of a general collapse.

    Still look on the bright side at least it is not a crime to pay for medical treatment in Britain – I believe it is in Canada.

  • pete

    The state needs to get its act together over health.

    For example, if obesity and inactivity are such serious causes of a lot of ill-health why does the state run a multi-billion pound broadcasting organisation to help keep people rooted to their couches, many of them munching junk food and swilling sugary drinks?

    Why not tax TV use as we do now, but use the revenue to fund health care instead?

  • Why not tax TV use as we do now, but use the revenue to fund health care instead?

    Or even better, lets NOT have the state tax TV.

  • Adam Maas

    Paul Marks:

    It is not a crime to pay for medical treatment in Canada. That is in fact very common.

    It is however considered a crime in most provinces to charge for medical treatment. This interestingly is a very grey area, as the enabling act is rather arcane on the subject. It’s generally been read of late to say that private for-pay care is only legal if the main system is overloaded.

    This leads to many Canadians going to the US for treatment, as well as increasingly to private clinics in the few provinces that told the Feds to pound sand recently in order to allow private care to reduce load on the public system (primarily and oddly the ever-so-socialist Quebec, usually the leader in the other direction)

  • PersonFromPorlock

    I’m not opposed in principle to health care being a government service, any more than I’m opposed to roads being a government service. But people need to realize that politicians will always be tempted to extend government services to new fields, to be paid for (to start with) with some new taxes and some redirection of existing taxes from existing programs. Which is why taxes always go up and the roads – and your NHS – always develop potholes.

    This is a fundamental dynamic, and is only exacerbated by the universal tendency of bureaucrats to justify their existence with paperwork. It will continue until those who make the decisions begin with the question “What can we, as an economy, afford?”

    Which is to say: “Rotsa ruck.”

  • Natalie Solent (Essex)

    pete, you write, “The state needs to get its act together over health.”. I don’t think it can. For me, the key parts of ARC’s account were the repeated references to the damage done by excessive regulation and excessive aversion to risk. Regulation and the quest to maximise “safety” are not incidental to what the state does, they are, to those who believe most in the state, the very bedrock of its reason for existence (given that the sort of people I am talking about tend to disapprove of cops and soldiers, which are the sort of things I would consider the bedrock of the purpose of a state, on the days when I concede it has one at all).

    The other point made by ARC which particularly struck me was this,

    The promise that the state will look after all has led more people to lead lives that make no other arrangements.

  • Frank Ch. Eigler

    But how can this be? No lesser soul than Paul Krugman delivered:

    “In Britain, the government itself runs the hospitals and employs the doctors. We’ve all heard scare stories about how that works in practice; these stories are false.”

  • Some guy

    Ask Bob Goldacre about it. He even wrote a whole book on this: “Bad Pharma: How drug companies mislead doctors and harm patients”.

  • Mr Ed

    The reason that the NHS is ‘in crisis’ is that it is agitprop by the Nomenklatura before the General Election, so that the NazionaleSchaltDienst can get the agitprop in for Labour before the General Election, and then let the slaughter recommence renewed in earnest.

  • Jim

    I think the NHS is testing to destruction the idea that complex structures and processes can be controlled from above and made safe, fair, and universal, at the same time as being free (to the people who use them at least). A collapse occurs, and everyone wonders why. And the reason won’t be because of any one thing that has made it happen, it’ll just the aggregate effect of X years of new rules here, and additional bureaucracy there, until at some unspecified point the system no longer functions.

    I think the time has come to stop pretending the NHS can be universal. I think we need to decentralise the entire thing. Give a lump of money to each area, and say ‘Right, thats your money for the year for healthcare for your area, its up to you people in that area how you spend it. No central targets, no rules. If you wish to charge people for GP appointments feel free. If you wish to stop non-Uk citizen using the service, go ahead. You choose which drugs you will provide, which operations you will do, how much you pay staff. If you end up killing thousands a la Stafford Hospital, you carry the can, with criminal charges if the locals see fit.’ And let everyone get on with it. It wouldn’t be fair, and there would be undoubtedly be some total f*ck-ups (as there are now, but better hidden).

    It can hardly be worse than what we have now, and things will only get worse still if there are no real changes.

  • Fully exploited cannabinoid medicine could save between 1/4 and 3/4s of medical expenses. Cancer (many? all?) could be treated at home with a pill. At nominal cost if the stuff wasn’t black market. And that is just one area. Diabetes is another. There are many more.

    http://youtu.be/0tghUh4ubbg

    What I don’t get is why only the US (and possibly Israel) have vibrant medical cannabis constituencies. We have numerous organizations and people dedicated to it. They are loud. They raise money. They elect (and defeat) candidates.

    I’d really like to know why anti-prohibition is mainly a US phenomenon. I rarely see anything on it around here. In the US it is one of the libertarians top two or three issues. So much so that it is a common joke. “Libertarans are Republicans who want to smoke pot.”

  • I’d really like to know why anti-prohibition is mainly a US phenomenon. I rarely see anything on it around here.

    Because in the UK people are in effect free to smoke as much pot as they like (as anyone who shared a student house in the past 30 years can verify). Oddly, we still have cancers.

  • Tim Newman
    January 19, 2015 at 8:25 am

    Well why not just wave it over your head and cure your cancer? It is magic.

    Actually like all medicines the result is dose related. Watch the video I linked. You need a pound or three reduced to oil and administered over a period of months.

    Another video “What If Cannabis Cured Cancer?” http://youtu.be/-jWWVtS2gEg about 45 minutes. Nice bit about Queen Victoria and her cannabis habit near the beginning.

    Or look up ” Dr. William Courtney brain tumor ”

    We have the same phenomenon in schools. And yet America is becoming more wildly anti-Prohibition. And is already very pro medical cannabis. About 60% to 80%. The vote in Florida was 57.5% in favor. In an off election year when the left votes less.

  • Stuck record

    In a few years time, if the NHS is so totally screwed up that even the leftists think it beyond salvage, then there is the last resort of nationalising it.

    Oh! Wait! Hold on. They tried that.

    Damn.

  • “What If Cannabis Cured Cancer?” is fairly off-topic (consider that ex-cathedra) so…

  • Watchman

    I see no issue with free at the point of use healthcare (so the NHS). The issue is the fact that for some reason government insists it must run and/or directly regulate almost all the hospitals in the free scheme, which seems to be an assumption too far.

  • AWM

    Good summary.

    I’ve also heard it mentioned that another element of the present A&E problems is the ‘I want it now’ mentality we mostly all have, which means that people aren’t prepared to suffer in silence for a week while they wait for a GP appointment as they might have done previously, and so take themselves off to A&E for immediate gratification. This must be a significant part of it.

  • Mr Ed

    “What If Cannabis Cured Cancer?” is fairly off-topic (consider that ex-cathedra) so…

    Surely handing out cannabis at A & E departments would result in massive queues?

  • Andrew Duffin

    “people aren’t prepared to suffer in silence for a week while they wait for a GP appointment as they might have done previously”

    No.

    What they “might have done previously” is simply go and see the GP, who would have seen them there and then – or if they seemed sufficiently unwell would have gone himself to see them.

    The other element of the problem actually is that you have to wait a week to see your GP, so you just go to A&E instead.

    The root cause of that, of course, is a combination of NuLab’s insane new GP contract (“pay them much more to do much less”) with the ever-increasing regulatory overhead that the post describes so effectively.

  • Here in Medway we have what they call MEDOCC (Medway On Call care) which is basically an out-of-hours Gp surgery. 111 often sends you there (I’m assuming from the post that this service does not exist in other areas).
    Most GP surgeries in the area operate on the “phone after 08:30 and keep hitting redial until 08:35 when all the appointments are gone, and don’t even think about trying to book an appointment for another day, even if we’ve asked you to come back after a specific length of time” policy so MEDOCC is usually quite busy.

  • Sorry, I shouldn’t have hit ‘post.’ The point I was getting at was that it isn’t that people “don’t want to wait a week for an appointment,” it’s that that option is simply not available.
    You phone when the surgery opens and either get lucky, or try again tomorrow.

  • I can certianly confirm the damage the Care Commission has done. My mother used to be on the advisory board of a Church of Scotland home, and I have a friend – a former NHS nurse – who manages a chain of homes in the South West. I think most people don’t have any idea how the Commission is constantly moving the goalposts. A home that was up to scratch a year ago can be threatened with closure today, even after installing improvements. I no longer bother to listen to these grim-faced news stories about the heroic Commission threatening evil cigar-chomping car home barons. Some of them may be true, but my assumption these days is that it’s just the regulator throwing its weight about again, and there isn’t a damned thing wrong with the places.

    And if there’s one thing that illustrates what’s wrong with the entire system, it’s 3). There is no room for entrepreneurialism or enterprise. Hell, for simple ingenuity.

    “to allow private care to reduce load on the public system (primarily and oddly the ever-so-socialist Quebec, usually the leader in the other direction)”

    Makes sense, actually. The more socialism you have, the more you need free enterprise.

  • nemesis

    The regulation, target driven, box ticking mentality is not unique to the NHS. Witness it in finance, education, the police, corporations, etc etc. It encourages a mentality to work to a minimum standard, excludes any initiative and a lot of time devoted to massaging figures and working out loopholes. You end up with systems and processes that do not allow for the human factor and the odd exceptional circumstances.
    I recently had to attend an ‘urgent care centre’ with a broken foot – nothing caring or urgent about it! I was processed in a system designed purely for convenience of staff. Very dispiriting.

  • Perry de Havilland (London)
    January 19, 2015 at 9:50 am

    I was addressing the cost of medical services. I proposed a way to reduce costs. I apologize for being OT.

  • guy herbert

    Point 2.2 – everyone working harder for poorer results, less time for informal cooperation – sounds remarkably like what happened in schools after Whitehall took over in the 80s & 90s (thanks Maggie, John!). I wonder if there is any common cause…

  • AWM

    Andrew Duffin said:

    “No.

    What they “might have done previously” is simply go and see the GP, who would have seen them there and then – or if they seemed sufficiently unwell would have gone himself to see them.”

    Yes.

    We waited patiently. Even if the GP did make a home visit, it was often days later, having presumably decided you weren’t in imminent danger of death. Your experience may be different but this is mine.

    Thanks for sharing.

  • John B

    My stint on the clinical side was 1971 to 1975 until I got out before I went mad and because the money was not good.

    The problems with the NHS… it is a State monopoly. When there has never been a State monopoly at any time in any place, why don’t people just accept the NHS CANNOT be any different, cannot be reformed (the other two dozen times since 1950 did not work, why would it do so this time/next time)and will always be what it is?

    If you want some specifics:
    Reward based on length of service and grade, not merit, hence no incentive to excel, work harder… in fact reverse effect: the general standard is mediocrity which few achieve. The best, leave or if not become part of the culture to survive.

    Management grade thus remuneration/status dependent on headcount/establishment. These can only be increased if workload ‘too much’ for existing resources. This provides incentive to find ways to slow down throughput.

    Finite budgeting: patients are a cost, the more treated, more expensive the treatment, the faster the budget is used. Intrinsic in this feature is waiting lists to push patients into the next budget period, offload them onto community budgets, chance the patient will die, seek private treatment, relocate.

    There is no reward for doing more, better… in fact a disincentive.

    A&E: being ‘free’ it has always provided a convenient walk-in centre for people passing, can’t get a GP appointment, can come in the evening/weekend or on the way home from nightshift so they don’t need to take time off from work.

    Medico-legal: thanks to legislation from the Labour idiots in the late 1960s, doctors/nurses dare not tell time-wasters to go and see their GP, so everyone gets a full work up clogging the system.

    It was like this back in the 1970s so this notion that the problems are recent is not true.

    And finally. The biggest increase in the famous ‘burden’ on the NHS… obesity, drunks? No… sport and exercise injury which has increased A&E attendances 13%… correlating nicely with the nudging, pestering and busybodying about more active ‘healthy’ lifestyle.

    One of those frequent unintended consequences of which Governments excel in creating.

    Solution: privatise it and make user pay. I guarantee waiting lists will decline and A&E will become unclogged.

  • Alex

    I doubt we will see a government willing to privatize the NHS in the foreseeable future. The sad fact is that the vast majority of people cannot and will not accept that the NHS doesn’t work. The notion that healthcare “should be free” will continue to make it politically impossible to actually privatize the NHS. However we can reasonably predict that the NHS will become increasingly poor at providing decent healthcare to the majority of people and that there could be a significant increase in people looking for affordable private healthcare until eventually nearly everyone will be receiving healthcare from non-NHS sources. I therefore think that the NHS will slowly be replaced by private organizations (both for-profit and not-for-profit) over the next 50-100 years.

  • […] Samizdata, Natalie Solent shares a post written by “ARC” discussing why the National Health Service seems to be […]