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At the heart of general practice since 1960

Politicians must stop producing gimmicky health policies

The NHS’s 66th birthday year was full of impractical NHS proposals, when what we really need is investment, writes Dr Kailash Chand

The NHS celebrates its 66th birthday this week - a milestone overshadowed by serious questions about its long-term future.

When looking at the history of the NHS, it is difficult not to be amazed by the fact that it has managed to become one of this country’s most treasured institutions. It came into being in the aftermath of a devastating war that had left Britain facing financial ruin. The population at the time struggled from a variety of health challenges that had been worsened by piecemeal health provision in the decades before the NHS was launched.

The fact that the NHS survived those early years – let alone being created in the first place – is a testament to its founding principles that promised to deliver free accessible healthcare to all those who needed it.

But as it edges closer to its seventh decade, it faces a combination of pressures: some new, some old.

Resources and funding have always been an issue for the NHS, unsurprisingly given its size and scope. However, demographic change is seeing our society age and placing a strain on the NHS and particularly GP services.  Already we have over ten million people over the age of 65, this will increase to 15 million by 2031. By the beginning of the next decade, a million people will be living with dementia and around the same time we will have close to three million with one or more chronic conditions. This shift would be a huge issue even if it didn’t come in an age of austerity where funding is being squeezed badly so that all parts of the NHS are under real pressure.

All of the challenges are intensified, however, by a political preferences for short-term gimmicks rather than long-term solutions. These problems need innovative, long term and sustained solutions, but sadly that is not what our political leaders are pursuing.

Recently, Jeremy Hunt’s proposals that GPs be ‘named and shamed’ when this miss cancer diagnoses was met with shock and horror by primary and secondary care doctors.

And while Labour’s 48-hour waiting time appealed to patients, the party’s own shadow health minster Jamie Reed admitted it wouldn’t be achievable unless GP numbers increased.

The Government’s controversial care.data scheme had to be delayed after outcry from the BMA and RCGP earlier this year, and surveys have since shown that over half the public are still in the dark about how their data is being sold off.

Meanwhile the Health and Social Care Act has insidiously placed competition into the health service, resulting in fragmented care and wasted resources.

Time to invest

GP facilities are in a worrying state of decline having been starved of investment for many years. Many GPs now have to deliver care in cramped conditions and are spending close to two-thirds of practice income on paying rising costs to maintain their premises. Other parts of the NHS are also suffering badly. Emergency care meanwhile is suffering from long running recruitment problems and like general practice, are finding it difficult to cope with the level of demand they are facing.

At such a crucial junction in the history of the NHS, we need to dispense with this short-term approach. And the public knows it. A recent BMA survey showed that three quarters of respondents believed that political parties are designing health policy to win votes, not to do what is best for the NHS.

Based on US experience, savings on market bureaucracy and commercial contracts could save billions, and fund more staff, better premises, and a better quality of care.

As the BMA’s ‘Your GP Cares’ campaign calls for, we need real investment in GP premises, services and staffing levels. And we need a comprehensive approach to the rest of the NHS too, which includes repealing the Health and Social Care Act.

But most importantly, we need all politicians stop meddling in a damaging pursuit of votes.

Dr Kailash Chand is the deputy chair of BMA Council and a former GP. You can follow him on Twitter @kailashchandOBE.

Readers' comments (10)

  • Vinci Ho

    NHS was born on a special day 4th July 1948(my daughter on 4/7/2000).
    It was then, what about now ?
    A BBC report (online now )on 50th birthday of NHS 16 years ago, 1998.
    Wednesday, July 1, 1998 Published at 13:38 GMT 14:38 UK


    'Patients broke down '

    The General Practitioner (GP), or family doctor, has been at the heart of the National Health Service (NHS) since its inception fifty years ago. Initially, many GPs were opposed to the whole idea. But, after reassurance from the government, they agreed to implement the great revolution in healthcare, even though it meant a substantial increase in workload. Dr Arnold Elliot recalls those early days.


    "General practice relied on placebos"
    The introduction of the NHS inspired a bizarre rush on cotton wool at Dr Arnold Elliott's east London surgery.

    When the free-for-all service was introduced in 1948 many patients flocked to see their GP with genuine medical complaints for which they had been unable to seek advice in the past.

    But one request puzzled Dr Elliott more than any other. "I personally was pleased I no longer had to worry about whether the patient could pay or not, but a few patients misused the system," he said.

    "For instance, one guy kept asking for large quantities of cotton wool on the NHS. I subsequently found he used it to wash his greyhound."

    The great and genuine need for the NHS, however, was painfully illustrated by some of the other patients who queued to see Dr Elliott. "I remember seeing a middle aged lady who had the most advanced, appalling cancer of the breast that she had not consulted a doctor about previously," he recalled with a grimace. Sadly, the patient died.



    "We thought we were doing something worthwhile"
    Rare breed

    Dr Elliott is one of an increasingly rare breed of GPs who started their career prior to the inception of the NHS on 5 July 1948 and is still practising. Although he gave up full time general practice in 1991, he still finds time for occasional locum work.

    Dr Elliott, 77, qualified in Belfast in 1944. While waiting to serve in the Royal Army Medical Corps he took a job at the Royal Berkshire Hospital, Reading, and then GP locum work in rural north Wales.

    He started his own general practice in Ilford, Essex, in June 1948, just a month before the launch of the NHS, and retired 43 years later. During that time he built the surgery from a solo operation based in a terraced house to a thriving five-partner practice based in a state-of-the-art health centre.



    "Scientific developments in medicine were only starting to take place"
    Cottage industry

    In the years before the NHS, medicine was often a shoestring operation, according to Dr Elliott. Doctors could neither call on advanced medical knowledge, or effective drugs.

    "General practice was a spoon and fork set up, a cottage industry," he said.

    "There was not much known about scientific medicine, most of the treatment was placebo.

    "At my first practice there were two large bowls. In one was a red mixture, and in the other a green mixture. They were both the same, but if you gave the wrong mixture to a patient there was hell to pay. All patients expected to have a bottle of medicine as a right.



    Streptomycin production conquered tuberculosis
    "In those days the illnesses which doctors mostly dealt with were the infectious diseases.

    Diphtheria was a deadly disease. The medical officer of health laid on a throat swab service for GPs to diagnose diphtheria. No other pathology facilities were available to GPs, or x-rays for that matter."

    The two other big killers were tuberculosis and rheumatic fever. Hospital wards were full of people suffering from the diseases.

    With disease rife, doctors were under intense pressure, but to make a decent living they had to take on as many patients as possible. This led to competition for patients.

    "There was a lot of advertising," said Dr Elliott. "Some doctors had neon lights outside that jumped up and down - the General Medical Council (GMC) had to clamp down on it."



    "GPs had neon signs outside their surgeries"
    Order from chaos

    The introduction of the NHS brought a degree of order to the chaos. Hospital consultants were for the first time paid a salary for hospital work, and GPs no longer had to tout for business from patients in order to make a living. Before that, some GPs had two entrances to their surgery, one for patients with national health insurance - who were known as panel patients - and one for private patients.



    Before the NHS, many GP surgeries had two entrances
    However, many doctors were unhappy that the poor often went untreated. "Before the NHS, many dependants of workers did not come to the doctor because they could not afford it, and many doctors, including myself, were reluctant to charge patients when they could not afford it, " said Dr Elliott.

    The NHS was initially opposed by GPs who feared it would compromise their status as independent contractors, and stop them selling on the 'reputation' of their practices when they retired.

    A deal was done, however, and in July 1948, 98% of the population signed up with an 'NHS GP'.

    Not everything about the new system was positive, however. Lord Beveridge, the economist whose report led to the foundation of the welfare state, thought that once the unmet demand had been satisfied the pressure on the service would reduce. Nothing of the sort happened.



    "Doctors were opposed to the NHS"
    'Awful occasion'

    "Many of my patients were suspicious to start with," said Dr Elliott, "but when they found out they were getting the same doctor and the same treatment and did not have to pay for it, they then came in their hoards.

    "The demands were great but they were uneven. In those days, you had to have a sick benefit at the beginning of the week on a Monday, and a signing off session at the end of the week on a Friday. On those two days people queued up outside, often in the rain.

    "On one awful occasion a patient came early in the morning, got very aggressive, broke the door down and came upstairs where I was in bed with my wife.

    "In those days it was usual to do about 30 visits a day, and on one occasion during a flu epidemic I actually did 50 visits in one day. That was killing.

    "It really was round the clock, on call. Family holidays were difficult. On one occasion when I did manage to get away I was stopped on my way back in the street by patients demanding a consultation."

    Work satisfaction

    Despite the round-the-clock service he was expected to provide without complaint, Dr Elliott said working in the nascent NHS was thoroughly worthwhile. It is not a sentiment he suspects is shared by many of his modern day counterparts.

    "Young doctors like myself were imbued with the good of the community and felt we were doing something very good. In spite of all the problems, we got work satisfaction," he said.



    Before the NHS, many GP surgeries had two entrances
    "The morale of the people working in the NHS was much better then. Morale has gone down the drain - the introduction of bureaucratic market arrangements upset doctors no end.

    "There is no doubt that if you like people and you are a caring person, the doctor-patient relationship in general practice can be very satisfying, although the work is awfully hard.

    "But young doctors are not prepared to put up with the pressure and hours that we did, and in a way I don't blame them because there is no doubt that the doctors' families suffered tremendously."

    Does Dr Elliott think the NHS has been a success? Yes, but a qualified one. "The qualification is the last ten years when they have introduced all these market reforms which have distorted the whole thing and taken resources away from patient care.

    "The developments in medicine have helped tremendously and also the higher standard of living of the population, but as a consequence of that people are living longer and that is in itself giving rise to problems." In medicine it seems the circle will never be squared.


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  • Vinci Ho

    Apology
    Due to slight error on paste
    'Patients broke down' should be
    'Patients broke down my door'

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  • Vinci Ho

    So NHS is the best health care system in the world(far better than US which was born independent on 4th of July , ironically)??
    (1) What I have learnt through 20 years in general practice is NOT to pay any attention to any 'credit' or 'condemnation' from the outside world. The job , however , is still about listening to our own patients, nothing more , nothing less. Hence, do not take 'opinions' too seriously( just like the bureaucrats don't take ours seriously either)
    (2) Charging or not charging targets only part of the whole problem. A system like NHS requires the full commitment of a government . That should be written in the constitution. Yes. People said we , doctors , should do this and do that because there is no chance the government will put more new money in NHS and hence general practice anyway. But why shouldn't that happen ? Why is it , for instance,the difference of corporation tax between US and UK is so substantial considering US does not have a social medicine system? I totally agree charging a small fees can help but will that give a government excuse to withdraw even more commitment from NHS? Think carefully , mate . Bottom line , it is all about the bloody old game, politics.
    (3) Surely, one can argue whether NHS should be scrapped altogether , same old right wing argument. Although I took very little away from this report about NHS being the best, I am sure people in other counties are having a lot of complaints about their health system ( at least I know about Hong Kong and China). Perhaps we really have overlooked the fact that we have a 'relatively' very good health system here. The old saying still applies ,' you only value something when you finally lost it'.
    (4) The government should take absolutely NO credit if NHS is the best in the world . It is all the people , us , who are loyal and believing what we are doing which keep NHS in its shape. Should be proud.
    (5) But like I said before , you have to believe what you say and do everyday before you can carry on. So yes, exit door is always there, no offence , we have to always make a choice about our lives .
    (6) NHS is a flag as I always say, good times and bad times. It has given us 'important' things in our lives( at least to me) but are we now willing to fight for it against those demons who want to burn the flag?
    (7) Life is only short, there are a lot of values and virtues which cannot be bought just by money.......
    (8)And for BMA/GPC
    Remember while we never really want to start a war, the war had already started on the day JH said he did not 'pick a fight' with GPs.
    For those who continue to insult and pay no respect to us , there is no room for 'being polite'....
    Of course, there are always 'prices' to pay in a war:
    There will always be those
    who mean to do us harm
    To stop them , we risk awakening the same evil within ourselves
    Kirk Star Trek into Darkness 2013

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  • Vinci Ho

    Thou shall not turn into demons by the politicians' bureaucratic and lying games.......

    "Demons" by Imagine Dragons

    When the days are cold
    And the cards all fold
    And the saints we see
    Are all made of gold

    When your dreams all fail
    And the ones we hail
    Are the worst of all
    And the blood’s run stale

    I wanna hide the truth
    I wanna shelter you
    But with the beast inside
    There’s nowhere we can hide

    No matter what we breed
    We still are made of greed
    This is my kingdom come
    This is my kingdom come

    When you feel my heat
    Look into my eyes
    It’s where my demons hide
    It’s where my demons hide
    Don’t get too close
    It’s dark inside
    It’s where my demons hide
    It’s where my demons hide

    At the curtain’s call
    It's the last of all
    When the lights fade out
    All the sinners crawl

    So they dug your grave
    And the masquerade
    Will come calling out
    At the mess you made

    Don't wanna let you down
    But I am hell bound
    Though this is all for you
    Don't wanna hide the truth

    No matter what we breed
    We still are made of greed
    This is my kingdom come
    This is my kingdom come

    When you feel my heat
    Look into my eyes
    It’s where my demons hide
    It’s where my demons hide
    Don’t get too close
    It’s dark inside
    It’s where my demons hide
    It’s where my demons hide

    They say it's what you make
    I say it's up to fate
    It's woven in my soul
    I need to let you go

    Your eyes, they shine so bright
    I wanna save that light
    I can't escape this now
    Unless you show me how

    When you feel my heat
    Look into my eyes
    It’s where my demons hide
    It’s where my demons hide
    Don’t get too close
    It’s dark inside
    It’s where my demons hide
    It’s where my demons hide

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  • Vinci Ho

    Remember William Beveridge Five Giant Evils?
    Five "Giant Evils" in society: squalor, ignorance, want, idleness, and disease.

    Those with virtue holding high position in a hierarchy spread the evils through the most.
    Mencius , ancient China.

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  • Vinci Ho

    Sorry
    ...those with no virtue ....
    One if those days!

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  • No chance of stopping political interference in the NHS. We are screwed. GPC please give grassroots gps an alternative model and get us out of this stupid contract . Only such an action or threat of such an action will be effective. Your current position and strategy is not working. The BMA bear is not going to save us. If the BMA does not have the balls to stand up for primary care then it's time for The GPC to become independent of the BMA as a separate union. If you don't take action, the BMA /GPC is going to become a redundant organisation with no members and no national contract as practices will risk local bargaining or simply fold.

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  • The NHS bashing in general and GPs in particular, which is now an almost daily feature from politicians needs stopping. Mr Hunt, instead of naming and shaming GPs, please invest in training, education and funding in primary care.

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  • its sad but we are let down by politicians because our leaders donot have any backbone-no point crying over spilt milk-get on and do something worthwhile

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  • I agree, 'politicians must stop gimmicky' If the politicians truly wants to reduce waste and inefficiency, it should abandon the mantra of competition, market forces and choice of provider and instead work towards developing a co-operative and integrated healthcare system, with collaborative commissioning at the heart of how precious resources are utilised. The risks of longer waiting times, the clogging up of primary care services, cancelled operations, instability in some major hospitals, and sinking NHS family's morale looms closer. Acting now ensures that some of the damaging effects of the reforms might be reversed.

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