Imagine you are the captain of a fine ocean-going vessel, embarking on an adventure to an unknown territory. Pride and excitement are coursing through your veins, and you feel sure your mission will be a great success. It has all been going so well, until you realise your ship has veered off course, and you find yourself in storm-ridden waters. A hole has appeared on one side of the ship, which is rapidly taking on water. Your sailors are terrified and have begun jumping overboard.
The decision you face as captain is when to concede that you and your men are no longer safe, and your mission is doomed. When should you abandon ship and man the lifeboats? Will you be branded a hero or a coward? Do you have any choice?
The pressing matter faced by the government, medical professionals, the media, indeed the general public, is at what point we might concede that the NHS is failing? Is the ship sinking?
We could consider which signs and signals we might detect in a situation where the health service was collapsing. Might we find that waiting times for routine and urgent surgery were lengthening? Would there be increasing waits to be seen in A&E departments? Would we see ever longer waits for ambulances? Would it be increasingly difficult to get an appointment with a GP? Might we even see that life expectancy started to fall, and excess deaths were rising unexpectedly?
Attempts to increase GP numbers by bringing more doctors into GP training, bringing in allied health professionals, grouping GPs in larger practices, have all failed to provide the solution to the crisis in general practice (yes, it is a crisis). Alongside the fixation on increasing GP numbers, there do not appear to have been any concerted efforts to reduce the demand coming into our service. The result we are seeing is an overwhelmed primary care system, an overwhelmed secondary care system, alongside a social care system which is deeply inadequate. Our patients are angry, frustrated, and increasingly desperate.
If I’m completely honest, I don’t think that we will ever be able to recruit sufficient GPs to cope with the workload that is being asked of us. A different strategy is needed; perhaps a different approach to the whole delivery of healthcare in the UK.
We need to find a way to communicate to the public that seeking medical advice should not always be the first port of call when you have a health concern. It may be that bringing in small fees might be the only way this can realistically be achieved.
Perhaps the government could invest in High Street health advisors, who could, for example, be based in a local pharmacy? These individuals could dispense commonsense non-medical health advice, and signpost patients to a pharmacist, over-the-counter treatments, health visitor, minor injuries, citizen’s advice, or a GP practice. 111 doesn’t seem up to the task.
With the health service creaking at the seams in the middle of August, with no sign of respite on the horizon, it is clear that the NHS finds itself in deeply troubled waters. I predict that by January, the crisis in the NHS will be on the front page of every newspaper. We could conceivably find that our lives are restricted this winter, for fear of circulating viruses putting extra pressure on the health service.
My question is how bad do things have to get? How many patients need to die while waiting for ambulances, in hospital corridors, or in pain – never having received their hip replacement? When will we admit that the NHS is failing, and a new model is needed? Those who can afford it are taking out private health insurance; but the whole population deserves safe, affordable and accessible healthcare. Surely we could deliver this via the equitable models which are common in Europe? Free at the point of access is utterly pointless if patients are unable to access medical advice, have to wait years for basic interventions, or the service provided is shambolic and unsafe.
I find myself looking around for a lifeboat – but all I can see is a blinkered captain sailing merrily towards an iceberg.
Dr Katie Musgrave is a newly-qualified GP in Devon and quality improvement fellow for the South West
READERS' COMMENTS [15]
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Yes. The NHS cannot push its staff to be all things to all people at all times. We need to provide core services for all, co payments for some things and full payment for others. Free at the point of delivery, paying people to be sick or maintain their addictions, house calls, calling ambulances when not essential all need a very careful rethink. So does inappropriate use of GP and A an E services. Over ordering of repeat medications is rife. Expensive end of life rescue treatment and expensive drug treatments need to be limited. The litigation system needs to change. In its current form it encourages over investigation, referral and treatment. The problem is the lack of political will to be realistic about what a publicly funded health system and human staff can actually safely provide.
What is all this preoccupation with men and manning things? If we weren’t so determined to preserving the Dr Findlay model of general practice and sailing ocean liners needing a huge staff, we could be flying planes, sailing bulk carriers around the world and organising and disciplining our work.
Let’s see what Amazon does with its healthcare acquisition. Everyone resents and dislikes them but almost eveyone buys from them.
We are clinging to an obsolete model when we have the power to change it, but only if we let go of the past and work together to seize the future. A fond farewell to Dr Findlay and hello to Dr Tomorrow – who is a woman by the way.
Have a great week!
Katie
You work in he South West as I do and should be aware of the gross shortage of pharmacists too.
Not enough to keep the pharmacies open their contracted hours and often long queues outside them .
Pharmacists have been added to the Home Office shortage occupation list too so they are not the answer in our area. .
The most immediate resolution to the workforce crisis is retaining the older GPs until the newer trainees can be trained and looking after them so they want to stay in the UK as future working GPs.
Also not having to hit all the targets of QOF and IIF at this time.
This government seems happy to let the current model collapse , so maybe Fay needs to share her radical new model with us and whether older men Like me will have any place in it !
I doubt even superwoman could solve where we are without a political culture change in government !
Why not just adjust the targets for 111 staff triage outcomes: reduce the number signposted to GP by 10%, or the regional 111-manager loses their job?
Make it cumulative monthly – ie reduce by 10 % per month every month, and we would soon be better off – we would have less NHS senionr managers, anyway!
Please do not bring in charging patients- aka collecting tax for the Government. A whole new system will have to be set up to manage the money, and can only end in refusals and complaints. Also charging little old ladies £10 for being late because the bus didn’t turn up on time is cruel,
What needs to be called out is that THE burden on the NHS is the 18-35 year old. The NHS was not set up for them and it is a chaotic disaster. They will be a burdensome population into their 40s and 50s with utter anxiety and hypochondriasis. The system cannot cater for all. Grandmothers are queuing behind instagrammers bored out of their head. That’s not right at all.
Nice story Katie!
Katherine Morrison and others above has listed the issues needing resolution, the main one being FATPOA.
And for Mark David above, ‘little old ladies’ live in all countries and cope, live a good life etc without having free access to our wonderful NHS.
No one will be officially calling out the failure and/or ‘sinking’ of the NHS any time soon. The NHS has been systematically broken for a number of years and yet an organisation carrying its name is still chugging on. The sinking ship analogy is a good one to a point, most useful to folk who find themselves in the first half of their career. From my perspective, having had similar aspirations to the author when I started out, the boat actually sank a while back and we’ve been in the lifeboats a few years already! The disappearance of the NHS is a gradual fading kind of thing, it just goes on and on. (most) people aren’t stupid, they can see it’s a mess. Private healthcare will continue to grow, health inequalities will continue to increase. Drs will continue to be used like consumables, burn out and retire to be replaced by new ones, who will in turn burn out and retire. (Some of whom will no doubt be drawn to thoughts of sinking ships) There will always be ill people and there will always a need for healthcare..it just won’t be provided in the same way .. we’ll all still be calling the NHS ..but if people continue to demand more and more..almost by definition (this being a resource limited system), individuals will receive less and less and eventually the NHS as WE knew it won’t be there anymore. Which is probably a good thing I think
The solution has been simple and obvious for a long time to anyone who understands economics, history and psychology – Abandon socialism/redistribution/obsession with inequality via the state. And not just with the NHS, with welfare and other sectors too. Putting this into effect is nigh impossible of course. All these sectors and the state need massive pruning down to essentials only (not complete abandonment).
But a quick look elsewhere offers up a glimpse of hope. In many other places you strive to afford what you need and want, you pay for it (via insurance, etc), you are free to help who you want to help (friends, family, sometimes even strangers) and competition is the only thing that drives affordability and quality. To put it even simpler: take the state out of it.
Both the analogy and the solutions are misconceived: the NHS ship never had a hole, it had a captain whose only experience was as a usurer, who was appointed to lead the voyage by a banker. The captain accused his experienced staff of mutiny and threw them overboard. The ship isn’t the problem.
Charges produce inequity and harm. There is no possibility that charges would in any case sufficiently reduce demand, but it would cause harm to the cohorts of people who would be put off from consulting their GP.
Charges wouldn’t, however, put off the cohort of middle class entitled worried well types for whom the government has been relentlessly promoting convenience and access as of prime importance.
Heralding as exemplars other health systems which charge patients is a spurious exercise in blinkered vision. Look at those systems’ investment per capita, their costs for collecting those charges, their numbers of GPs per capita, their outcomes for managing chronic diseases, and their accessibility to the rest of those systems.
The NHS model is and never was the problem. The problems we have now are very clearly and evidentially the direct result of more than a decade of neoliberal political interference and their incompetence on the job.
Charges would create more problems without solving the problems we have. I despair at the alacrity with which some doctors are willing to abandon an evidentially excellent and fair system, whilst clinging to ill-informed tabloid ‘solutions’.
Over the past couple of decades, NHS data gathering has increased and the number of managers has increased along side. Do we ever see figures of clinical v non-clinical staff (both numbers and costs) employed by the NHS across primay and secondary care?
“Charges produce inequity and harm” – Yes, people are just dropping on the streets wherever there isn’t socialised healthcare.
And no, the NHS treats everyone quickly and efficiently… is what no one said ever.
I wonder Nick, when you have to wait 3 yrs for your hip replacement, or 2 yrs for your child to see CAMHS, after paying 40 yrs of taxes, is when you’ll change your tune. You think that the NHS model (i.e taxation funded) can function WITHOUT political interference and incompetence??? The state IS entirely part of it. Remember the fundamental principles –
1. It is always easier to spend someone else’s money.
2. Socialism works until you run out of other people’s money.
The problems are basic. Demographic changes with more elderly people with cormorbidities and fewer working age people to look after them. Funding that has not kept up with demand. Cultural shifts with an emphasis on convenience and immediate access to all services at all times, with a loss of broader community cohesion and autonomy in solving one’s own problems.
None of these things are new. Taxes will need to go up and expectations pruned back, and an honest conversation with the public that the NHS is not your answer to your socio-economic problems. None of these things have happened and therefore the system is now failing.
“Taxes will need to go up” – time for some economics 101. When taxes go up, the actual tax take goes….. you guessed it – down.
Just 1 example here – https://www.thetimes.co.uk/article/high-tax-rates-in-scotland-bring-in-200m-less-says-ifs-m6j9szcrh
And many other historical examples if you do your research.
Humans aren’t bank accounts just waiting for you to tax them. They’ll be incentivised to pay less tax, and look at means to do so.
“Honest conversation with the public” – doesn’t work, fundamentally people will generally take what you will give them (self-interest), and the state is not spending its own money (see point 1 in prev posting), i.e. hugely inefficient. Either it prunes back hugely, or stops intervening altogether.
Not sure I agree there. It’s a case of reducing demand or increasing supply, but in our system there’s not much you can do to reduce demand, at least not quickly. There are plenty of other countries that do have a higher rate of tax and a better provisioned healthcare system. When services are “pruned” inequality and outcome discrepancies worsen. Not saying that the NHS shouldn’t stop doing some things, but it’s not going to fix the demographic challenges.
And the idea that it’s 18-35s causing this as someone suggested above – just go take a look at the median age of your clinic tomorrow to see that’s rubbish.