It’s election time, so arguments over waiting times and who is going to give the NHS the most money are all but inevitable. That’s politics, but it’s also a symptom of a certain kind of tunnel vision. It’s crucial that the public understand that lack of money is not the only reason hospitals are failing to meet demand. If they are not given the whole picture, voters will feel let down in years to come. So, what is behind soaring waiting times?
It might sound obscure, but one important factor is a recent Treasury pensions relief change. The irony is the problem arose because of too much NHS money. Older consultants on high salaries (over £110,000) were benefiting disproportionately from pensions relief compared to lower paid staff. Treasury rules were changed to make this fairer.
Consultants found providing extra waiting list sessions or taking on extra work led to tax bills which in some cases meant they were paying more out in tax than they were earning. Even the most altruistic will not pay the Treasury for the pleasure of working extra evenings and weekends. Understandably this led to a big drop in service provision. An important economics lesson for any incoming government – one can never fully predict the effect of a change. Be prepared for unexpected outcomes, in this case longer patient waits.
This is against a backdrop of workforce planning that has become centralised, bureaucratic and non-responsive. Recruitment numbers have been based on historic training levels, then tweaked to allow for population expansion. What they did not factor in was the gender shift in medicine and that female staff have children and need time off. Managers then failed to predict that male staff would copy their female colleagues and choose to work part-time.
Indeed, in general practice the previous norm of an eight-session (four-day) week is now six sessions. This leaves a big shortfall of clinic slots. This is critical for the viability of the NHS as GPs are the only ones providing holistic care and act as the front door and gatekeeper.
The last 10-20 years has seen the introduction of intensive monitoring and tracking of all doctor activities. These quality systems have been successful in raising standards of care and identifying trainees in difficulty, but the current implementation is slower. Furthermore, the shift from a relationship-based work system to a transactional system has had the unintended consequence of lowering morale. The loss of the medical ‘firm’ was, I suspect, a key contributor to the junior doctors strike and the decreased cohesion amongst medical staff now.
We are seeing hospital systems go digital. Paradoxically this is slower, particularly when implemented in the wrong way thanks to the time taken to search for the correct fields, click boxes and refresh screens The result is a more structured dataset and less potential for errors, which is good, but it is slower.
In the US, the move to electronic health records is thought to be a key reason for physician burn out. A workaround in one US hospital group is to have a doctor in India present by video link during the consultation who takes the notes and fills in the forms.
Another under-reported issue is the NHS litigation and complaints system. Most people are shocked to learn that the UK is the medical litigation capital of the world. Shockingly, the NHS pays out three times as much per capita as the US, amounting to nearly £2bn a year out of the NHS budget and overall liabilities approaching £100bn.
GPs carry the most risk and, given how long each case takes to resolve, may endure litigation for a quarter of their working lives. The most reliable way to avoid this is by seeing fewer patients, avoiding out-of-hours emergency work and retiring early.
The reason dates back to the Law Reform (Personal Injuries) Act of 1948, the same year the NHS was founded. This legislation essentially says that a compensation award must be based on the cost of treatment in the private sector – although the patient is entirely at liberty to use the NHS for treatment and bank the money. Given that this act benefits the rich at the expense of the poor it’s surprising Labour have never called for its repeal. They obviously did not read the recent CPS report which outlines the solutions.
What else has changed over the last 20 years? The population is older, with more complex co-morbidity, but also the population has greater risk factors, such as obesity. This tends to make disease more chronic and requiring more clinic slots. Somewhere between 30-40% of NHS spend is lifestyle-related. It is a societal choice whether or not to try and alter the environment and change incentive structures. But the fact is these have a big impact on clinic demand and there is a choice to be made in whether to spend money and effort into addressing risk factors, or increasing capacity to deal with the consequences.
So we find ourselves nationally short of doctors and in a crisis because as salaries are, barring minor changes, state-controlled and the same for every speciality and region of the country, the least desirable areas and least desirable specialities such as psychiatry will suffer the most. Another CPS report, an NHS Bonus, suggests some reforms that would both promote equality and productivity.
That the NHS is free at the point of delivery is a wonderful thing, but a consequence is the system’s trade-offs are hidden, particularly when patient expectations are fuelled by politicians. It is entirely appropriate to argue about money, but this is just one axis – and politicians who think the only thing that needs to be done is write a bigger cheque are wrong.
Until we can stand back and consider these other factors and remember the point of the NHS is to promote health in a fair, equitable way, we will be stuck with a one-dimensional debate about funding and a disappointed public.
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