Morale in the NHS is at rock bottom, to judge from the hundreds of replies to Times2’s appeal for personal experience of the organisation. Yet spending is at an all time high: £92 billion is the total budget this year, while in 1996-97, it was £33 billion. That translates as £1,388 per sore head or broken limb.

But stripped of the excuse that all its problems are caused by lack of money, NHS doctors, nurses and other staff are still seriously questioning whether it has a future in its present form.

In their correspondence, no two writers held exactly the same views, but fear and anger dominated, and a few key themes were repeated. The public expects too much; doctors as a profession have lost control; nurses no longer nurse; and managers have proliferated, in a setting of constant and bewildering change. More than one doctor was in despair. “I just hope I am never ill,” said one. From another: “I can’t wait to retire, but I hope I’ll never be ill.” From a third: “The job I loved is now a job I hate.” The underlying reason is the mismatch between the values of medical professionalism and the realities of life in the NHS. Doctors are driven by clinical need, treating the sickest first, and on the basis of their judgment and experience. Today’s reality is that they must treat those who have waited longest first, and on the basis of national guide-lines. More than one said they they have become “deskilled box-tickers”.

The NHS is sucking the professionalism out of the profession. Powerless to change how the service is managed, doctors’ unhappiness stems from the feeling that they are short-changing their patients, and themselves, by the compromises they are constantly forced to make. Some believe that structural change would improve matters, others that change is the problem, not the solution. Quite a few favour the idea of an independent body to run the NHS, while others lean to French-style social insurance to pay for it. Many think the purchaser-provider split was a change for the worse.

“The NHS is ethically and intellectually corrupted,” said one, adding: “It is like a tooth that should be removed, only we keep refilling it.” Many respondents were critical of the quality of nursing. As the profession has raised its educational standards, it has lowered its standards of care: nurses with degrees look at computer screens but do little actual caring. That is often left to less-qualified nursing assistants, who lack the clinical skills to keep track of how patients are faring. “This is bad news,” said one GP.

While this critical view of nursing is held largely by doctors, some nurses shared it. “It can hardly get worse,” said one. “It is Darwinism in reverse: the survival of the least competent.” Managers replied in much smaller numbers, with some trepidation. “Please guarantee anonymity; our trust sacks whistleblowers. I’d lose my pension,” says one. Only one respondent takes the government view that all would be well if the media would stop publishing critical stories about the NHS.

One very cogent analysis came from a private sector manager employed as a consultant in the NHS, who says it has “woolly clinical governance, high levels of trade union interference, poor resource allocation (though no poverty of resources) and inadequate general management”. Change in the organisation is largely staff-centred, he says, and patient service is poor at every level. “When one adds to this mix that no UK patient has to pay for his/her NHS treatment, it means that an extremely valuable service is undervalued by its recipients, while leaving its providers feeling negative and unsatisfied.” Patients are increasingly seen as a problem. “No one understands the deal any more,” said one doctor, bewailing the disappearance of a culture in which patients would not bother a doctor until they were half-dead. Many feel that patients have unrealistic expectations of what the NHS can deliver, and nurses complain that patients are often abusive.

Few respondents had anything good to say about the Government’s reforms; these had introduced “market forces, without market benefits”, one said. Independent Sector Treatment Centres had sucked money out of hospitals without treating many patients; Choose & Book was a waste of time; there were too many managers chasing too many targets. Very few respondents acknowledged that these changes might be designed to turn a system designed in 1948 into one fit for the 21st century, where patients, not staff, are supposed to be the focus of attention. One doctor who did said that he had left the NHS after realising the absurdity of a “tax-based, Soviet-style queueing system”.

Another questioned whether doctors had ever welcomed the NHS, and included a newspaper cutting of a poster displayed on the walls of St Thomas’ Hospital – opposite the Houses of Parliament – when the NHS was being launched by Aneurin Bevan in 1948. “Boot Out Bevan,” the poster read.

How other countries do it

The NHS is unique in the world as a single, national, universal healthcare system funded out of general taxation, and free at the point of delivery (if you exclude dentistry, prescription charges and sight tests). It employs 1.3 million people and has a budget this year of £92 billion. Only the Red Army, the Indian railways and (maybe) Wal-Mart employ more people. But it is not unique in delivering universal care: many systems do that, in ways that differ from the NHS model. They tend to be less monolithic, and funded by insurance rather than taxation. Critics of the NHS say that they are also more responsive and more patient-centred.

GERMANY pays for healthcare through Sickness Insurance Funds (SIFs), based on compulsory payroll contributions, shared equally by employers and employees. The funds cover 92 per cent of the population; the rest are covered by private medical insurance.

FRANCE has a similar system of SIFs, funded in the same way, and topped up by payments from taxes for the unemployed. Patients do make modest payments, recoverable for the poor, and many people buy top-up insurance for private rooms and other benefits. The service delivered is outstanding, the best in the world, some experts say, but costs are high, and rising.

SPAIN’S system has performed impressively during the past 20 years. It is funded through taxes, topped up for the better-off by private medical insurance. Hospitals are locally run and the system is strongly decentralised.

THE U.S. is the exception. There healthcare is based on private medical insurance, with employers usually paying premiums for their employees. But those in low-paid jobs, whose employers don’t provide insurance, find it hard to obtain cover they can afford. The system is topped up by Medicaid (for the poor) and Medicare (for the elderly), but the uninsured are the last in the queue for treatment. The system is the most inequitable in the world, offering care that is outstanding for some, but much less good for others.

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