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.
