Max Pemberton

How to fix the NHS: a doctor’s prescription

Competition – and ideology – isn't working

How to fix the NHS: a doctor's prescription
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I’m a doctor, and I don’t care about the NHS. In this country, that’s an almost heretical statement — but it’s true. What I mean is that I have absolutely no interest in ensuring its survival simply because it’s a great national treasure. What I care about is making sure that we have the best possible and most cost-effective healthcare system. And as it happens, despite the strikes, panic and doom-mongering, I think the NHS — by which I mean a nationalised healthcare model — is the best option available, if only someone were brave enough to make the right changes in the right way.

Don’t expect this government to try. Senior cabinet ministers said this week that their attempt to reform the NHS (which culminated in the 2012 NHS Health and Social Care Act) was their ‘biggest mistake since coming to power’. As angry, beleaguered nurses and frontline staff begin striking, there is a cross-party consensus that the NHS can’t be touched: it’s just too toxic politically. So instead of making amends for the former health secretary Andrew Lansley’s botched attempts at reform, Cameron decided he’d rather ‘park’ the issue. That’s like a surgeon splaying open the patient, then realising he’s made a mistake and just walking away from the operation with a nonchalant shrug. The NHS has been left haemorrhaging on the table. Sorry, but that’s not good enough — there’s lots that could and should be done.

The Commonwealth Fund survey, which uses a range of measures to analyse healthcare systems around the world, has consistently found that the NHS is one of the best. But the attempts — first by the Labour government and then subsequently the coalition — to introduce more efficiency through competition have in fact meant an explosion of expensive bureaucracy. It’s quite clear that the more providers of healthcare there are in the system, the less efficient it becomes, and the risk of duplication, confusion and misunderstanding grows. I see this day in and day out in my own practice.

Research conducted by the NHS Confederation showed that clinical staff spend up to ten hours a week collecting or checking data — more than a quarter of their average week. It also shows that more than one third of that work was neither useful nor relevant to patient care. I frequently feel I am drowning in forms that demand to be completed, statistics that need to be gathered and boxes that need to be ticked. Every clinician I know feels the same. I work in a hospital providing tertiary care to people with complex mental health problems. I typically see patients for 30 minutes to an hour. For every patient I see, I have at least one hour of paperwork to do. Some of this has a clear benefit to the patient — for example, I write detailed letters to the GPs, providing in-depth history and giving plans. But the letters are only a small part of the paperwork. A manager pulled me aside to explain that if I don’t complete some forms, the service doesn’t get paid.

If it’s bad for doctors, it’s worse for nurses. Every admission triggers an avalanche of forms to fill. How have we got to the state in which, according to research by the Royal College of Nursing (RCN), the amount of time nurses spend away from patients, on non-essential paperwork, has doubled since 2008, with 2.5 million hours lost a week?

Entire departments have sprung up in hospitals of managers writing bids and business cases to ensure that their department can compete in the internal market, instead of worrying about the quality of the service being given. It’s not cost-effective and it’s not good for patients. But the coalition doesn’t dare go back to the problem it created. The current political mindset is that further NHS reforms would be a vote-loser.

So what can be done to save the healthcare system from the wreck that the government has created? While it may be painful for those who are ideologically wed to the free market, there is no evidence of significant benefit to support the wholesale introduction of competition within national healthcare systems. Similarly, the tortuous, labyrinthine bureaucracy of commissioning, which sees NHS services being delivered by a host of different providers, all of whom must compete for business and contracts, must be brought to an end. It is grossly wasteful and drains resources, time, money and manpower and has no demonstrable benefit. The tendering process for contracts needs to be stopped and services brought in-house, so that healthcare services are provided by the NHS. That doesn’t mean that there must be no private involvement, far from it, but private companies must support the NHS, not the other way around.

We also need to centralise all the debt accrued by the private finance initiative (PFI), the absurd public-private partnerships that proved very profitable for a few companies but utterly disastrous for the public purse. Labour essentially sold off the family silver and we’ll never get back many of the buildings, resources and land that we gave to the private sector under ludicrously in-equitable terms. Sadly, there’s not much we can do about that now. We have to cut our losses and get out of these PFI deals.

The internal market model was brought in to answer concerns about ensuring innovation and quality within the service, and these remain vitally important areas to address. We need to adopt a value-based outcome model across the NHS. This idea, developed by Professor Michael Porter at Harvard Business School, may sound dry, but in fact it offers a clear way of assessing how much value for money each service provides. It is not based on targets set by politicians, but on what is important for patients. Porter’s team is in the process of developing a list of the most important outcome measures for all major conditions and treatments. So rather than slapping a blanket four-hour turn-around target on everyone coming into A&E with chest pain, hospitals can try to measure the time it takes to reduce that pain, or how long it took to carry out heart imaging to assess the seriousness of the condition.

By using specific, internationally agreed and academically validated measures for treatments or interventions, we can ensure we are properly comparing like with like. We can then quickly and easily analyse what trusts are getting right or wrong, and see which ones are doing things well.

The answer is not just to pump more money into the NHS. Again, the evidence suggests this doesn’t help unless the funds are highly targeted. There is a good argument for raising health spending so that it is in line with the spending of most other European countries, but that needs to be done with very clear objectives in mind. Increased spending on prevention and primary care makes sense. We should be spending a lot more on mental health, too. Where I work, the waiting list to have psychotherapy for an eating disorder — a condition which carries a mortality rate of 25 per cent — is more than two years. How is that acceptable?

More generally, we need to educate the British public about the cost of the service, drugs and treatments that they receive. I suggest that, as well as a national campaign to tell people precisely how much that course of antibiotics they didn’t bother finishing actually cost the taxpayer, they should also be sent an automatic message when they miss an appointment, telling them how much money has been wasted and the impact it has had on waiting times. Some trusts already do this, but it should happen everywhere. The suggestion that we charge for missed appointments will only lead to more administration, form-filling and litigation. It’s easier to use social pressures than punitive measures. ‘Nudge’ theory has worked well in other areas — such as tax collection — so we should apply it to the NHS as well.

An evidence-based healthcare system would be painful for politicians, because it would require them to put aside their ideologies. But the medical profession has had to embrace evidence-based practice, and although it was hard at first and doctors resisted because they felt comfortable in their old ways, the result was that patients have benefited enormously. Now it’s time for the politicians to take the same medicine.

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Dr Max Pemberton is editor of Spectator Health, which has regular online coverage at