Defensiveness and hostility pervade the health service, and despite many patient safety reviews, very little has changed or is changing. Rob Behrens tells Abi Rimmer in the BMJ. Dec 2023 I would go further. The “recurrent scandals” those more recent listed below, and going to get worse. NHSreality believes that “no fault compensation” is an essential element in the honest debate needed to create cultural change. Reckless politicians! A Wonderful exposee is in the Times. Isobel Hardnan and Aaron Davis ( See books) must be smiling…The big Q ” How to change the culture so that more family men are prepared to stand as politicians?”… “Yet the very people who need most to tread carefully, tread most dangerously. The number of MPs who have lost their party whip now exceeds the total Lib Dem parliamentary party. Why?”.. “….I know why, (some want to be politicians) and the answer is simple. The sample is skewed. People who want to be MPs are not normal. They are not representative of the general population, but a very distinct personality type: a minority whose nature disposes them to take stupid risks.”….. No one should let these people anywhere near a betting shop. They have only got this far by defying risk. They are, by having got this far already, gamblers. No unadventurous family man in search of security is likely to want a career in politics….”Like me, most get away with it, always have; and there were plenty such in my time. I do, though, think that the proportion of young, male risk-takers in recent parliaments has grown, especially in the Conservative Party…..” Every aspirin politician should read Isobel Hardnan and Aaron Davis books..
NHS culture change is difficult, not impossible—but essential, says health ombudsman BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2742 (Published 06 December 2023)Cite this as: BMJ 2023;383:p2742 A toxic culture of defensiveness and hostility pervades the NHS, and despite many patient safety reviews nothing has fundamentally changed, Rob Behrens tells Abi Rimmer Early on in his career as a civil servant, Rob Behrens, now the parliamentary and health service ombudsman, was sent by the UK government to South Africa, to work on the transformation from apartheid to democracy. “People in Britain used to say what they had to do was hard. I would come back from South Africa and say, ‘You don’t know you’re born.’” It’s an anecdote he uses when talking about culture change in the NHS. Although change might be difficult, it is not impossible, and it is something that needs to happen, says Behrens, whose role is to adjudicate independently on complaints that have not been resolved by the NHS in England and UK government departments. “There is huge professionalism and commitment throughout the NHS. It’s been through the mill in a way that no other institution has—because of covid, strikes, and shortages of staff,” he says. “But unless we call everyone together to have a conversation about the emerging problems around the suboptimal culture in the NHS, then we will miss a big opportunity.” Behrens was appointed to his current role in 2017, having previously worked investigating allegations of public service failure in the legal and higher education sectors. During his six years as parliamentary and health service ombudsman, a non-governmental role, he has seen many investigations and reviews into poor care in the NHS. He has, however, seen little change. “We’ve had a lot of inquiries into leadership, distressing events, and organisational cultures but the fact is nothing has fundamentally changed,” Behrens says. “I understand that everyone has a massively busy job, that ministers, managers, and clinicians are doing the best that they can. But that doesn’t alter the fact that there are things that are fundamentally wrong that need to be tackled.”
Depressingly little learning
It’s not just his own learning that Behrens is reflecting on. He says that Bill Kirkup, a public health doctor with a specialty in obstetrics who led reviews into maternity services at the University Hospitals of Morecambe Bay NHS Foundation Trust (published in 2015) and East Kent Hospitals University NHS Foundation Trust (2022), had similar observations.12 “When he reported on East Kent, Bill Kirkup said that what depressed him was how little learning there had been from the first time he looked at these matters,” Behrens says. “Secondly, he said this is multifaceted—it’s not just about managers and clinicians, it’s about tribalism among clinicians themselves. “Thirdly, it’s a failure to listen to patients and their families. That adds up to a toxic culture, which we need to talk about so that we get the one thing that makes an organisation effective: a disposition to learn rather than just to move on.”
Staff are victims too
As well as describing the culture in some parts of the NHS as toxic, Behrens says it is suboptimal, hostile, and defensive. “This leads to a perception that organisational reputation and professional reputation are more important than patient safety. And that is very dangerous.” It is not just patients who suffer from such a culture, staff are victims, too, he says. “It’s not that they’re sitting there twiddling their thumbs. This is an enormously difficult climate in which to work and to tackle difficult problems.” Medical education has a role to play in improving this culture, Behrens says, especially when it comes to relationships between doctors and patients. He has heard doctors say that their education was based on the premise that they had to stand by their decisions and not “back off just because people don’t like them.” “First of all, that says that medical education is very important to the disposition of people, even before they get into senior positions,” Behrens says. “Secondly, it says there’s an implied arrogance that results from that education that stops communication between doctors and their patients. It’s not just about what you do in the NHS, it’s also about the education of people before they get there.” He says there is now a “golden opportunity” to think more radically about staff development and to link it to accountability and performance. “We should be spending more on the professional development of clinicians and managers in the NHS in a way that enables them to respond to the need to change the culture of their organisation. I think that’s very important.” Focusing on managers, Behrens stops short of calling for their regulation, but he does support calls for more accountability. “The impression that one gets is that people move from job to job as senior managers without their performance being scrutinised. That needs to be carefully looked at.”
Leaders at all levels
While it would be easy to lay the blame for cultural problems in the NHS at the door of politicians or leaders of national NHS organisations, Behrens says it is not so simple. “You have to have leaders at all levels throughout the NHS. You can’t just say this is about ministers and trust boards, it goes right the way through. I know from the visits I have made [to organisations] that if you have a powerful, compassionate person leading a ward, for example, that makes a significant difference to the morale and the disposition of people working there.” The power of good leadership is a point that he emphasises repeatedly. “People say culture changes from the top. Well, that’s true, but you can’t change the culture unless you have buy-in from people,” Behrens says. He adds, “The key thing about leadership is empowering the people who work for you to do the things that need to be done. You can’t do it on your own. You can’t be a general without an army. You have to make sure that your people are with you, whether it’s at a ministerial level, at NHS England level, or at a GP surgery level.”
“Bunker-ism”
Within his own world of ombudsmen, Behrens has introduced peer review, something he thinks the NHS could benefit from. “We now have, through the International Ombudsman Institute, a group of validated reviewers who are ombudsmen in other countries who, if they are asked, come for a short period of time to review one of their sister institutions and then write a report on what they found. “It doesn’t solve the problem, but it provides a perspective of learning and drawing on the expertise of your colleagues. I don’t always see that in the NHS because there’s an element of bunker-ism about it.” Behrens, who is coming to the end of his time in the role, has called for a thorough, independent review of NHS leadership, accountability, and culture. He reissued this call in the wake of the case of Lucy Letby, the neonatal nurse convicted this summer of the murder of seven babies at the Countess of Chester Hospital, but he says the culture of fear and defensiveness that the case highlighted is not isolated to one organisation. “We have to be less defensive, and we have to be more collaborative. It’s not easy, but it’s not impossible. Surely, after Chester, after [other NHS patient safety scandals] Birmingham, Bristol, Shrewsbury, East Kent, Essex, there needs to be a systemic reflection on what this means for the culture of the NHS. “It doesn’t matter what you call it, but the thinking has to take place. The debate has to take place.”
No need to say more. An endemic can become an epidemic. The perverse incentives to delay, deny and defend are too great. So the litigation anxiety of Trusts leads to a system on denial – the opposite of a learning organisation is one going into decline. The Times letters 15th April 2024: NHS whistleblowers Sir, Dismissal of doctors by NHS trusts for raising patient safety concerns has reached epidemic proportions (“Consultants accused of covering up fatal flaws”, Apr 12). We recently asked the Department of Health for the number of whistleblowers in any given period and how much taxpayers’ money was spent defending the claims. We were informed that such information was not held. The public has a right to know why and how these sums are dispersed, especially when they could be better spent on patient care. We need a national inquiry into the scandal of the persecution of doctors who speak up for patient safety. Witnesses might include unregulated hospital trust managers, who instigate and sustain the persecution, and the Department of Health, which appears to condone it. Members of the legal profession including judges should also be required to give evidence. They often display little or no understanding of how doctors and hospitals function, as evidenced by the contrivances designed to deter whistleblowers, such as cost threats and non-disclosure clauses. It’s hardly surprising that doctors are afraid to speak up and that they are leaving the NHS in unprecedented numbers. Dr David E Ward Cardiologist (ret’d) Professor Jane Somerville Emeritus professor of cardiology, Imperial College London Sir, Your article draws attention to the longstanding culture of cover up in the NHS. When members of staff raise concerns about patient safety they are subjected to unfair disciplinary proceedings. It is of great concern that despite many catastrophes over the past 40 years, the changes made to date have been advisory and non-statutory. It is time to establish an independent scrutiny panel with statutory powers at each hospital, from which management would have to seek permission before embarking on any investigatory or disciplinary process. Dr Arun Baksi Emeritus consultant physician, Ryde, Isle of Wight
Multiple reforms of the Health Services have failed. No wonder the public feels disillusioned. The long term opportunity to tell the truth is lost because politicians know that if they implement what is needed they wont be elected again. A scapegoat government is needed. Mr Streeting talks about the NHS, but he means England.On this he knows he is “gagged” by his own party. The letter below about staffing for surgery is easily addressed by the current administration: just let “medical assistants” operate instead of real doctors! The Times letters April 10th 2024 following Wes Streeting trying to make Labour think seriously about reform: “Reform of the NHS”. Sir I am not sure if Wes Streeting is correct in identifying “middle-class lefties” as those who seek to prevent him from using private hospitals to reduce waiting lists, but I applaud his intention to take them on (“ ‘Middle-class lefties’ won’t hold me back, says Streeting”, Apr 9). That vocal group insist all services must be provided by direct employees of the NHS. Do they not appreciate that a large proportion of NHS services are already provided by private enterprise? Medicines, drugs, operating equipment (scalpels, lights, gases, etc) and prostheses are all provided by private industry. Perhaps they are referring only to staff? One of the largest contributory sectors of the NHS, GPs, are not employees of the NHS but are private contractors. The critical element in Mr Streeting’s objective is that, whoever provides the service, it is free to the patient, ie the cost is borne by the taxpayer. All strength to Mr Streeting’s elbow. John Evans Wingerworth, Derbyshire
Sir, Wes Streeting is right to question the shortcomings in our health system but his contention that “everyone should be able to have timely access to healthcare but not have to worry about the bill” seems an aspiration too far. While users of healthcare services may not have to worry about post-treatment costs, they will certainly have to contribute through better advance funding mechanisms. He may consider the difference in waiting times between the NHS and private healthcare to be “a disgrace” but those going private have paid twice (once to the NHS through tax and national insurance contributions and again to their insurer), whereas many NHS users have paid very little or nothing. Stuart Southall East Horsley, Surrey
Sir, It is not “inexcusable” that NHS operating theatres lie empty in the evening and at weekends, it is inevitable (“Sacred Cow”, leading article, Apr 9). There are too few staff to safely man the service during the week, so how will any government find the additional trained staff to provide a full weekend service? This is political magical thinking. Dr Bob Bury Leeds
The Sun April 7th 2024: THE Shadow Health Secretary warns the NHS today that there will be no additional funding without the “major surgery” of reform under Labour. – Wes Streeting asks for Sun readers’ backing for a massive overhaul of our troubled healthcare system. Wes Streeting warns the NHS that there’ll be no additional funding without ‘major surgery’ under Labour. Wes Streeting and Sir Keir Starmer unveil plans to digitise massive amounts of NHS paperwork with an overhaul of the NHS app. It would include bringing in the private sector to help cut waiting times. Mr Streeting says an extra £1.1billon of funding will only come with agreement to get the NHS operating throughout the weekend to slash lists. He also vows that “spare capacity in the private sector” will be used to help. Pitching himself against healthcare unions and Labour supporters, he says “middle-class lefties cry ‘betrayal’”, but he is “up for the fight”. And he warns the entire conversation about our creaking system must move from money to results. Writing below, he says: “The NHS is a service, not a shrine. “It is judged by how well it serves the public, not how heavy a price we’re paying for failure.” The fiery words come as he and Labour leader Sir Keir Starmer unveil plans to digitise massive amounts of NHS paperwork with an overhaul of the NHS app — giving notifications of scans, GP availability and direct access to medical records. And children’s health records will be available to their parents via the app to allow mums and dads to easily see if little ones are behind on jabs or check-ups. It is hoped that the changes will turn around falling numbers in vaccines for measles.
‘ONLY WE CAN CURE THIS’
By Wes Streeting, Shadow Health Secretary JUST one in every four people say they are satisfied with the NHS today. Who can blame them? Record numbers of people are waiting for treatment, and they are waiting longer than ever before. 24 Hours In A&E isn’t just a TV programme, it’s reality for thousands. Patients are literally queuing around the block to see a dentist. Rishi Sunak responds that he is putting in record amounts of funding. But the NHS is a service, not a shrine. It is judged by how well it serves the public, not how heavy a price we’re paying for failure. The problems with the NHS are clear. It’s a 20th century service that hasn’t changed with the times and isn’t fit for the modern era. It catches illness too late, which means worse care for patients at greater cost to the taxpayer. It costs the NHS about £40 to provide a GP appointment. But if patients can’t get an appointment, they end up in A&E, which costs around £400. We’re paying more but getting less. This can’t go on. If the NHS doesn’t change, it will die. For the Conservatives, the NHS is covered in flashing signs warning, “Danger: Do Not Touch”. They know the public don’t trust them with it, so they daren’t change it. Only Labour can reform the NHS. It won’t happen overnight. It will take a decade of change and modernisation to make the NHS fit for the future. But if we marry Britain’s greatest scientific minds and tech entrepreneurs with the NHS, this country will go to the front of the queue for the revolution in medical treatments coming over the horizon. That’s how the NHS rolled out the fastest vaccine in history. If we did it to defeat Covid, why not to cure cancer and dementia? Cutting waiting lists will be our top priority and Labour has a plan to do it. Operating theatres lie empty on weekends while millions of patients wait. Labour will get the NHS working around the clock, with an extra two million appointments on evenings and weekends a year. That’s the reform. It will come with investment of £1.1billion, to pay staff for the extra shifts. With Labour, investment will always be linked to reform. Pouring more money in without reform would be like pouring water into a leaky bucket. We will also use spare capacity in the private sector to cut the waiting lists. Middle-class lefties cry “betrayal”. The real betrayal is the two-tier system that sees people like them treated faster — while working families like mine are left waiting for longer. Hours of doctors’ and nurses’ time is wasted by outdated equipment. Labour will bring our analogue service into the digital age. As a first step, we will put artificial intelligence technology in every hospital, and make proper use of the NHS app to give patients real choice and control. GPs are currently measured by 55 targets. Too much time is spent filling in forms and ticking boxes. Labour will fix the front door of the NHS so more people get care in their own neighbourhood, starting by cutting the red tape that ties up GPs’ time to bring back the family doctor. I don’t pretend reform will be easy. There will always be vested interests who resist change, but I’m up for the fight. The NHS saved my life when I had kidney cancer and now I’m determined to save our NHS. That is why I’m asking Sun readers to vote for change, and give Labour the mandate we need to fundamentally reform the NHS. Sticking plasters won’t do — the NHS needs major surgery and only Labour can deliver.
On Radio 4 today Dr Adrian Boyle from the Royal College of Emergency Medicine ( 07.13) opines on the perverse outcomes in A&E. Some prople wait a very long time indeed. The low threshold for performance means that all the attention is made on people who can return home. There is a financial incentive for hospitals to deal with those who are less unwell faster! The perverse outcomes are exposed by Dr Boyle. He is not against a target (or two) but he points out that the strokes and heart attacks dont get the speedy attention they deserve. At @ 06.40 Hugh Pym describes the claim for “improved” waiting, but the “long waits” have got worse. At 07.21 Philip Hammond describes the “three Ds” meaning: The Demographic challenge, Decarbonisation, and Defence. “The challenge with a more honest conversation in a democracy is, as all politicians know, voters don’t want to hear this: they want politicians to resolve it for them. They want politicians to find a way round it, and so politicians either focus on an economic solution, which is a productivity revolution, or they focus on improving the efficiency of public serv ices at the margin, or collecting a bit more tax from people who are perhaps not paying as much tax as they should be. I think the real issue here is to get the public to engage with the opportunity of technological innovation across the economy being a way of raising our productivity game, but the truth is we have not done well on productivity, certainly since the 2008 global financial crisis. The formidable problem is for our democratic politics …. despite the polls rejecting the conservatives the labour party has no magic bullet. The Luxemburg Prime Minister, Xavier Bettel said “We all know how to reform our countries, but we then dont know how to get elected afterwards”.
We are in a medical war, and during a war we dont mind who tries to save us as long as they try their best. \this is the political solution with “medical assistants” and “physician assistants” and with continuity of care. Without enough diagnosticians, doctors and surgeons, nurses and physios, mental health and social workers, we are going to have to doo with less=r mortals. My generation of medics and nurses, and other professionals, will never recieve the quality and continuity of care that we gave our patients. NHSreality warned readers of the coming implosion – 10 years ago. Opinion – The GMC’s future vision for medical training must be challenged BMJ 2024;384:q728 David Oliver, consultant in geriatrics and acute general medicine1, Louella Vaughan, consultant physician in acute medicine2 On 12 March the General Medical Council (GMC) published Our Vision for the Future of Medical Education and Training.1 This was accompanied by an explanatory blog from Colin Melville,2 the GMC’s medical director and director of education and standards, in which he queried whether the current system of undergraduate and postgraduate medical training was “fit for purpose” and suggested that “medical education needs transformation.” An enthusiastic and uncritical endorsement was published the next day by the three Royal Colleges of Physicians of London, Edinburgh, and Glasgow.3 Readers might wonder why this “vision” is even worthy of comment. But, as with so many policy documents that pass by the attention of jobbing clinicians busy with patient care, both the policy statement and the accompanying blog bear further scrutiny. The GMC outlines changes in three key areas of undergraduate and postgraduate training:
Building a bigger workforce including multidisciplinary educators,
Changing “prequalification education,” and
Supporting career development and lifelong learning.
Superficially, this all seems completely reasonable. The teaching of doctors has always involved staff other than doctors, especially academic scientists during the undergraduate years and specialist allied health professionals and nurses in postgraduate settings. More of this would be useful. However, what’s actually being suggested is that staff other than doctors should be involved in all aspects of educating, supervising, training, and mentoring doctors. The changes proposed to undergraduate education are even more radical. Melville is explicit that, since the advent of the mobile phone, doctors no longer need a “huge repository of facts in [their] heads.” This would allow medical school curriculums to be “streamlined” and quite possibly much shorter. The GMC then responds to the problem of younger doctors declining to enter traditional postgraduate medical training (the five to eight years needed to become a GP or consultant). Instead of career progression being contingent on formal training pathways, this will be replaced by an approach based on “outcomes rather than time spent or numbers.”
Changing patient population
Readers may ask what’s contentious about any of this. As Melville admits, UK medical graduates feel increasingly unprepared for work as doctors. So, perhaps a radical shake-up is exactly what the doctor ordered. The GMC and Melville link their proposals to the changing nature of the patient population (more people living longer with multiple long term conditions, using multiple services) and the greater need for population health approaches. Both require a greater emphasis on skilled expert generalism, holistic approaches to care, and a focus on prevention. The last attempt to improve postgraduate education, 2013’s Shape of Training,4 made a considered effort to tackle these issues. But the relative lack of success of those proposals doesn’t mean that narrower and shorter training, with less emphasis on knowledge, will better prepare today’s doctors for caring for increasing numbers of older and more complex patients. Plenty of doctors would support a reduction in the burden of portfolio assessments and documentation. But the rigour of multistage exams and repeated assessment, based on curriculum content developed over the past two decades, is a key plank of postgraduate medical training. This also ensures that all doctors have basic competencies to practise safely, regardless of where they train. While other countries have shown that innovations such as modular training can provide the flexibility much desired by the younger generation, it’s surprising to see royal colleges, whose international reputations are built on high standards, happy with suggestions that assessment of competence should devolve to local employers. A few things are striking about the GMC’s new vision and its endorsements. The first is that major changes to medical education and training are usually presaged by a period of intensive evidence gathering and self-examination, with the publication of a detailed analysis of what’s wrong and how this might be fixed. This is entirely absent from these proposals. The GMC already seems confident that it knows exactly what the problems are and how to fix them. Second, there’s a stated and naked urgency to this. The GMC claims that it has already been “working in the background” to get buy-in—yet this is the first that many people involved in medical education have heard of this initiative. And now the GMC seems to gallop ahead with a brief period of “listening” and then the formation of a “stakeholder group,” while simultaneously working on enabling legislation.
Quickly and cheaply
None of this is reassuring to a profession already uneasy and unhappy. Much has been driven by a GMC that has emphatically not been listening to concerns about the scope of practice of physician associates and has instead been reactive and tone deaf to legitimate concerns about patient safety. The sad conclusion is that this is really about bums on seats, producing the next generation of doctors as quickly and cheaply as possible. This comes at the cost of less education, less training, less experience, and less expertise—which in the long run can only lead to poorer and less safe care for patients. Future doctors will also be the losers. It’s very likely that other countries will no longer recognise British doctors as adequately trained and allow them registration without additional qualifiers, if at all. Moreover, the stated desire to take the responsibility for the next generation of doctors away from doctors, devolving this to other staff and employers, strikes at the very heart of what it means to be a profession. Only doctors should be responsible for supervising, training, mentoring, and setting standards for the next generation. The GMC’s vision for the future of medical education and training risks destroying the rigour and credibility of the medical profession and the reputations of its once illustrious universities and royal colleges for years to come. Let us please wake up and push back, before it’s too late.
If we can consider paying for the BBC in proportion to our means or tax code status then why not for health? We know that the current implosion in the 4 services means that the whole health service(s) are more regressive than they were. Those with more means and education are able to use the services ( those that there are- excluding A&E ) better. The NHS staff survey shows increasing levels of abuse. If the right questiosn were asked it would also show that staff have a very different perspective for the future of the 4 health services. Any questionnaire is debateable. The questions are usually designed to avoid revolutionary changes (or charges) and they certainly dont take account of those patients who died and were part of the “excess deaths”. There is not much worse for morale than working for a failing organisation, and one where gagging and retribution for speaking out are commonplace. To add debt to this is adding insult to injury. Nurses particularly.. Nick Bostock reports for GPonline “Public satisfaction with NHS and GP services sink to another all-time low” – Public satisfaction with the NHS overall and with GP services have sunk to the lowest levels ever recorded, figures from the latest British Social Attitudes (BSA) survey reveal. A deeper analysis can be read (Nuffield Trust and Kings Fund) but don’t be decieved by the Times. The evidence does NOT support the recommendations of the Times report on the future options – rather it shows that unreality of a population who have survived so far, and hope that their number won’t come up. Doctors and nurses ( 70%) believe health care should be rationed overtly. Emergency care is the worst area of the 4 services, and all doctors need to help out in any future reconfiguration. This is the safety net that is really badly holed (see below). The prospect of paying a small amount for seeing your GP or going to A&E / Urgent Care is discussed in “The rest is politics” by Rory and Alistair and albeit reluctantly, Mr Cambell accepted Mr Stewart’s proposal that we adopted an Australian or NZ approach in order to make the system sustainable, and that rationing should be overt. We all may be getting ready for the honest debate – but not our political parties. This will only happen bottom up.
Eleanor Hayward & Chris Smyth report 27th March 2024: Satisfaction with the NHS falls to record low – Experts said the public felt like they were in a ‘toxic relationship’ with the health service, with only 1 in 4 people saying they were satisfied Satisfaction with the NHS has fallen to a historic low, with only a quarter of the British public believing that the health service is working. Experts said people felt trapped in a “toxic relationship” with the NHS, supporting the institution on principle but increasingly fed up, sick and anxious because of its failures. The annual report by the King’s Fund and Nuffield Trust think tanks found that public confidence in the health service was at its lowest since polling began in 1983. The difficulty of seeing a GP was the biggest source of frustration. Just 24 per cent of people said they were satisfied with the NHS in 2023, a year of “strikes, scandals and sustained long waits for care”. This had fallen from 29 per cent the previous year and a peak of 70 per cent in 2010. Before that, the lowest satisfaction level had been 34 per cent in 1997, when Labour won a landslide election victory promising to “save the NHS”. The findings underline the importance of The Times Health Commission, a year-long inquiry that published its report last month, a set of evidence-based policy recommendations aimed at reforming the NHS. The British Social Attitudes survey is the gold-standard measure of public attitudes to the NHS, based on the responses of a nationally representative sample of 3,374 people polled in September and October last year. Approval rates have dropped to historic lows for almost all NHS services, including general practice, dentistry and hospitals. Long waits for a GP or hospital appointment were cited by 71 per cent of people as a key reason for their dissatisfaction. Only 24 per cent of the public were satisfied with dentistry, down from 60 per cent in 2019. Half of the people surveyed supported raising taxes and spending more on the NHS, suggesting the state of the health service will be the No 1 issue for voters. Dan Wellings, senior fellow at the King’s Fund and the report’s author, said that, with the general election approaching, “political leaders should take note of just how far satisfaction with this celebrated public institution has fallen”. Conservative voters reported only marginally higher levels of satisfaction with the NHS than Labour supporters — 29 per cent to 24 per cent. The overwhelming majority of those surveyed still supported the principles of the NHS, with nine in ten saying it should be free at the point of use. Wellings said the national sentiment was encapsulated by one patient who remarked that they “love our NHS” but “it’s a bit of a toxic relationship”. Wellings added: “People don’t want to criticise it. They don’t want to be negative about something which has been there for them, for their families, from cradle to grave, for a long time. There’s still a huge belief in the institution.” Rishi Sunak said on Tuesday that rising levels of sickness were a “tragedy”, arguing that they had “been one of the unfortunate consequences of the pandemic”. Asked at the Commons liaison committee whether the upward trend of spending on sickness benefits was unsustainable for the public finances, Sunak said: “Yes. The welfare system needs to be sustainable, so it’s important that we look at this.” He said the proportion of universal credit claimants signed off unfit for any work had tripled in the past ten years, with more than 60 per cent of those undergoing work capability assessments now deemed too ill to look for a job. “I think most people intuitively would think that the country is not three times sicker than it was a decade ago. So that is suggestive of a system that isn’t working as intended,” he said. Arguing that the government was doing “a bunch of things” to get people back to work, Sunak said: “Everyone who can work, I believe, should work, not just because that’s fair to everybody else and helps financial sustainability and gives them financial security, but actually because it can bring that purpose and dignity to people’s lives.” A separate report published on Wednesday shows that the economic and social costs of mental health problems in England have more than doubled in the past 20 years. The report, by the Centre for Mental Health and the NHS Confederation, estimates that poor mental health cost £300 billion in 2022 — twice the NHS’s entire budget in England. Wes Streeting, the shadow health secretary, said: “After 14 years of Conservative neglect, the NHS has never been in a worse state. The last Labour government achieved the highest patient satisfaction in the history of the NHS. We did it before and we will do it again.” The Department of Health said NHS funding would be a record £165 billion a year by the end of this parliament, adding: “We are fully committed to a faster, simpler and fairer NHS, free at the point of need.” Laura Roddy reports 24th March 2024 in the Times: Health service’s spending on costly drugs ‘not sustainable’
Sir, No amount of opinion-polling, however well intentioned, can conceal the obvious fact that the welcome developments in treatment of all kinds, the increase in the UK population, obesity and mental ill-health far exceed the planning assumptions that were the basis of the NHS 76 years ago (“Just 1 in 4 say NHS is working”, Mar 27). This surely demands a non-political review of what the NHS should provide and how it is to be paid for — in other words, we need a royal commission. Peter Williams Croxton, Cambs
The NHS has always been mediocre to poor in terms of measurable medical outcomes regardless of funding or public adulation, says Kristian Niemietz Public satisfaction with the NHS has fallen to the lowest levels since records began, according to the latest edition of the British Social Attitudes Survey (BSA), which was released this week. 52 per cent of respondents are dissatisfied with the health service’s performance, and only 24 per cent are satisfied. This is not supposed to happen in Britain. It is as if a survey among the residents of Vatican City showed that more than half are dissatisfied with the Pope. If I were a professional NHS cheerleader, I would have decided to go quiet for a couple of days, and sit this one out. Yet NHS campaigners have reacted by doubling down. This is not supposed to happen in Britain. It is as if a survey among the residents of Vatican City showed that more than half are dissatisfied with the Pope. If I were a professional NHS cheerleader, I would have decided to go quiet for a couple of days, and sit this one out.
Yet NHS campaigners have reacted by doubling down. For example, the campaign group “Keep Our NHS Public” tweeted: “In 2010 public satisfaction with the NHS was 70 per cent. After 13 years under this govt it’s now just 24 per cent. The NHS isn’t failing, it’s being failed. What an appalling act of state vandalism.”Similarly, Dr Andrew Meyerson, a Corbynite doctor-activist, posted:“In 2010, the NHS was the world’s best healthcare system and satisfaction stood at a massive 70 per cent. After 14 years of a govt-led assault on public health, it’s now 2 per cent%, a prerequisite to force desperate patients into private healthcare.”
Richard Murphy, the “Corbynomics guru” (as the Guardian once described him), wrote on his blog: “The Tories have now defunded the NHS sufficiently to leave it in a state of such chaos that it does not work for too many people, meaning that they are angry with it and are open to change. Bizarrely, the Tories have laid the groundwork for the NHS privatisation that Labour’s Wes Streeting seems so desperate to deliver. […] [N]one of this was an accident. All of it was deliberate.” Both of these claims – that the NHS has been “defunded” since 2010, and that everything was rosy up until that point – are completely untrue. In 2010, public spending on healthcare was 8 per cent of GDP. In 2022, it was 9.3 per cent, which puts us comfortably into the global top ten. In absolute terms, the Department of Health and Social Care Budget has gone up from £134bn in 2010/11 to a little over £185bn in 2023/23, in today’s prices. If that constitutes “defunding”, one wonders what a spending spree would look like. What about the idea that NHS performance was vastly better until 2010? People who make that claim usually refer to a ranking of healthcare systems by the Commonwealth Fund, a US think tank, in which the NHS repeatedly came out on top. But in order to interpret this ranking correctly, we need to have a closer look at what the Commonwealth Fund actually measures. The Commonwealth Fund study is unusual in that it pays relatively little attention to healthcare outcomes. It is mostly concerned with procedures, and polling responses from patients and doctors. It does have an outcomes-related category, but that category only accounts for 20 per cent of the overall result. This means that, hypothetically, it is possible for a healthcare system to have poor medical outcomes, and still be ranked as “the best”. And when I say “hypothetically”, I mean “not hypothetically at all”, because that system is the UK’s NHS. In the Commonwealth Fund’s outcomes category, the NHS has always been ranked as one of the worst systems – even when it still enjoyed North Korean levels of public satisfaction. There was no “golden age” in the past. Not in 2010, and not ever. Yes, the NHS used to enjoy phenomenally high public approval, and top marks in one very particular ranking. But in terms of measurable medical outcomes, it has always been somewhere between mediocre and poor, a fact which even the Commonwealth Fund acknowledges. Record levels of spending have done little to change that. Dr Kristian Niemietz is the Editorial Director of the Institute of Economic Affairs
Hospitals are cynically burying evidence about poor care in a “cover-up culture” that leads to avoidable deaths, and families being denied the truth about their loved ones, the NHS ombudsman has warned. Ministers, NHS leaders and hospital boards are doing too little to end the health service’s deeply ingrained “cover-up culture” and victimisation of staff who turn whistleblower, he added. In an interview with the Guardian as he prepares to step down after seven years in the post, Rob Behrens claimed many parts of the NHS still put “reputation management” ahead of being open with relatives who have lost a loved one due to medical negligence. The ombudsman for England said that although the NHS was staffed by “brilliant people” working under intense pressures, too often his investigations into patients’ complaints had revealed cover-ups, “including the altering of care plans and the disappearance of crucial documents after patients have died and robust denial in the face of documentary evidence”. Behrens urged ministers to overhaul the way the NHS deals with complaints and how the array of regulatory bodies scrutinise it. His concerns included that: Avoidable deaths were too common, especially in maternity care, mental health and cases of sepsis (blood poisoning). The NHS sometimes did “dreadful” and “cynical” things in obstructing families’ pursuit of the full facts about a death, including lying and concealing evidence. The service’s legal “duty of candour” was not forcing hospitals to be open when things went wrong. Although Martha’s rule, which enables families to seek an urgent second opinion if a patient’s condition deteriorates, was a major step forward, bereaved families still struggled to overcome trusts’ reluctance to admit mistakes, he added. In a plea to the health secretary, Victoria Atkins, and the NHS England boss, Amanda Pritchard, Behrens said: “NHS leaders, including ministers, set the tone for the whole organisation. Time and again we hear that patient safety is a priority, but actions too often suggest otherwise. “We need to see urgent significant, joined-up intervention to accelerate improvements in culture and leadership, not just in trusts or primary care, but also in NHS England and government. “Culture is determined not only from the core of an organisation but also from its top leadership.” The ombudsman voiced alarm at the recurring pattern of hospitals intimidating whistleblowers rather than taking their concerns seriously. He cited University Hospitals Birmingham trust for referring 26 of its medics over 10 years for alleged misconduct to the General Medical Council, which regulates doctors, in an apparent attempt to punish them for raising concerns. None were found to have committed any wrongdoing. The trust’s board and regulators should have acted earlier to tackle the trust management’s “disgraceful” behaviour, which was well known in the NHS, Behrens said. The Health Service Journal reported last week how North Tees and Hartlepool NHS trust had been told to pay the surgeon Manuf Kassem £431,768 in damages for racial discrimination and harassment he encountered after he told bosses of his fears that patients had “suffered complications, negligence, delayed treatment and avoidable deaths”. Last year the same trust had to pay £472,600 in compensation for unfair dismissal to another whistleblower – a nurse – who warned that a patient had died as a result of heavy workloads. James Titcombe, the chief executive of Patient Safety Watch, who did not get a full explanation for 17 months after his son Joshua died in 2008 of sepsis at nine days old, said he endorsed Behrens’s concerns. He said research had found that tens of thousands of avoidable deaths occur in the UK every year because safety standards are lower than in other countries. Paul Whiteing, the chief executive of the patient safety charity Action Against Medical Accidents, said the Countess of Chester NHS trust’s failure to act on doctors’ concerns about the serial baby killer nurse Lucy Letby – including forcing them to apologise to her for doubting her integrity – was an example of Behrens’s charge of “reputation management”. Last year, a third of NHS personnel during their work saw errors, near misses or incidents that could have hurt staff or patients, according to the latest annual NHS staff survey, he added. Responding to Behrens, an NHS spokesperson said it was “absolutely vital that everyone working in the NHS feels they can speak up and that their concerns are acted on. “The NHS has updated its freedom to speak up guidance [and] brought in extra background checks for board members to prevent directors involved in serious mismanagement from joining another NHS organisation. “As the ombudsman is aware, there have been major efforts to prioritise patient safety in England and progress in creating a more positive safety culture amongst the workforce, which has led to higher levels of patient safety incident reporting than ever before and a widespread focus on improvement, including through the new patient safety incident response framework.
A Department of Health and Social Care spokesperson said: “The safety of all patients is of vital importance, and we have made significant improvements to strengthen protections for patients including publishing the first NHS patient safety strategy. “We are determined to make the health service faster, simpler and fairer. We are putting record levels of investment into the NHS, and training and retaining staff through the long-term workforce plan to properly resource our NHS for decades to come.”
Sunday Times letters 10th December 2023: Fear of hindsight paralyses public service Matthew Syed’s excellent article ( Grovelling to wokeism has tipped our universities into an ethical void The Times 9th December 2023) should become required reading for any judge, KC, independent investigator or “victims” group before they are allowed to start picking over the complex and at times split-second decisions of others (“Hugo Hindsight KC is doing a grand job knifing hapless public servants”, Comment, last week). The tyranny of hindsight is not confined to public inquiries into Covid and the like: Sir Mark Rowley has rightly criticised this trait in the decisions of the Independent Office for Police Conduct. After the passing of the Freedom of Information Act, both Jack Straw and Tony Blair lamented that they had gone too far. We are at risk of public-service paralysis: officers and officials petrified to act for fear of being forensically second-guessed in five years’ time. We will all suffer for this; but it is a scenario we have wished on ourselves. James Morgan, former police superintendent, Kings Ripton, Cambridgeshire
Doctors tied up Sadly, Syed’s “knifing of public servants” is as endemic in other areas of public service as it is in politics. In my own field of healthcare, clinicians are hamstrung by the need to future-proof all their consultations to avert the, albeit rare, chance that they might appear in front of an omniscient barrister. More time is expended on extensive, self-justifying record-keeping than on managing the patient’s concerns — one reason improved productivity has been so hard to achieve in the NHS. Dr James Sherifi, Stratford St Mary, Essex
Answers for the bereaved Recalling past events is not difficult if they are minuted, unless of course that consists of WhatsApp messages that have been inexplicably lost. As for civil servants being hapless, that is precisely the reason the inquiry was convened in the first place: to establish why. The Covid 19 inquiry, which is proving so embarrassing for Boris Johnson and his government, is offering bereaved families exactly what was intended: the pursuit of integrity and accountability. Ann Shilcock, Granada, Spain
Debate silenced I found myself entirely in agreement with Syed’s remarks. As a long-retired civil servant who participated in many group meetings, although hardly of the same national importance as the ones attended by Mark Sedwill, I join him in his prediction of how emasculated future meetings will be. Those Covid inquiry prima donnas have a lot to answer for. David Houghton, Hastings
The reasonable request for the truth when things go wrong is perversely argued by the lawyers, because litigation will rise. Only a “no fault compensation” act could deal with this and create the honest cultural change needed for a duty of candour to be meaningful. Meanwhile an even greater problem is brewing. As standards fall do physicians have a duty to point out the non health service alternatives? James Titcombe in the Health Services Journal 9th December 2023: Patient Safety Watch: ‘Being candid about candour‘ – Duty of candour to be reviewed The Department of Health and Social Care has announced a review into the duty of candour. The duty – also known as “Robbie’s Law” – has been in place for NHS providers since 2014 and for all other Care Quality Commission-regulated providers since 2015 and is set out in regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Parliamentary and Health Service Ombudsman Rob Behrens welcomed the announcement, saying: “Despite it being a statutory duty to be open and honest when things go wrong with a patient’s care, I know from the cases we investigate that this doesn’t always happen. Patients and their families deserve better.” My view? It’s now almost a decade since duty of candour came into force, yet as Mr Behrens highlights, a lack of openness and honesty when things go wrong sadly remains a theme in far too many cases. A process that takes a hard look at what more can be done to change this is welcome but the key to success is likely to go beyond any statutory duty on its own. Fostering a culture that supports openness and honesty in healthcare is a complex challenge that requires all parts of the system to pull in the same direction. Regulations and punitive levers will only ever have a limited impact. We also need to look at pre-registration education, leadership and the role of the wider system (including litigation, regulation, coronial and criminal systems) and how these can better support the wider culture change needed. I’d also like the review to consider whether the statutory duty should be extended to require healthcare providers to share information about known patient safety risks and problems with patients, families and communities proactively. If such information was shared openly (rather than sitting on internal risk registers), perhaps patients and their families would be empowered to make more informed choices about their care and to be active participants in their safety.
I contend we need to give “hard truths” on many issues, including health We need to redefine what the 4 health services are for, and where/ for what services patient autonomy is more important than state paternalism . We can reinvent the wheel or we can copy a service that works already. NZ, Australia and Canadian states are relevant models, as is most of the EU . Liberal conference has always ducked “hard truths” but the nation is ready for them. ID cards will follow seat belts as essential..and reluctantly accepted ID cards (virtual and physical) will allow means tested copayments for all healthcare whilst standards rise from the current nadir . During this period the two tier system has to be reluctantly accepted, until we choose our model(s). John Britnell was unable to mention “rationing” and unable to choose between systems as various had some parts that were better than others. In John Bretnall’s book, “in search of the perfect healthcare system” he acknowledged that some bits could be taken from different systems (mental health from Holland?) But he fails to use the honesty of ” rationing”. There is no government that can keep up with the cost of all new technologies, treatments, advances, and therefore rationing is essential. The shape of my former job as a GP has changed beyond recognition since 1976 when I began. (see graphic below) . The young doctors in GP training realise that their reality will be very different from the taught theory implying long term relationships and advocacy with a varied day. So they have the options of a different UK medical career, going to another country with their well respected degree, or changing to a different career. For someone used to handleing complexity and multi tasking there are many more attractive opportunities. ( see second graphic below). Yes the waiting lists may be long in Southend, but they are longer in Wales!
It is a “hard truth” that very few child graves are evident in graveyards after 1952, When did vaccination start? It is evident that good dental care has reduced the incidence of Heart Valve Disease and untreatable oral cancer. Both these are likely to increase in the years ahead as access to NHS dentists becomes harder and harder. It is evident that cancer survival has increased, for most common and some rarer cancers. It is probable that Cancer Cervix will kill far fewer people, but this will be due to the HPV vaccine more than to cervical screening. The same may be true in 10 years time for Cancer Breast. How to we tell the “hard truth” that its time to disinvest from, or charge for, some screening services? How do we address the lack of progress on sepsis over a decade? How do we reinstate the Public Health system that would have helped prpare and deal with a pandemic better? How do we reinstate post mortems: the truth is out there but we wont find it out. How will we make junior doctors feel valued and stay in the UK, and how will we make oldies feel they want to work on in the interim? How can we manage a service divided into 4 with different rules and it be fair? How can we reduce the cost of the last year of life? How can we bring back choice? How can we reduce gagging and increase whistleblowing, and be honest about near misses and significant events? How can we bring back teams and improve training standards back to whatb they were before EU working time directive was so aggressively implemented? How can we reduce tribalism in maternity care, ensuring consultant led care for all mothers in an ageing demographic with high risk? How do we make young people feel their vote counts? How do we depoliticise health so that its not an issue at each election? How do we manage waiting lists fairly and avoid a two tier system which does not have the consent of the people? How do we get honest politificans to debate the above issues? How do we get fewer jokers and chancer/gamblers putting themselves forwards as politicians? How do we stop the abuse and trainign degradation of trainee doctors? How do we get meaningful exit interviews and feedback, from all employees and patients, including commissioners and board members? nd Am I in Wales still part of a National Health Service?
The Sunday Times leader 12th November 2023: As the NHS waiting list keeps growing, our leaders keep quiet -No one is addressing that millions are waiting for operations Thursday’s news that the NHS waiting list had hit yet another record high, with 6.5 million patients needing 7.8 million operations, was the latest data point on the road to a dystopian reality. But, as we have noted before, it was barely acknowledged by a political class that has long since switched off when the subject of healthcare reform is raised. Our data editor, Tom Calver, visited Southend, the conurbation in England with the highest number of operations needed per capita. His report includes comments from a 64-year-old man who could barely walk by the time he got a hip operation on the NHS. “I think they delay saying you need the op,” he said. “I had a scan, and was told they would ring me in six weeks. I waited — delay, delay, delay — until I rang them and they said, ‘Oh no, you were supposed to call us!’” The degradation of trust in the NHS, which consumes almost 40p in every pound spent on public services, is dangerous. We are tacitly moving towards a system in which the wealthy pay to go private for scans or surgery while the less well-off are left to suffer in silence. Steve Barclay, the health secretary, has been preoccupied with procuring more beds in care homes to ease the strain on hospitals, setting out a much-delayed NHS workforce plan and holding the line in pay disputes with striking doctors. Wes Streeting, his opposite number, speaks sense about boosting primary care, preventing illness instead of simply treating it and reform rather than blank cheques. But both parties are falling well short of providing the detailed answers Britain needs. Another data point arrived on Friday, showing the economy was flat in the quarter to September. With little growth and the tax burden already so high, the pips are squeaking. Creative thinking will be needed.
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