Even Can-kickers Need a Road Map

First published in the NASGP Newsletter on 25th January 2023

“Falling ill made me realise the true wonder of the NHS.” So said media medic Dr Xand van Tulleken. Many voters in need of treatment feel the same. So, it’s a view to which most politicians subscribe. But they are reluctant to face up to how much it would cost to restore a service starved of money for more than a decade.

Only Tony Blair’s government has in recent times put significantly more money into the NHS. Not all the investment and changes worked, but for a few years patients got better treatment, and staff too. But since 2010 the NHS’s social capital has been squandered and the workforce shredded and demoralised.

There are three elephants in the House of Commons: Brexit, social care, and a workforce plan. They rub shoulders, but we’re in the workforce, so let’s consider that.

Governments keep on postponing a long-term Workforce Plan. But even to kick a can down the road you need a road map. Where are we heading? As the peasant leaning on his hoe said to the motorist asking for directions, ‘I wouldn’t start from here’.

Hospital doctors can’t do their job without nurses, and most GP practices would struggle without practice nurses. So when nurses leave, doctors leave.

In 2011 applications for nurse training exceeded the places available. So, despite warnings about a future staffing crisis, the government cut training places. Then in 2016, George Osborne abolished bursaries. Applications plummeted. Now there are more than 50,000 nurse vacancies, meaning more than 10% of UK nursing jobs are unfilled. Meagre pay increases and inflation mean that many are working one day a week for free on punishing rotas in understaffed wards. You can get better pay and work better hours in a supermarket. No wonder thousands of nurses leave the NHS every year.

In 2015 Secretary of State for Health Jeremy Hunt promised 5,000 more GPs by 2021. He recently claimed that the 3,500 new GPs who materialised equalled success, but he admitted that he hadn’t anticipated that so many others would leave general practice. Did he not listen to his department? And of his ‘new’ GPs, many are trainees. One in eight of these told the BMA they had no intention of working in general practice.

Of more than 350,000 doctors on the UK GMC register, twenty percent – around 70,000 – are GPs. But the number of full-time equivalent GPs working in England is estimated to be less than 30,000. Practising GPs still enjoy seeing patients but 42% expect to quit in the next five years because the working environment is oppressive. So areas of the country are bereft of adequate primary care.

Hospitals are no better off. The massive financial penalties for continuing to work when your pension pot has reached the threshold is the last straw for some consultants, and no longer being able to afford private education for their children is a deal breaker for others. Nearly 10,000 specialists gave up their licence to practise last year. Fifty percent will not be replaced – advertisements for consultants may get no applications at all.

Around 1000 newly qualified IMG GPs receive their licence to practise and a deportation order in the same post.

The GMC foresees that the gap will be plugged with International Medical Graduates (IMGs) taken on in Specialty and Associate Specialist posts and as Locally Employed doctors. Yet, a visa anomaly means around 1000 newly qualified IMG GPs receive their licence to practise and a deportation order in the same post. Recruitment agencies, often abetted but never monitored by the government, have websites which feature glowing accounts by smiling doctors. While the GMC reports that the reality is ‘rudeness and incivility, and belittling and humiliation’, often racially motivated.

How very depressing that we treat the staff on whom the NHS depends so shabbily. A bit of human consideration could make a huge difference. Hospitals could provide decent hot food 24 hours a day, childcare, a collection facility for Amazon deliveries and transport home at hours when public transport is unavailable or risky. The government could quickly resolve the pension problem and comms teams should be challenging anti-GP headlines in the right-wing press.

Every few years since the NHS was founded in 1948, someone has decided it would work better with a shake-up. You have probably lived through at least one, maybe three or four of these seismic shifts. Every change is massively costly and disruptive. Each may aim to improve whatever problems triggered the restructuring, only to create new obstacles. A few years later, someone will have another bright idea . . . in 2011 it was Andrew Lansley’s turn. Predicted problems rapidly surfaced and his reorganisation has been unpicked bit by bit until this year, when the government totally dismantled it.

Few patients understand the significance of these reorganisations. They just want good treatment available locally without avoidable delays.

Even if we can create enough medical schools to grow our own doctors, it will be years before they join the workforce. Can we fill the gaps with overseas doctors? Saves us paying for training, too. Brexit has made EU doctors feel unwelcome, so a fortune is being spent trying to lure staff from outside Europe. It’s immoral as well as illegal to poach staff from countries on WHO’s Red List, but taxpayers’ money is being spent finding loopholes around the law.

Given that there aren’t, and never will be, enough doctors and nurses in the world to meet demand, it is a credit to the ideals of the NHS that it has attracted staff from over 100 nations. Teams from more than half the UN member states generally work together with surprisingly little friction. But all feel ground by the millstone of government pressure from above and an inexorable workload from below.

Some people advocate turning the NHS into an insurance-based system. They quote someone they know who has had prompt and brilliant care in France or Germany. They don’t talk about those who have been unable to afford premiums, or cannot access care because their local hospital has gone bust, or the rationing or cuts to other services that government-backed insurance systems have to make.

Government-initiated reorganisation has rarely been more effective than changing deckchairs on the Titanic. But faced with the pandemic, NHS staff pulled together to reconfigure services and everyone including managers and consultants stepped out of their silos, rolled up their sleeves and joined the work gang. ‘Self-assembly’ produced effective and rewarding results but has proved hard to sustain once the pandemic crisis had blown over.

So, we are left with tinkering. We can improve working conditions, use IT to save staff time and money, ‘build back better’ locally by changing the way things are done. We can make jobs more interesting and offer opportunities for career development; we can streamline training (you don’t need to train for seven years to extract cataracts safely). Specialist nurses, link workers and care-co-ordinators have integrated effectively into the workforce, though other new roles such as ‘Digital Healthcare Scientists’ haven’t had time to demonstrate their function. We can reintroduce cottage hospitals. We can support pressure groups tackling the wider determinants of ill health.

We should not have to start from here, but here is where we are, and we need a direction. Where’s that can and where are we heading?

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