In 2005, I was just starting to be released onto the wards in the third year of my medical degree. One of the dullest weeks focused on orthopaedic surgery. The operations were life-changing for the patients but struck me as a sterile version of Meccano. The techniques were ingenious, but their application to a conveyor belt of patients felt depressingly repetitious. Give me a knotty, intractable problem to tilt at (and fail to solve) any day.

The specialty wasn’t right for me, and I wasn’t right for the specialty: I have neither the ego nor the bravado to be an orthopaedic surgeon. I sincerely hope things have moved on in the past two decades, but the male orthopaedic surgeons’ changing rooms were Lynx-Africa, Page-3, clothing-on-the-floor hellholes ripped from straight from a sleazy gym. No thanks.

My over-riding memory of that week, though, is not the surgery: it’s a specific patient. She was in her late 80s, she lived alone, and she was fiercely independent. She had never married and was proud of the fact: woe betide anyone who prefixed her surname name with ‘missus’. She had fallen a couple of years previously and broken her hip. She was in hospital because, unfortunately, the nail which was holding her femur together had fractured following another fall.

I met her shortly after her admission, when I was allocated to her to practice my history-taking and examination skills. We fell into a long chat about her fascinating career, an area of work I knew (and know) nothing about.

One thing she was keen to tell me was how ‘miraculous’ the NHS was. She grew up in a poor household. She talked about her experience of TB in her youth, and of being isolated in a charitable sanatorium with no contact with her family for months on end. She talked movingly about one of her younger brothers becoming very unwell when she was a teenager, her parents being unable to afford to call a doctor and having instead to seek help from the church. Her brother died, having never seen a medic.

I remember going with the occupational therapy team to see this lady’s house: a standard part of their practice to see what home aids she might require, or what trip hazards might be lying around. The house was immaculate, not a thing out of place. I could scarcely believe that someone in their late 80s could keep a house so beautifully.

Her surgery turned out to be more complicated than was initially expected. The broken nail proved difficult to remove—by virtue of being broken, it couldn’t just be cleanly pulled out of the hole it had been driven into. Once it had been quite traumatically extracted, the patient required a plate to be screwed in to hold her femur together, with something like a dozen screws. It wasn’t a light undertaking, and this lady ended up spending quite some time in intensive care.

By rights, my story should end there: I moved onto other training weeks. But I kept popping back to see this lady. Every time I saw her, without fail, she talked about the ‘miracle’ of the NHS. She talked about how, when it was first introduced in her twenties, people were terrified to call a doctor as they couldn’t believe there would be no bill. It took a long time and countless leaflets and word-of-mouth until people really trusted that they could use the service. She talked more eloquently than I ever could about how it transformed the life chances of those around her: how gradually, over time, illness came to lose its life-changing significance, and became more of an irritation than a life event. She lamented the loss of her brother.

She talked, too, about her concern for the future of the NHS. She thought that those who hadn’t lived without it didn’t appreciate it. For some reason or other, NHS waiting lists were in the news at the time. She saved a newspaper clipping for me, and when I went to visit, remonstrated with me: why did these people not realise how lucky they were to be on a waiting list for free care? Would they complain if they were on a waiting list to win the lottery? People won’t realise what they’ve got until it’s taken away again.

Over the course of about six weeks, her tenacity and drive—plus support from nurses, physiotherapists, occupational therapists, and pain management specialists—resulted in a truly astounding recovery. My last memory of her is of her being wheeled off the ward—backwards, for some reason—with a massive grin on her face, arms waving in the air, thanking everyone she passed (even the other patients). Remarkably, she was going back to her own home, to continue living independently.

Clare Gerada, the president of the Royal College of GPs, once wrote:

One cannot see patients, day in day out for years, without being profoundly affected by this experience and the struggles we witness. Even now, as I write this chapter, I see the faces of my patients and hear their words, some long deceased. I see their ghosts as I walk my dog, shop in the supermarket or walk past their old homes. Many of my patients still live in my mind.

I agree, and today—the 75th anniversary of that day in 1948 that this patient remembered so well—this patient is making her unique presence very well known to me.

Of course, her reflections aren’t really about the NHS as it is currently structured: her point is about the value of care which is free at the point of use, funded through general taxation. Politicians like to politic about the specifics: organisational structures, social insurance models, completely free care¹ versus co-pay models, the level of involvement of the private sector. At it’s founding, NHS hospitals were made into a single organisation. These days, there are countless separate organisations, many operating in competition with one another, mostly on the basis of finance rather than quality of patient care.

But sometimes, and particularly on an anniversary like this, it’s worth taking a step back and realising what we’ve got: the NHS is a miracle. We shouldn’t forget that it wasn’t always like this, and won’t necessarily be like this forever.

The NHS is under extreme pressure at the moment: it feels like it’s falling apart in front of our eyes. But at least we still have an NHS which strives to deliver its founding principles. Sadly, these days, political rhetoric around the NHS has become entirely about patching it up, about making it live within its means—as though those means are not entirely determined by us.

How wonderful would it be if we used the 75th anniversary to invent the same thing for social care? To have the vision to say “the whole of society will take the risk” instead of the individual? To proceed with visionary boldness to meet the need, not balance-sheet-driven timidity. To prioritise compassion over efficiency.

My birthday wish for the NHS is that, perhaps, we’ll have moved in that direction before it reaches its century.

1. We don’t have completely free care in England: there are prescription charges, dental charges, optical charges, and so on and so forth.
   

The image at the top of this post was generated by Midjourney.

A couple of years ago, I wrote a post for the Fuse Open Science Blog about the system failures which lead to patients ‘inappropriately’ presenting at A&E, and how this is often blamed on patients who are expected to self-triage with a high degree of accuracy. I’ve thought of this today because it popped up in my Facebook ‘memories’.

This has prompted a couple of completely disconnected thoughts.

My first thought is that what I wrote then remains true today, and has become even more relevant with ever-increasing pressure on NHS Trusts. Effective triage of patients to the ‘correct’ NHS services is a nut that remains stubbornly uncracked.

More money has been ploughed into putting GPs in A&E departments, despite mixed evidence on cost and patient throughput. Some companies are experimenting with triage chatbots for the NHS which feels to me like an unlikely solution to the problem of sorting acutely unwell patients. The NHS Choose Well campaign keeps steaming ahead at various levels of the NHS as though doing more of the same will result in a completely different outcome.

Anecdotally, clinical colleagues tell me that last winter was ‘better’ than others in recent years, in as much as A&Es were over-filled with patients who should be there rather than patients who shouldn’t be there. Of course, that means departments are more pressured. Perhaps the fear of long waits and ‘chaos’ puts off ‘inappropriate’ attendees. I’m certain that it puts off some ‘appropriate’ attendees and that this will, at least in a very small way, have contributed to excess winter deaths for 2017/18.

My second—unrelated—thought is that I have absolutely no memory of writing or publishing that Fuse article. I mean, I know I wrote it, but I have no memory of constructing it, or of looking up the stuff about Joseph Hodgson and drawing a parallel between misuse of historical charitable hospitals and the modern NHS.

I’m always bad at remembering things I’ve worked on in the past, but to have such a complete absence of any memory for something I wrote (and clearly put thought into) only 24 months ago is remarkable even for me.

I can only assume I was knackered when I wrote it… which would also explain the slightly crap call-back pun in the last line. I can see what I was trying to do, but reading it now, I think it slightly missed the mark.

The picture at the top is a cropped and edited version of a photo published on Flickr by gwire. I’m using it under its Creative Commons licence.

There are roughly half a million beds in residential or nursing care homes in the UK.¹ Private providers operate almost all of these beds (90%) though the sector isn’t particularly lucrative: the average operator draws a profit of less than £5 per resident per day. Most beds are funded either in full (40%) or in part (10%) by local authorities. The NHS pays for a few (5%).

Central Government funding to local authorities was cut by 25% per person over the period of the last Government, though these cuts were not uniformly distributed across the country. This came on top of smaller reductions in funding over the previous five years. As a result, local authorities had much less to spend on social care. The number of day care places plummetted by 50% over a decade. About 20% fewer people received local authority funded care in their own home. And, partly as a result of this, the number of older people in residential or nursing care homes rose by more than 20%.

Over the next five years, we will see a perfect storm in social care for elderly people. The number of people aged over 75 is predicted to grow from 5.3 million today to 6.1 million in 2020 (a virtually unprecedented rate of increase, almost double what happened over the last five years). Yet Central Government funding to local authorities is to be cut further. Funding is being reduced while demand is predicted to increase more than ever before.

The burden will fall on the NHS, as it is in NHS beds that people often wait for care home places. The absurdity of this is that the average per-night cost of staying in an NHS hospital is three times greater than the average care home cost.

Yet there is another insidious factor imposed by Government which will push this situation from ‘substantial problem’ to ‘perfect storm’.

Most workers in residential and nursing care homes are paid minimum wage. By 2020, this will rise fromt £6.50 to £9.

Few could argue with giving hard-pressed workers a living wage. But given that average care home profits are less than 21p per patient per hour, care homes cannot maintain their current charges while increasing staff wages by £2.50 per hour. Yet they cannot raise their fees because Government cuts mean that local authorities can’t pay.

So what happens when care costs increase and funding decreases? First, care is cut: HC-One, Britain’s third-largest care home provider, is already training carers to take on highly skilled tasks which were previously done by more experienced and expensive nursing staff. But, since the cost of those carers is also increasing rapidly, this is only a stop gap solution. As Southern Cross, previously the UK’s largest care home provider, showed in 2011: care home providers can and will collapse.

As care home companies collapse, the supply of care home beds collapses with them. More elderly people get ‘stuck’ in NHS beds, at much greater cost to the taxpayer, and much greater risk to their own health.

And, to add extra thunderbolts to the storm, the number of NHS beds is decreasing rapidly: by nearly a quarter over the last ten years, with no sign of slowing. In this context, an increase in elderly people needlessly occupying NHS beds due to a lack of social care will cause the NHS to grind to a halt.

The underlying problem here is that the Government fails to understand that protecting NHS funding does not protect NHS services. Health and social care are two arms of the same beast: cutting one leaves the other with more to do. Yet the long-term solution isn’t obvious: there are limits to the burden of tax people are willing to carry to fund health and social care services.

The forecast is for bigger storms ahead.

A number of politicians have recently made absurd statements about the role of the market and profit in healthcare, and specifically in the NHS. In political terms, the two worst culprits are the Labour Party and the National Health Action Party.

When the Labour Party left office in 2010, data¹ showed that roughly 5% of NHS procedures were carried out in the private sector. Under the current Government, as of the most recent set of statistics, this is roughly 6%. It’s just worth bearing those proportions in mind whenever you hear Labour pontificate on the role of the private sector in the NHS. But I digress.

In his Party Conference speech, Andy Burnham asked:

And for how much longer, in this the century of the ageing society, will we allow a care system in England to be run as a race to the bottom, making profits off the backs of our most vulnerable?

I’ll answer that question in a moment. But to illustrate that Burnham is not alone, let us turn to the National Health Action Party.

You may not have heard of the National Health Action Party: it is a well-meaning but misguided Party whose platform—to defend and improve the NHS—is as vague as it is logically flawed. Dr Richard Taylor, co-leader of the party, was previously an MP; he signed an Early Day Motion in support of homeopathy, and praised the use of acupuncture and reflexology in cancer treatment. To date, the party has contested and lost nine elections² with their best result being a 9.9% share of the vote for a single council seat in Liverpool. Again, I digress.

In The BMJ, in reaction to the news that Circle Health plans to withdraw from its contract to run the Hitchingbrooke Hospital in Cambridgeshire, a National Health Action Party representative said:

This perfectly illustrates the difference between the private sector, which seeks profits, and public NHS Trusts … This shows exactly why the market has no place in healthcare.

So, you ask me, what’s wrong with those quotes? They seem like perfectly sensible sentiments to me!

Both of these quotes are simply nonsense. Neither the Labour Party nor the National Health Action Party are campaigning for the removal of profits and the market from the NHS—and nor is anyone else.

Any modern business, be it a hospital or fishmonger, is reliant on suppliers who will draw a profit. The NHS doesn’t manufacture its own light bulbs and baths, nor generate it’s own electricity,³ so people will draw profit from supplying them.

Alright, you might be saying, but that’s not really medicine, is it?

But of course, profits are made on medicine too. Sure, the NHS could manufacture all the medicines it needs—it already manufactures some.⁴ But many medications are under patent. Are NHS patients to be prevented from accessing patented drugs? Of course not: so companies will draw a profit. And the more sick people there are, the bigger the profit there is to draw.

OK, you say, but medicines are a special case.

Except they’re not. Almost every product used to deliver healthcare—from syringes to catheters to implants to surgical tools—will generate a profit, as it is almost all bought in from commercial manufacturers.

Come now, you say, supplies are a red herring. I’m interested in healthcare—a human caring for another human. There’s no profit to be made there!

Oh, but there is. Management of human resources is a tricky business. Often, Trusts will hire in external experts to help with training, planning or management, many of whom will work for consultancies which make a tidy profit.

Everyone knows human resources officers aren’t human, you intone—though I couldn’t possibly comment, I’m talking about a nurse looking after a patient at the bedside. Where’s the profit in that?

The scenario you describe is just dripping with profit—from the agency that recruited the nurse, to the profit on the manufacture of his uniform, to the cut of his pay which goes to the nursing agency he’s working for, to the cut of his car parking fee which is given to the private company managing the facility.

Ugh. You do go on a bit. What’s your point?

Suggesting that the NHS be removed from the commercial market and freed from the pursuit of profit is nonsense. Of course, the internal market in which NHS providers compete with one another could be reformed or removed, but the NHS is involved in a wider external market which is here to stay. The NHS is one of the country’s biggest purchases of goods and services, and each supplier will be doing the best they can to—effectively—profit from the sick.

Even if, for the sake of a thought experiment, we say that the NHS could be isolated totally from the battle for private profit, the end result in terms of the health service alone might not be that different: there would be continual pressure to reduce costs to the taxpayer, which is effectively the same financial pressure as increasing profits to shareholders.

The true argument is about the extent of involvement of the private sector.

Consider privately-employed doctors. Would we trust doctors to the same extent if we knew their interests balanced our interests with profit potential? This isn’t something we have to treat as a thought experiment: most GPs are small businesses and work on exactly this principal with little discernable effect on levels of trust. But, again, it feels icky.

Consider private sector management of whole NHS hospitals. This might look like a step too far: it takes a layer of previously publicly-funded management, who perhaps tried to balance the drive for profits with the best interests of patients, and moves them to the profit-hungry private sector. Yet, the management would always be accountable to commissioners, who would be looking out for the patients: so does it really matter? Perhaps not from the conceptual standpoint—but I’ll admit that it makes me more than a bit uncomfortable. And while a sample size of 1 makes for a poor trial, the fact that the first hospital so-run has become the first hospital to be rated as “inadequate” on patient care does not feel reassuring.

Consider public health campaigns teaming up with well-known brands. Is it okay if public healthcare money inflates Aardman Animations’s bottom line, if using Aardman characters is a good way to get health messages to children? I’m not sure: evidence about cost-effectiveness could sway me one way or the other.

Wouldn’t it be wonderful if we could have a debate on these issues that’s based in the real world, rather than the five-word soundbite world? Wouldn’t it be great if politicians would describe the extent of private involvement in the NHS that they believe to be appropriate, and we could then vote for the Party whose ideas most closely align with our own? Wouldn’t it be peachy if our politicians would stop patronising us all and treat us like adults?

As I said in my last post, the current model of delivery for the NHS is unsustainable. This is a problem that needs statesmanship, cross-party exploration, and—most importantly—tackling by adults.