Changing the conversation about health

Discussion Paper: Future Direction for the NHS – Reconnect, Revise, Restore

Dr Michael Dixon and Dr Sam Everington, Chair and Vice Chair respectively of The College of Medicine, have authored a new discussion paper on how to fix and future protect our healthcare system…

Image: Pixabay/Geralt

What are the problems that we want to solve? 

Deteriorating life expectancy, 60% of the population overweight or obese, one in five adults on antidepressants and a significant increase in mental health problems in children from 12-17% in the last 5 years.  Also, loss of staff good will and discretionary effort and an NHS bureaucracy that has disengaged clinicians from the financial system and from population health management.  Increasing waiting lists for primary and secondary care (7.5 million).  Loss of around 20,000 doctors from the NHS last year alone, industrial action and lowered NHS productivity.

The College of Medicine believes that the NHS’s problems are rooted in disconnection and overregulation.  Clinicians in training today are disconnected from their geographical areas, from other clinical staff and from the patients and wards that they care for. This disconnection and a feeling of not being valued continues in their early clinical years resulting in them having little affection or loyalty for an NHS that hasn’t cared for them.  They live in fear of litigation within a blame culture where autonomy and independence are squashed by overregulation with their work dominated by restrictions and financial incentives. 

The College believes that integration is the answer – integration of clinicians in their early years with their communities and within a supportive continuing team. 

Integration of medicine with health, self-care and the needs of the community.  Particularly so as only 20% of a patient’s health and wellbeing comes from traditional services within the NHS.  The other 80% is about connection to family, community and nature, about physical activity and good food, about connection with nature, job, education, the environment and creative and spiritual needs. 

The College also supports a greater emphasis on personal care that better respects the professionalism of the clinician, the perspective of the patient and their mutual and crucial role in personal care and health.

How do we fix them?

RECONNECT YOUNG DOCTORS AND DOCTORS IN TRAINING WITH THEIR TEACHING HOSPITALS AND THE NHS 

SOLUTION: Restore the “firm” (Team) of Consultant, Registrar, Senior House Officer and F1/2 with mutual respect, support and accountability so junior doctors don’t feel beleaguered. Virtually every one of the multiple maternity reviews in recent years has labelled poor team work as the major cause of failures.

Restore basic privileges that should be available to junior doctors working all hours – e.g. dining facilities, car parking and facilities for rest when on call. Recruit medical students geographically so that they can train and then practice in their own communities, (research show that the major determinant of recruitment and retention is where someone was brought up and where they were trained). Provide financial assistance for medical education in return for a minimum period of NHS service.

Recreate a system that appoints F1/2 doctors on the basis of merit, enables senior doctors to lead and support their teams and offers choice with preference to doctors who have been bought up and trained locally.  For general practitioners, establish in time a system of training that is based within general practice supported by hospital input rather than based in hospitals with GP input.

TACKLE OVERREGULATION 

The NHS is vastly overregulated with consequent loss of productivity and demoralisation of clinical staff.  Statutory training, to take an example, is expanding unchecked, reduces time that clinicians spend with patients and leads to loss and early retirement of clinicians, who are fed up with having to jump through hurdles that they feel to be unnecessary.  Statutory training should be replaced by a face-to-face team learning and protected learning time to learn as teams.  

Overregulation is also a cause of long waits. The productivity (e.g. operations per day) of surgeons for instance, is vastly reduced in the UK compared to many other countries because of organisational and bureaucratic inefficiency and is a cause of frequent cancelled operations and surgeons wishing to work elsewhere.  The problem arises from many origins – CQC, NHSE, HEE (which is now NHSE), GMC etc… 

SOLUTION: Create the equivalent of a Cabinet Committee on NHS Bureaucracy, which includes those that can explain the problems from the frontline (and empowering departments to challenge the system) and those that can activate solutions by negotiation with all relevant departments.

RESTORE STRONG GENERAL PRACTICE AND PUBLIC HEALTH 

The World Health Organisation has shown that investment in primary care as compared to secondary care leads to less deaths, better health and reduced costs.  Against this, the NHS spends proportionately less on general practice year on year with a reduced number of GPs, while workload and the number of appointments has disproportionately increased. 

This not only leads to burn out and long waits but also to loss of personal care and continuity, which has been shown to reduce prescribing, hospital use and also to improve health and reduce costs.  A recent Norwegian study on continuity of care showed it produced a significant increase in the pickup of cancers and other life-threatening conditions.

SOLUTION: If NHSE/ICBs prove unable to reverse the increasing investment in secondary over primary care then earmarked funding for primary care may be necessary – albeit on a temporary basis.  General practice funding streams themselves also need radical overhaul moving from the purely biomedical towards a more psychosocial (outcomes) model that better supports personal self-care and improved health and connects to initiatives to improve the health of the surrounding local community.  

FINALLY, THE SOLUTION IS NOT JUST MORE HOSPITALS, MORE GP SURGERIES, MORE DOCTORS AND MORE NURSES 

For instance, what is the point of training more GPs, when there are now unemployed doctors in general practice because primary care has insufficient funds to employ them. Or is there any point in creating training places when we are haemorrhaging expensive fully trained doctors. Golden handshakes and similar have not worked historically and failed to sort the underlying problem.

During Covid some of the weight of regulation in general practice was lifted without any ill effects and then restored afterwards without any good explanation. Today is an opportunity for renewal and many of the suggestions above would actually save rather than cost money. 

The NHS will not survive long term without radical long-term solutions that address the fundamental and long-term problems that contribute to the unhappiness of patients and staff alike. 

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