An excellent and clear summary of the issues. I look forward to reading the main report. I have worked in and alongside the NHS for over 30 years - as a Chief Executive (FHSA, DHA, HA, SHA) and a Director of the NHS Modernisation Agency, leaving to become an independent consultant after one too many heaves of the Magic Roundabout of reorganisation. I would add some additional reflections.
Almost all reorganisations in the past 30 years have been shifting the commissioning/regional national Arms Length Body landscape - performative policy making allowing it to seem that something is being done when in reality it has made little difference to the fundamentals. Not least because another reorganisation that fits within the parliamentary lifecycle comes along soon after the last and disrupts what little progress was being made after the previous reorganisation. Change takes 5+ years to bed-in, new relationships to be developed and appropriate capability and capacity to deliver the new roles to be developed. The management savings rarely appear given the costs of redundancy and the other associated costs not being recouped before the next change.
A significantly under-rated cost of these reorganisations and of high staff turn-over at all levels is the loss of 'organisational and system memory' - the network of relationships and 'deep knowledge' that allows patient pathways to function effectively. The Lansley reforms - 'Shifting the Balance of Power' - made the mistake of breaking up established Health Authority teams and insisting that the new Chief Executives not be drawn from from the same geographical area that they were in as current CEs. We were all shifted to different patches and had to completely rebuild our knowledge and networks. As a result many major long-term programmes were badly disrupted if not abandoned altogether as new teams came in without the understanding of the history and the effort already invested.
Alongside this we have seen the decline in investment in Public Health. It's shift from HAs to Local Authorities, whilst it made theoretical sense in terms of bringing a more informed focus to the fundamentals of community health and well-being also exposed them to the prolonged squeeze on local government funding which in many cases has significantly curtailed their role and contribution.
Another observation is linked to your comment on under-management. I would add an additional dimension. I was in the Army before mysteriously finding myself an FHSA Chief Executive in 1989. I have never ceased to be amazed and frustrated by the failure of the NHS to systematically equip its operational managers with the basic survival tools/skills required to do their jobs effectively. For example Operations Management as a discipline is not taught or required as a pre-condition for operational posts. Capacity and Demand, Theory of Constraints, measurement tools such as Statistical Process Control, process mapping and a host of other useful skills are not systematically deployed - and this lack of knolwedge leads to those skills being undervalued at a senior level. And dont get me onto the basic 'field skills' of email, calendar and task management and report writing! Attempts by the NHS to develop this capability and capacity have failed time and again - the NHS Modernisation Agency, NHS Institute for Innovation and a range of successors have always been on the fringes and never mainstream for a variety of reasons.
My final observation relates to the NHS and IT - an area I have always been closely involved with. Large NHS IT projects whether nationally, regionally or locally have never been a career enhancing prospect for thrusting Chief Executives and Directors. A major Electronic Patient Record (EPR) implementation may take more than 8 years to deliver any significant benefits and needs constant focus and support to ensure staff and patients get the best out of the system rather than finding ways around it. It is interesting to note that there are few if any independent peer-reviewed research papers into the benefits of EPR - not that I am saying there are no benefits but that health organisations are bad at systematically identifying and measuring benefit not least because to do so shows the level of cost outweighs benefit for 5 or more years and this is not a comfortable message in a business case where savings are an urgent priority.
The result of this is that senior leadership (managerial and clinical) engagement with IT is not wholehearted (with a few notable exceptions) and as a result the deep knowledge of the fundamentals of the application of technology to the business is not as well embedded as it is in many other industries.
Great article and great report, Sam. I have three twists to suggest to what you have found:
1. It’s not only the most senior and experienced clinicians who are leaving; the same has been true of non-clinical leaders too. It started with the Langley “reforms” and never really stopped.
2. The NHS is routinely, massively, outcompeted on pay and conditions for managers by the private sector. So the managers who it does employ are a mixture of the selfless and the really not very competent.
3. In your description of the reasons why staff have left, you cited workload and pay etc. But there is also just the sheer grinding awfulness of the working conditions: petty decisions that often feel very performative and have a big impact on people’s stress levels. Some of it is caused by the lack of experienced managers, which leads to poor operational decisions.
Personal anecdote. I have a long-standing ear problem with a mass of scar tissue/something more sinister in one ear. An ENT consultant had just got a £15K machine that goes into the ear and takes pictures. The benefit is my pictures are now stored on his system for our Trust. But as he hadn’t seen my ear before, and notes from previous appts have no pictures, I was sent for an expensive MRI scan. He also asked me to take screenshots in case I move trusts, as there he thought there would be no way of sharing them.
Similarly my wife’s HPV consultant whom we’ve known for years, and has now retired, had recently built up a huge collection of digitised penises (sic) in various states of decay, which she proudly showed us. A massive diagnostic resource which she can’t take with her, and has no means of sharing outside the Trust.
You’re absolutely correct - it’s infrastructure, equipment, capacity and support staff.
This article reminds me of what I have read about one of the key differences between the Russian and Ukrainian armies. The Russian army controls from the centre and gives very little strategic and tactical autonomy to officers on the ground, while the Ukrainians set key strategic objectives centrally and gives far more autonomy to the people on the ground who know how best to achieve those objectives in a dynamic environment. The Russian model is less effective.
I wonder whether these same management problems are manifesting with the NHS.
- prevention - we have underfunded primary and secondary prevention forever and therefore miss a cost effective way to reduce demand and improve patient outcomes. We further silo it by putting funding via Local Authorities rather than the NHS, increasing fragmentation and making alignment of services harder
- social determinants of health - integrated care systems were set up in recognition that the causes of poor health and inequity were often rooted in broader factors - housing, transport, nutrition, social networks. These are all supported via investment into Local Authorities which has faced increasing cost pressures. Until we look upstream and improve the inputs to people’s health, we will always be facing an increasing spend curve on health. However at Whitehall level it’s not clear to me whether this is acted on in a joined up fashion
- innovation - the adoption of technology and use of data has so much potential but faces the challenge of a high threshold of evidence for funding (due to scarce funding probably), the difficulty of double running new things alongside existing things when there aren’t enough staff in the first place, the need to negotiate with multiple different organisations
There is potential in all of these areas but it requires joined up thinking, system process reform and patient investment.
On holiday I met two GPs, who both qualified a year or so ago. They work in the north west, started med school in 2015.
“The NHS is barrelling towards disaster,” said one. They then explained in turn how the lack of people to do the semi-qualified work such as checking prescriptions and filing or taking action on letters that come back from patients’ hospital appointments means that workload falls on them in the two-hour slot in the middle of the day when they’re meant to do house visits and call patients if one of those hospital letters means urgent measures.
The IT is also crap, they said. Ancient and creaking and prone to falling over, which screws everything because everything’s on there.
Yet at the same time they were dedicated and fascinated by the challenge of helping people in some of the most deprived areas and one of the least deprived (they’re in almost adjacent geographical areas).
They also had criticism for how hospital capacity has been cut down: “when I started you used to see the occasional empty bed in a ward. Now, never. There’s a brand spanking new hospital where the A+E has put signs on the corridor: Bed 1, Bed 2, Bed 3, because they don’t have the capacity. It’s just not treating people with the dignity they deserve,” one said.
It was fascinating to hear it direct from them, and it backs up everything you’ve said above, Sam. Basically, get any NHS staffer and they can identify the problems in moments. Incredible that politicians then seem completely unable to enunciate what needs to be done, or to do it.
This article rings true to me, and the stats about beds and scanners are massively relevant. Try getting one bit of the nhs to talk to another. It’s like foreign countries that have no formal diplomatic relations!
I would concur with Sam on this having had the misfortune to spend 6hrs in Watford General A&E a few weeks ago. The medical care from the time I called 111 to being seen, bloods taken, ultrasound scan and an initial diagnosis was excellent. It's the facilities that were unacceptable. The building needs demolishing. They have been talking about it for 10 years or more but nothing has changed. The only way to fix the NHS and all the other problems in this country is to look around the world and copy other countries where they do it well. We don't and probably have never done
NHS is a reflection of much of the rest of public infrastructure in the UK; a rich country that has left it's money in private hands and inevitably, to a visiter, looks poor....see the transport system for instance! France has gone in the other direction, placing much, if not all, of its money in the public sphere leaving too little to the private....and is rapidly becoming poor; a state and direction that the Euro currency is currently abetting. Both are nolonger providing for the health of their people. The money is there but it is spent with reference to the election cycle and not the people's needs.
Both countries remind me now of Harald Wilson in the early 1970s who opined that he was "managing the decline into poverty so that it didn't hurt too much!"
Hi Sam - enjoyed this as always and will be discussing it with my wife as she is an exec director at an NHS Trust. Much of this rings true... one question though, on staffing levels... which was a huge surprise to me, is the data for posts or actual staff numbers? I assume the latter, but I always hear a lot about unfilled vacancies and shifts in staffing in part caused by Brexit (eg whole maternity unit of midwives leaving as it was essentially a Spanish speaking community so many left back to Spain). So I wondered whether there is data on vacancies and whether that might provide some explanation as staffing levels will be very poor in pockets leading to inefficiency/breakdown. Also hearing a lot of individual stories about impact of lack of acute mental health beds having a big knock on effect into hospitals as they don’t have appropriate beds for them so huge staff time to dealing with it...
Just read this on another substack account for someone who sought healthcare in both Canada and the UK:
"I find the GP system in the UK utterly baffling. Whereas in Canada I could book doctor's appointments weeks, months, or even a year in advance, in the UK I have to call in at 8 a.m. and hope to be allotted one of today's available slots. If I don't manage it, I have to try again tomorrow."
It is true that for Canada, for non-emergency healthcare, it is possible to book a doctor's appointment weeks or months in advance. This is true for most of the US as well.
If it is the case that one can only book an appointment on the same day, then that is likely one reason why so many patients end up coming for emergency care.
Canada, at least in some provinces, has a shortage of hospital beds as well.
I have an observation about how to reduce emergency room wait times:
In Canada, they deal with this by triaging patients in the emergency room. My very young daughter and I once spent eight hours in an emergency room in Alberta waiting for them to assess and treat a broken arm. It was on a weekend, they were short staffed, and my daughter wasn't going to die from a broken arm. Still, it was extremely challenging to sit there with a toddler with a broken arm in the emergency room for eight hours.
In California, one thing I've taken advantage of many times is something called "urgent care". There are various forms of urgent care, but basically, it is set up as a clinic for things like strep throat, things that require stitches, an xray, or a prescription. The idea is to allow for same day or next day appointments for urgent, but non-emergency care. This tends to reduced the number of patients in emergency waiting rooms. The other advantage of urgent care is that many semi-retired expert older doctors, who no longer want to work in emergency care, have no problem working in urgent care. The hours are more structured and the patients are usually not at immediate risk of dying.
There is a fee incentive structure where the co-pays for urgent care are much lower than for emergency care. The other advantage is that the patient knows they are not going to get stuck in an emergency room for an extended period.
Looking online, I can see that the national health service does have some urgent care services:
In spite of all that might not be working with the NHS, strengthening urgent care, not only at local clinics away from hospitals, but also at hospitals with an emergency room, might alleviate some of the demand for emergency care.
Much thanks Sam - and other commentators for a thoroughgoing survey. Seen from the point of view offered by our experience in regions of Brazil and Canada where effective state intervention is the difference between life and death in those continental-scale countries the UK is in a state of paralysis. The structural changes inflicted by the unravelling of the 'Washington Consensus' and the unplanned exit from the EU - trivialized by a succession of incompetent ministries 2008-2023- have not been dealt with in a competent manner. Successive Parties have sought to dismantle state capacity driven by ideological considerations: there is little evidence that programs to create an NHS fit for the 21st century can be fully worked through let alone implemented across multiple Parliamentary cycles unless an enduring political consensus - in Brazilian terms a 'conciliation' in Canadian a 'settlement' can be agreed and provided for. The administrative, fiscal and social implications of the Post-Covid consensus - that the NHS must be enhanced to match the offerings of our near neighbours - can then be faced. Pending that 'conciliation' the UK remains mired in the spiralling costs and growing inequalities that ensue.
Excellent analysis Sam. One thing, you highlight here an increase in raw junior doctors numbers since 2019. What you haven’t mentioned, and I wondered if you measured it, was how many of those junior doctors work on a reduced rota. Our eldest is the only specialist trainee in her specialism in the Trust she works for who still does a 100% rota. All the others have gone to 80%. And it makes sense. Junior doctors’ basic weekly hours are significantly longer than the working week for the rest of the country and when you add in nights, long days and weekends the hours are brutal. Many people, with or without young families, find moving to 80% enables them to continue their learning, prepare for the everlasting exams and cope with the role whilst still having a life. I’d be really interested to know how much of that increase in numbers has vanished as a result of more junior doctors doing reduced time. Did you look at this?
Anecdotally my recent experience of the NHS has been excellent. BUT that was possibly because I'm reasonably computer literate, patient and able to drive to the nearest Minor Injuries Unit in North Wales. Interaction with management was minimal but in the end a conversation with 111 and a telephone booking at my local GP worked better than searching through myriad websites and apps. KISS as they say in management
Of late I’ve found myself in conversation with several people supporting change in the NHS at the top three layers of the system.
Professionally my focus is on supporting leaders of large organisations and systems around massive change, the type that takes bravery and commitment over both short and long term.
I see the NHS needing this type of change.
I’d love to talk to senior leaders in the NHS. I promise to listen deeply and simply see what comes from that. Potentially I can offer sone insights they can apply. At the very least I can connect sone dots.
PS for clarity my offer is absolutely pro bono. The NHS saved my life last year. I was already a fan, but had not been a patient for decades. Seeing so many people working first hand (often on and with me!) brought my attention to this system.
I am reading this as a total outsider, not having lived in the UK for ages, and not having much interaction with the NHS before.
This is only one angle, but could not also be part of the problem that the fundamental life-style disease load is compounding even more than before? And that the NHS is not fixable, because as long as people are so spectacularly unhealthy, the demand for treatment for non-communicable diseases will be rising ahead of any spending capacity?
Sure, some things are being done already -- but perhaps the policy measures that are needed to reduce the pressure on the NHS are much much more radical to flatten that curve, than the comparative fig-leaves that are applied to what is an overwhelming problem.
It would be interesting to dig into where the pressures, in the end, are coming from, as focusing on demand for NHS services may (medium term) be the one (only?) way out of this situation.
An excellent and clear summary of the issues. I look forward to reading the main report. I have worked in and alongside the NHS for over 30 years - as a Chief Executive (FHSA, DHA, HA, SHA) and a Director of the NHS Modernisation Agency, leaving to become an independent consultant after one too many heaves of the Magic Roundabout of reorganisation. I would add some additional reflections.
Almost all reorganisations in the past 30 years have been shifting the commissioning/regional national Arms Length Body landscape - performative policy making allowing it to seem that something is being done when in reality it has made little difference to the fundamentals. Not least because another reorganisation that fits within the parliamentary lifecycle comes along soon after the last and disrupts what little progress was being made after the previous reorganisation. Change takes 5+ years to bed-in, new relationships to be developed and appropriate capability and capacity to deliver the new roles to be developed. The management savings rarely appear given the costs of redundancy and the other associated costs not being recouped before the next change.
A significantly under-rated cost of these reorganisations and of high staff turn-over at all levels is the loss of 'organisational and system memory' - the network of relationships and 'deep knowledge' that allows patient pathways to function effectively. The Lansley reforms - 'Shifting the Balance of Power' - made the mistake of breaking up established Health Authority teams and insisting that the new Chief Executives not be drawn from from the same geographical area that they were in as current CEs. We were all shifted to different patches and had to completely rebuild our knowledge and networks. As a result many major long-term programmes were badly disrupted if not abandoned altogether as new teams came in without the understanding of the history and the effort already invested.
Alongside this we have seen the decline in investment in Public Health. It's shift from HAs to Local Authorities, whilst it made theoretical sense in terms of bringing a more informed focus to the fundamentals of community health and well-being also exposed them to the prolonged squeeze on local government funding which in many cases has significantly curtailed their role and contribution.
Another observation is linked to your comment on under-management. I would add an additional dimension. I was in the Army before mysteriously finding myself an FHSA Chief Executive in 1989. I have never ceased to be amazed and frustrated by the failure of the NHS to systematically equip its operational managers with the basic survival tools/skills required to do their jobs effectively. For example Operations Management as a discipline is not taught or required as a pre-condition for operational posts. Capacity and Demand, Theory of Constraints, measurement tools such as Statistical Process Control, process mapping and a host of other useful skills are not systematically deployed - and this lack of knolwedge leads to those skills being undervalued at a senior level. And dont get me onto the basic 'field skills' of email, calendar and task management and report writing! Attempts by the NHS to develop this capability and capacity have failed time and again - the NHS Modernisation Agency, NHS Institute for Innovation and a range of successors have always been on the fringes and never mainstream for a variety of reasons.
My final observation relates to the NHS and IT - an area I have always been closely involved with. Large NHS IT projects whether nationally, regionally or locally have never been a career enhancing prospect for thrusting Chief Executives and Directors. A major Electronic Patient Record (EPR) implementation may take more than 8 years to deliver any significant benefits and needs constant focus and support to ensure staff and patients get the best out of the system rather than finding ways around it. It is interesting to note that there are few if any independent peer-reviewed research papers into the benefits of EPR - not that I am saying there are no benefits but that health organisations are bad at systematically identifying and measuring benefit not least because to do so shows the level of cost outweighs benefit for 5 or more years and this is not a comfortable message in a business case where savings are an urgent priority.
The result of this is that senior leadership (managerial and clinical) engagement with IT is not wholehearted (with a few notable exceptions) and as a result the deep knowledge of the fundamentals of the application of technology to the business is not as well embedded as it is in many other industries.
Fin
Great article and great report, Sam. I have three twists to suggest to what you have found:
1. It’s not only the most senior and experienced clinicians who are leaving; the same has been true of non-clinical leaders too. It started with the Langley “reforms” and never really stopped.
2. The NHS is routinely, massively, outcompeted on pay and conditions for managers by the private sector. So the managers who it does employ are a mixture of the selfless and the really not very competent.
3. In your description of the reasons why staff have left, you cited workload and pay etc. But there is also just the sheer grinding awfulness of the working conditions: petty decisions that often feel very performative and have a big impact on people’s stress levels. Some of it is caused by the lack of experienced managers, which leads to poor operational decisions.
Agree on all points.
Personal anecdote. I have a long-standing ear problem with a mass of scar tissue/something more sinister in one ear. An ENT consultant had just got a £15K machine that goes into the ear and takes pictures. The benefit is my pictures are now stored on his system for our Trust. But as he hadn’t seen my ear before, and notes from previous appts have no pictures, I was sent for an expensive MRI scan. He also asked me to take screenshots in case I move trusts, as there he thought there would be no way of sharing them.
Similarly my wife’s HPV consultant whom we’ve known for years, and has now retired, had recently built up a huge collection of digitised penises (sic) in various states of decay, which she proudly showed us. A massive diagnostic resource which she can’t take with her, and has no means of sharing outside the Trust.
You’re absolutely correct - it’s infrastructure, equipment, capacity and support staff.
This article reminds me of what I have read about one of the key differences between the Russian and Ukrainian armies. The Russian army controls from the centre and gives very little strategic and tactical autonomy to officers on the ground, while the Ukrainians set key strategic objectives centrally and gives far more autonomy to the people on the ground who know how best to achieve those objectives in a dynamic environment. The Russian model is less effective.
I wonder whether these same management problems are manifesting with the NHS.
Spot on. I would also add:
- prevention - we have underfunded primary and secondary prevention forever and therefore miss a cost effective way to reduce demand and improve patient outcomes. We further silo it by putting funding via Local Authorities rather than the NHS, increasing fragmentation and making alignment of services harder
- social determinants of health - integrated care systems were set up in recognition that the causes of poor health and inequity were often rooted in broader factors - housing, transport, nutrition, social networks. These are all supported via investment into Local Authorities which has faced increasing cost pressures. Until we look upstream and improve the inputs to people’s health, we will always be facing an increasing spend curve on health. However at Whitehall level it’s not clear to me whether this is acted on in a joined up fashion
- innovation - the adoption of technology and use of data has so much potential but faces the challenge of a high threshold of evidence for funding (due to scarce funding probably), the difficulty of double running new things alongside existing things when there aren’t enough staff in the first place, the need to negotiate with multiple different organisations
There is potential in all of these areas but it requires joined up thinking, system process reform and patient investment.
On holiday I met two GPs, who both qualified a year or so ago. They work in the north west, started med school in 2015.
“The NHS is barrelling towards disaster,” said one. They then explained in turn how the lack of people to do the semi-qualified work such as checking prescriptions and filing or taking action on letters that come back from patients’ hospital appointments means that workload falls on them in the two-hour slot in the middle of the day when they’re meant to do house visits and call patients if one of those hospital letters means urgent measures.
The IT is also crap, they said. Ancient and creaking and prone to falling over, which screws everything because everything’s on there.
Yet at the same time they were dedicated and fascinated by the challenge of helping people in some of the most deprived areas and one of the least deprived (they’re in almost adjacent geographical areas).
They also had criticism for how hospital capacity has been cut down: “when I started you used to see the occasional empty bed in a ward. Now, never. There’s a brand spanking new hospital where the A+E has put signs on the corridor: Bed 1, Bed 2, Bed 3, because they don’t have the capacity. It’s just not treating people with the dignity they deserve,” one said.
It was fascinating to hear it direct from them, and it backs up everything you’ve said above, Sam. Basically, get any NHS staffer and they can identify the problems in moments. Incredible that politicians then seem completely unable to enunciate what needs to be done, or to do it.
This article rings true to me, and the stats about beds and scanners are massively relevant. Try getting one bit of the nhs to talk to another. It’s like foreign countries that have no formal diplomatic relations!
I would concur with Sam on this having had the misfortune to spend 6hrs in Watford General A&E a few weeks ago. The medical care from the time I called 111 to being seen, bloods taken, ultrasound scan and an initial diagnosis was excellent. It's the facilities that were unacceptable. The building needs demolishing. They have been talking about it for 10 years or more but nothing has changed. The only way to fix the NHS and all the other problems in this country is to look around the world and copy other countries where they do it well. We don't and probably have never done
NHS is a reflection of much of the rest of public infrastructure in the UK; a rich country that has left it's money in private hands and inevitably, to a visiter, looks poor....see the transport system for instance! France has gone in the other direction, placing much, if not all, of its money in the public sphere leaving too little to the private....and is rapidly becoming poor; a state and direction that the Euro currency is currently abetting. Both are nolonger providing for the health of their people. The money is there but it is spent with reference to the election cycle and not the people's needs.
Both countries remind me now of Harald Wilson in the early 1970s who opined that he was "managing the decline into poverty so that it didn't hurt too much!"
Hi Sam - enjoyed this as always and will be discussing it with my wife as she is an exec director at an NHS Trust. Much of this rings true... one question though, on staffing levels... which was a huge surprise to me, is the data for posts or actual staff numbers? I assume the latter, but I always hear a lot about unfilled vacancies and shifts in staffing in part caused by Brexit (eg whole maternity unit of midwives leaving as it was essentially a Spanish speaking community so many left back to Spain). So I wondered whether there is data on vacancies and whether that might provide some explanation as staffing levels will be very poor in pockets leading to inefficiency/breakdown. Also hearing a lot of individual stories about impact of lack of acute mental health beds having a big knock on effect into hospitals as they don’t have appropriate beds for them so huge staff time to dealing with it...
How do Canada and Sweden get by with fewer per-capita beds than us? Or is it not comparable somehow?
I haven't looked at Sweden but Canada is the most comparable to us in terms of problems.
Just read this on another substack account for someone who sought healthcare in both Canada and the UK:
"I find the GP system in the UK utterly baffling. Whereas in Canada I could book doctor's appointments weeks, months, or even a year in advance, in the UK I have to call in at 8 a.m. and hope to be allotted one of today's available slots. If I don't manage it, I have to try again tomorrow."
It is true that for Canada, for non-emergency healthcare, it is possible to book a doctor's appointment weeks or months in advance. This is true for most of the US as well.
If it is the case that one can only book an appointment on the same day, then that is likely one reason why so many patients end up coming for emergency care.
Canada, at least in some provinces, has a shortage of hospital beds as well.
I have an observation about how to reduce emergency room wait times:
In Canada, they deal with this by triaging patients in the emergency room. My very young daughter and I once spent eight hours in an emergency room in Alberta waiting for them to assess and treat a broken arm. It was on a weekend, they were short staffed, and my daughter wasn't going to die from a broken arm. Still, it was extremely challenging to sit there with a toddler with a broken arm in the emergency room for eight hours.
In California, one thing I've taken advantage of many times is something called "urgent care". There are various forms of urgent care, but basically, it is set up as a clinic for things like strep throat, things that require stitches, an xray, or a prescription. The idea is to allow for same day or next day appointments for urgent, but non-emergency care. This tends to reduced the number of patients in emergency waiting rooms. The other advantage of urgent care is that many semi-retired expert older doctors, who no longer want to work in emergency care, have no problem working in urgent care. The hours are more structured and the patients are usually not at immediate risk of dying.
There is a fee incentive structure where the co-pays for urgent care are much lower than for emergency care. The other advantage is that the patient knows they are not going to get stuck in an emergency room for an extended period.
Looking online, I can see that the national health service does have some urgent care services:
https://www.england.nhs.uk/urgent-emergency-care/
In spite of all that might not be working with the NHS, strengthening urgent care, not only at local clinics away from hospitals, but also at hospitals with an emergency room, might alleviate some of the demand for emergency care.
Much thanks Sam - and other commentators for a thoroughgoing survey. Seen from the point of view offered by our experience in regions of Brazil and Canada where effective state intervention is the difference between life and death in those continental-scale countries the UK is in a state of paralysis. The structural changes inflicted by the unravelling of the 'Washington Consensus' and the unplanned exit from the EU - trivialized by a succession of incompetent ministries 2008-2023- have not been dealt with in a competent manner. Successive Parties have sought to dismantle state capacity driven by ideological considerations: there is little evidence that programs to create an NHS fit for the 21st century can be fully worked through let alone implemented across multiple Parliamentary cycles unless an enduring political consensus - in Brazilian terms a 'conciliation' in Canadian a 'settlement' can be agreed and provided for. The administrative, fiscal and social implications of the Post-Covid consensus - that the NHS must be enhanced to match the offerings of our near neighbours - can then be faced. Pending that 'conciliation' the UK remains mired in the spiralling costs and growing inequalities that ensue.
Excellent analysis Sam. One thing, you highlight here an increase in raw junior doctors numbers since 2019. What you haven’t mentioned, and I wondered if you measured it, was how many of those junior doctors work on a reduced rota. Our eldest is the only specialist trainee in her specialism in the Trust she works for who still does a 100% rota. All the others have gone to 80%. And it makes sense. Junior doctors’ basic weekly hours are significantly longer than the working week for the rest of the country and when you add in nights, long days and weekends the hours are brutal. Many people, with or without young families, find moving to 80% enables them to continue their learning, prepare for the everlasting exams and cope with the role whilst still having a life. I’d be really interested to know how much of that increase in numbers has vanished as a result of more junior doctors doing reduced time. Did you look at this?
There isn't any data on it annoyingly but anecdotally we heard similar.
Anecdotally my recent experience of the NHS has been excellent. BUT that was possibly because I'm reasonably computer literate, patient and able to drive to the nearest Minor Injuries Unit in North Wales. Interaction with management was minimal but in the end a conversation with 111 and a telephone booking at my local GP worked better than searching through myriad websites and apps. KISS as they say in management
Of late I’ve found myself in conversation with several people supporting change in the NHS at the top three layers of the system.
Professionally my focus is on supporting leaders of large organisations and systems around massive change, the type that takes bravery and commitment over both short and long term.
I see the NHS needing this type of change.
I’d love to talk to senior leaders in the NHS. I promise to listen deeply and simply see what comes from that. Potentially I can offer sone insights they can apply. At the very least I can connect sone dots.
PS for clarity my offer is absolutely pro bono. The NHS saved my life last year. I was already a fan, but had not been a patient for decades. Seeing so many people working first hand (often on and with me!) brought my attention to this system.
I am reading this as a total outsider, not having lived in the UK for ages, and not having much interaction with the NHS before.
This is only one angle, but could not also be part of the problem that the fundamental life-style disease load is compounding even more than before? And that the NHS is not fixable, because as long as people are so spectacularly unhealthy, the demand for treatment for non-communicable diseases will be rising ahead of any spending capacity?
Michael Pollan made this point in the US that you cannot fix Big Health unless you fix Big Food. https://michaelpollan.com/articles-archive/big-food-vs-big-insurance/
Sure, some things are being done already -- but perhaps the policy measures that are needed to reduce the pressure on the NHS are much much more radical to flatten that curve, than the comparative fig-leaves that are applied to what is an overwhelming problem.
https://commonslibrary.parliament.uk/research-briefings/sn03336/#:~:text=Adult%20obesity%20in%20England,is%20classified%20as%20'overweight'.
It would be interesting to dig into where the pressures, in the end, are coming from, as focusing on demand for NHS services may (medium term) be the one (only?) way out of this situation.