The NHS: decline and fall?

I’ve worked in the NHS for 32 years, man and boy, so to speak.

I don’t do private work, though I don’t have an issue with it ideologically.

I admire Bevan and Beveridge who kicked off the whole enterprise in 1948, although I’m pretty sure that they’d be horrified by what much of the NHS and the associated welfare state has become.

We do seem however, to be approaching an NHS End of Days scenario, by which I do not mean the ludicrous cry of “they’re privatising the NHS”. ‘They’, generally speaking, are not capable of such sophisticated thinking, and ‘they’ are unable to tame the behemoth of NHS spending. It’s probably not possible under the current provision. The answer is not more money.

It’s always interesting to gauge what outside healthcare providers think of the NHS. When I get tourists and similar in as emergencies, they often can’t believe that all this is ‘free’. It isn’t of course, if you pay tax, but you know what they mean. The unappealing spectacle of billing and insurance checks is absent from our clinical areas. But what seemed free, high quality and good value, has been overtaken by hangers on, from the shop floor to the upper tier of government. Everyone wants a slice of the pies – both the goodwill and ‘nobility’ associated with providing healthcare, and also the financial rewards*** embedded within its now enormous bureaucracy.

Here is Ted Noel, a retired US anaesthetist, musing on the problem:

Bevan succeeded, but his victory is being erased by the Law of Subsidy**. What was sold as a boon to the poor has become a subsidy for bureaucrats. The Law of the Bureaucrat declares that while a bureaucracy may have been created to deal with a perceived problem, the bureaucrat’s Prime Directive is to ensure that he has a job forever. And because he was appointed to solve the problem, he’s smarter than everyone else and should be paid accordingly.

Perversely, the bureaucrat can never solve the problem, or his job would disappear. So he continues with the language that created him, trying to sell greater and greater funding for his failed enterprise. And when it fails more dramatically, he blames anyone but himself, and gets rewarded with a bigger budget. Ultimately, as Margaret Thatcher famously quipped, “The problem with liberalism is that eventually you run out of other people’s money.”

The Law of Subsidy has killed the NHS. It just doesn’t realize that it is dead. But thousands of those it was created to care for are dead, because it simply cannot fulfill its promised goals.

He may be right.

…good times


**The Law of Subsidy says that “When you subsidise something, you get more of it and it gets more expensive.”

*** subsequent to this blog post, here’s a nice confirmatory piece from the estimable Max Pemberton


1001 things wrong with the #NHS (998): Committees

Pretty simple, and universally applicable

The Knife has done lots of formal hospital management, though on the principle of ‘quit while you’re ahead’, I voluntarily stepped down quite a while ago. I don’t hate it, usually, but I prefer clinical work by far, and if I leave this earth having done any good, it’ll be in the latter sphere, by a long way. If you step too far away from the clinical stuff, you start to act and think differently, ego takes over and your peer credibility dies.

That’s guaranteed.

That said, it’s an interesting milieu, not least because of the subterfuge, inconsistency and indecision that abounds, usually combined with declarations of ‘caring’. The much hated private sector – which happens to constitute most of the healthcare in the developed world – would never tolerate the crap that goes on. (For the record, I do no private work.)

And today, as it happens, was one of the most gruesome** management meetings that I’ve ever attended – I won’t bore anyone with the details, but it was actually depressing. It was an absurdly large group attempting to share a process that neither needed it, nor was amenable to it.

Where to go for solace, some reassurance that my negative feelings are in fact appropriate?



….the author is talking about restructuring the playing season for American football. The key quote is “committees are what insecure people create in order to put off making hard decisions”. It’s nice to be inclusive, if possible, but it’s no surprise that the phrase ‘design by committee’*** is never used in  complimentary way.

Even worse than that is that such large unwieldy groupings always contain people with nothing to lose, no axe to grind, and indeed no expertise worth having. As any endocrinologist will tell you, a negative feedback loop is an essential regulatory part of a well functioning system. You need people with what Black Swan author and polymath, Nassim Nicholas Taleb calls ‘skin in the game’ (1, 2). I don’t want my clinical practice parameters decided by a committee of people without skin in the game. Nor would they, if it was their area, and nor would my patients want it.

What’s the answer to this?

Well, here is the same author. I agree wholeheartedly with it, not least that it’s coming on the back of a riff about the uselessness of management consultants (who should be barred from the NHS)…


…for money, read clinical practice.

You can guess the author, I would imagine


**if you want to know how gruesome the NHS can be, this vivid account (spoiler: bad language), gives a fair appraisal of a bad spell. I did not write it!


***As advertising pioneer and author of Confessions of An Advertising Man, David Ogilvy said: ‘Search your parks in all your cities. You’ll find no statues of committees.’

The damned statistical lies of the NHS (hip replacement edition)

A quick observation. The ‘top nurse’ in NHS England, Jane Cummings, is quoted in today’s Times as follows:

A million more cataract operations or 250,000 hip replacements could be funded if the NHS did not have to pay for appointments that people failed to attend

Of course this is only the latest in many claims about the NHS which appear shocking, eye catching and as one might expect, either unprovable or simply untrue.

A few facts, assuming that Ms Cummings is primarily referring to missed outpatient appointments. Depending on your specialty, very few operative patients fail to attend:

a. Patients who fail to attend are very often patients who shouldn’t even have had an appointment. Many have got better. Many were given appointments ‘just to check’. There is lots of evidence that the clinical yield from an arbitrarily timed clinic appointment is minimal. Who is benefiting here? Do not assume that these appointments were necessary. The fault may lie with the hospital.
b. It depends if your outpatient clinic template already factors in DNA (Did Not Attend) patients. Mine used to. If your clinic is very busy then these absent patients are actually a great relief. If there is a factored in DNA factor and they all do attend, then it creates a real problem. In other words, it’s not always an administrative disaster, just as it’s not always (or ever) a clinical disaster – see point a.
c.  The claim that these DNA’s mysteriously add up to a quarter of a million hip replacements is a classic piece of pseudo-statistical rubbish. It probably emanates from an NHS head office algorithm built on crazy assumptions, or on the specious views of overrated NHS parasites like the oft-quoted ‘charity’ The Kings Fund. The Times article states:
At an average cost of £120 per slot, this indicates that doctors’ time worth about £950 million was wasted last year.

In the real world, in the unlikely event that your clinic finishes early, then you probably do one of the following valuable things: speak to colleagues (including non-medical ones), have lunch, conduct a ward round, review investigations, write to GP’s, make necessary phone calls, answer emails, complete training dashboards online, speak to management and much much more. All necessary parts of the job. What this unexpected ‘spare’ time does not, and cannot equate to is knocking off a quick hip replacement.

Oddly enough it might, if in a parallel universe the NHS had spent a bit more of its already colossal budget on meaningful infrastructure, like operating theatres. There is no shortage of patients who can come in at short notice, and NHS admin staff are now often superbly responsive at  getting hold of patients in a hurry. That is the sort of NHS of which Nye Bevan and William Beveridge would approve. The NHS desperately needs to factor in some free space in both its physical and administrative infrastructures, if it wants that kind of flexibility. I think it should.

Ms Cummings is describing a made up situation that is misleading at best. It appears to be part of a national drive. Some Scottish health boards, for example, are claiming that these DNA’s cost an unlikely £4 million a year, based on back of an envelope calculations.

If, however, you want to save millions of actual cash payouts for work not done, generally speaking, try rescinding the increasingly absurd and profligate New Deal contract.

There’s a suggestion for 2018.

surgery day
….it’s actually a bit more complex than this

Random Lists (3): things I can’t stand in NHS management/groupthink

These things seriously peeve me, despite my tolerant and accommodating nature. Honest:

  1. People who claim they ‘speak truth to power’ – the opposite is usually true
  2. Quoting TED talks
  3. Bringing in expensive outside advisers – who are all in it for the money. They are treated with a reverence they do not deserve, and they have no ‘skin in the game’.
  4. The (occasional) unspoken assumption that acute care mysteriously takes care of itself, when it comes to allocating budgets
  5. The lack of challenge to the New Deal and the GP Contracts – time to shift the Overton Window on these, they are not in the public’s best interests

I have to add, though, that there is much to admire and praise in NHS management.  Many of these colleagues work their socks off and do a great job. It’s just not that exciting to blog about, sadly.

Thomas Sowell never lets you down

The future of the NHS, AKA “stopping doing some things”

…he has a point

Nearly 70 years ago,  the declared bases of the NHS, were the much-quoted three founding principles, courtesy of Aneurin Bevan, a remarkable politician:

  • that it meet the needs of everyone
  • that it be free at the point of delivery
  • that it be based on clinical need, not ability to pay

This nice summary from the NHS’ 60th birthday in the BMJ provides the narrative:

The three principles stand up well. American patients admitted as emergencies often can’t believe how good things can be in a quality NHS unit. It’s true though that maintaining such quality without financial incentives/disincentives (unlike most developed countries) is getting harder to do.

Did we need to add to these three principles? I don’t think so, but in the time honoured manner of bored self important managers and clinicians drifting away from the frontline, we have. Try this, from a big cheese Welsh NHS seminar in 2011:

Universal access, based on need
Comprehensiveness, within available resources
Services free at the point of delivery
A shared responsibility for health between the people of
Wales and the NHS
A service that values people
Getting the best from the resources available
A need to ensure health is reflected in all policies
Minimising the effects of disadvantage on access and outcome
A high quality service that maximises patient safety
Patient and public accountability
Achieving continuous performance improvement across all
dimensions of healthcare

I’ve italicised the ones that I would call mission creep – they’re not strictly NHS issues – and also the ones that are platitudinous and glaringly obvious. I’ve put in bold the bits with which I agree, but nobody really means, as ‘within available resources’ in practice means rationing. I have yet to hear a sensible debate on real rationing of NHS services, which means stopping doing some things. The Scottish NHS goes on about ‘realistic medicine’, but despite lots of hype, it remains somewhat undefined in terms of stopping doing some things.

Principle 6 in the now seven principles of the NHS spelt out in the NHS Constitution, also from 2011, alludes to this:


Which actually is worth spelling out. It’s the only way to keep the NHS viable. And what that means is….stopping doing some things. There are plenty of things that would have appalled Bevan and his colleagues, had he realised that’s what the NHS smorgasbord would end up providing. I have my particular favourites, you may too, and I include in my unpublished list quite a few of the elective procedures offered by my own specialty.

Bevan was following on from the flawed intellectual William Beveridge, who had a slightly broader remit looking at the role of the postwar state in more general terms:  “five giants on the road to reconstruction” that needed to be slayed: want, disease, ignorance, squalor, and idleness.

Beveridge was on to something then and now.

None of this is new of course, but my suggestion is that these admirable and clear principles have been abused by the sprawling megacity of the welfare state of 2017, the most loved component of which is the NHS.

For the record, I’ve worked in the NHS for decades, I don’t do private work. What we badly need, as taxpayers, patients, healthcare workers, rational human beings etc, is to restructure what the NHS does (which means stopping doing some things). It’s not hard in principle. Here’s the order of priorities:

  1. Lifesaving emergency treatment
  2. Pragmatic management of life-threatening conditions, mainly cancer
  3. Rapid access General Practice that includes real out of hours care
  4. Elective procedures that work – so stop doing things that don’t have proven benefit of adequate clinical significance. That’s actually quite a lot of things that currently go unquestioned.
  5. Appropriate public health/screening. So more colonoscopies, fewer stupid campaigns against booze (just to be topical).
  6. Better end of life care

There are lots of other areas of neglect – for example the adult physical handicapped – but many of these are primarily social care issues, and I would like to see that separated from the NHS conceptually and financially, whilst accepting that the much neglected interface between the two is very important.

Where Beveridge, Bevan and the modern welfare state collide is in at least two areas. Firstly, it would have been impossible for them to foresee the exponential expansion of high quality, effective but costly medical interventions. The human race got good at this very quickly. Affordability became difficult within a few decades of  the 1948 landmark.

Secondly, note Beveridge’s specific mention of ‘idleness’, which is effectively a codeword for what is loosely referred to as the Benefits Culture. Guardianistas don’t tend to focus on it. It is equally unaffordable in its current iteration. I’m not going to explore it, but interested readers will find illuminating references to it throughout the works of a master medical chronicler of these two centuries, Theodore Dalrymple (1, 2). Anyone with their eyes open in the developed world, particularly the UK, will know what I mean. As would Beveridge.

It’s fascinating to learn from the acerbic and erudite Geoffrey Wheatcroft something that may seem minor, but isn’t: Beveridge detested the expression “welfare state”.

…another zinger



Free the serfs!!

The Foundation doctors arriving at the hospital

In these exciting times, when morons/Lib Dems drone on about the entirely fictitious entities of hard and soft Brexit, I recommend interested parties to read a charming Spectator piece from last year: Reasons to be Cheerful. A symposium on the benefits of Brexit. All of it is good, with contributions from right across the spectrum of beliefs and politics.

Here is my favourite, because it begins to address a problem that’s blighted British medicine, the EWTD and the associated serfdom of medics in the NHS. It doesn’t mention the equally pernicious New Deal junior doctors’ contract, but it’s a fine start. The author is one of the great British medical writers, Theodore Dalrymple (AKA Anthony Daniels), a terrific writer and experienced clinician, with quite a fan club online (1, 2). Here he is:

No one wants to be treated by a dog-tired doctor, but even less does he want to be the parcel in the medical game of pass-the-parcel that is now commonplace in our hospitals. The European Working Time Directive has transformed doctors into proletarian production-line workers, much to their dissatisfaction with their work and to the detriment of their training and medical experience. It means that doctors no longer work in proper teams, patients don’t know who their doctors are and doctors don’t know who their patients are. The withdrawal of the directive would improve the situation.

Every working doctor that I know would recognise the problem described. Whether abandoning the EWTD (I would) and introducing a more sensible hours regulation would help is a moot point.

But we now need to at least have the conversation.

Junior doctors, Trump, and the Overton Window

Overton himself, looking good

These junior doctors, eh? Their ridiculous contract ‘negotiated’ by the canny BMA, who steamrollered the Labour government of the day, creating an unworkable melange of the European Working Time Directive and the New Deal, that has badly damaged training, introduced perverse financial incentives (possibly more later) and made hospital rotas (and therefore safety) very difficult to organise. Ever wondered why you can hardly find a doctor at night in a hospital ward? Even the BMJ acknowledges there’s a problem. This is a detailed and very prescient piece on the mess, from NHS ophthalmologists in 2006.

However, that’s not my main point, it’s just one of the most familiar, and egregious, examples of the EWTD, which in theory might affect any of us. A perfect example of how being in the EU has all sorts of unanticipated effects.

The point is this: 10 years ago, if you raised concerns re the EWTD, you were told that it was ‘non-negotiable’, because our membership of the EU was set in stone. The overt implication was that would never, ever change, and very few people questioned it. UKIP were barely on the horizon.

Look at it now. A pro-Europe Prime Minister with a majority is pressing on with a referendum to potentially leave the EU. This is the Overton Window in action. In 2007 the official government view (via a question in the Lords) was reluctantly expressed, by Lord Triesman as: Parliament may amend or repeal any existing Act of Parliament, including the European Communities Act 1972. There is no formal procedure for withdrawal in the EU treaties, nor are there any provisions in the treaties or any other international obligations which affect the ultimate ability of the UK to withdraw from the EU. However, given that the UK has been a member of the EU for more than 25 years, and its laws and economy are intricately bound up with those of the EU, the Government would in practice have to negotiate the terms of any departure over a lengthy period. Otherwise known as: ‘forget it, it won’t happen’. Yet here we are.

The Overton Window is best described as the range of policies acceptable to the public, or more specifically, to quote Wikipedia: a range of policies considered politically acceptable in the current climate of public opinion, which a politician can recommend without being considered too extreme to gain or keep public office.

This week’s main example is of course thanks to Donald Trump, and despite the reflexive Trump hating in the media (and I’m not a Trump supporter), I think he rather cynically made his comment about Muslims and immigration to shift the window. What he actually said was slightly more nuanced than has been widely reported. Specifically: Donald J. Trump is calling for a total and complete shutdown of Muslims entering the United States until our country’s representatives can figure out what is going on. That was Trump moving the window, and already the discourse is changing. A lot of US media types think it will allow the more moderate Ted Cruz to hoover up votes from this part of the political spectrum. They may be right. This beautifully presented discussion by David French is worth reading.

Another current example lies in the reporting of the futile Paris climate change love in. It’s not just the BBC, Sky and ITV are reporting it without any sense that there is a very real and growing debate over the validity of the assumptions that lie behind it. In TV terms at least the Overton Window has shifted to the climate-change-is-real-any-action-however-expensive-or-impractical-is-good axis. Dissent is simply not mentioned. That is probably an example of the TV media’s OW being in a somewhat different position to that of the average punter, on reflection.

No-one at all, back in 2005 when NHS medics were wrestling with producing EWTD compliant rotas, would have predicted that we would now be discussing the possibility/probability that we could dump the reason for the EWTD, yet here we are, and a good thing too.

Control the window, you control the debate.





Those junior doctors: another viewpoint

I’ve taken the original post down for a while. I can’t be bothered with the possibility of lots of online whingeing/abuse.

The essence was: the current Junior Doctors’ Contract is  a rubbish contract for reasons of complexity,  training/experience, continuity of care, harmony, financial transparency and vocational medicine (as opposed to highly paid serfdom).

It needs reforming. The devil is in the detail, of course

I’ve left one pic, to give people a taste of how it currently works