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 I have my particular favourites, you may too, and I include in my unpublished list quite a few of the elective procedures offered by my own specialty.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:
Lifesaving emergency treatment
Pragmatic management of life-threatening conditions, mainly cancer
Rapid access General Practice that includes real out of hours care
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.
Appropriate public health/screening. So more colonoscopies, fewer stupid campaigns against booze (just to be topical).
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”.
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.
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 hasbadly 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? Eventhe 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 wouldnever, 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 theOverton Windowin action. In 2007 theofficial 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 heactually saidwas 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 thefutileParis 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 theclimate-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.
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