‘Voters are unhappier with the NHS than they’ve been for 30 years. As a GP, I feel the same’

On an ordinary Tuesday morning I arrived at my GP practice for a day’s work. It was 8.30am, and the receptionist on duty was a colleague named Nicola. “Any dramas?” I asked her as I approached the desk. “Not yet, but it’s early,” she said with a wry laugh.

From the moment the phones begin to ring in the morning until they hand over to the evening service at 6pm, practice receptionists are at the frontline of the health service, bearing the brunt of patients’ anger, disappointment and frustrations with the NHS. A couple of years ago, I stopped saying “Good morning” and began to experiment with alternative, more optimistic greetings. “It’s going to be a Tuesday of happiness,” I said to Nicola as I stopped at the desk. “Let’s hope so!” she replied.

I left a cup of tea cooling as I switched on the computer, which runs on an old operating system and usually takes a few minutes to get going. The GP computer systems don’t talk to the hospital systems, and clinicians often feel as if they’re drowning in passwords and glitches. Some parts of the NHS still use pagers and, until very recently, fax machines. Most of us are trying to provide medical care fit for the 2020s with computer systems better suited to the 1990s.

There were two letters with handwritten Post-it notes laid over my computer keyboard – urgent messages left by colleagues for me to action today. Modern healthcare is so complicated that no one case or story could capture all the problems of today’s NHS, but these two letters, left out for my urgent attention, illustrate some of the pressures on the health service today.

One was a discharge letter about Helen (not her real name), a widowed former schoolteacher in her early 80s, who was also a formidable bridge player, and who I’d admitted to hospital three weeks earlier for treatment of a kidney infection. The infection had made her confused and unsteady, and she waited most of the day for an ambulance, during which time she became progressively more unwell. In the first hours of her admission she had fallen out of bed on to the hard hospital floor and broken her hip. I know from speaking to hospital colleagues that, at the time she fell, the ward had been very short of nurses. I felt a flash of guilt as if I’d caused her broken hip myself, though I’d had no choice other than to send her in – the acute medical unit had been the only option open to me to keep her “safe”. But because of understaffing, the hospital ward had proven anything but safe.

The other letter was about William, a man in his late 40s who had been referred for colonoscopy after coming to see one of my colleagues several months ago, complaining of persistent diarrhoea and blood loss, with a discomfort in his lower belly. He had been anxious that his new symptoms might be a sign of bowel cancer, and my colleague had referred him urgently for specialist assessment. But because of his relative youth (under 55) and the huge pressures on the service, that referral had been downgraded from “urgent” to “routine”, and he had waited many months for the test. Now the colonoscopy confirmed what William had most feared: cancer. It had likely spread to the liver, and a hospital appointment had been scheduled for the following week to discuss what treatment options remained to him. I made a note to call William later, to see how he was taking the news. Pressures on the service are now so extreme that urgent referrals are routinely downgraded, and life-threatening diagnoses are being missed.

The computer seemed to be working reasonably well, so I opened the four different applications I needed to access the different elements of my patients’ notes. There were 35 pieces of correspondence to read – specialist letters, scans, X-ray reports – and two screenfuls of blood tests to review.

When there is adequate time in the day, I enjoy going through these letters, reports and results: they tell me whether the working diagnoses I made were correct, and where a test or scan result is unexpected, they offer learning points. Specialist letters help me to plan my next encounters with each patient, and unanticipated results feel like puzzles to be solved, rather than unwelcome irritations. But on pressured days, those anomalous results feel like obstacles, slowing me down when there is already insufficient time to get through the workload. I start to hurry; the chance of things being missed begins to rise.

Many of the letters would need to wait until lunchtime to be read properly, but before clinic started I cherrypicked some easy issues that could be dealt with swiftly. Only when I had scanned the correspondence did I open my NHS email. A motley collection: one message told me that the local Marie Curie hospice was closed to new admissions and the community palliative care nurses were struggling to cope. They asked that I avoid referring all but the most complex cases their way, and handle the rest on my own. If any dying patients were in crisis they would need to be admitted through A&E.

There was an email, too, from the clinical leader of primary care to let me know that the front door of the local hospital was experiencing “extreme pressure”, urging me to explore all possible alternatives before considering an admission for any of my patients – as if I didn’t do that already. The tone of the letter was apologetic; this particular clinical leader still works as a GP, and knows how frustrating and patronising these letters can be. The community psychiatry team had rebuffed one of my urgent referrals, and asked me to follow up a suicidal patient myself as they had no capacity to see her. I forwarded the email to the receptionists, and asked them to find out if the patient could come in today and be added on to the end of my already full clinic.

A doctor in a consulting room.
A doctor in a consulting room. Photograph: parkerphotography/Alamy

The local hospital for children had put out a message to say that if any GPs would like to order blood tests for a child, there was a three-month wait for an appointment at the local dedicated paediatric clinic – a service so slow that it might as well not exist. I don’t make the decision to send children for blood tests lightly, and I can’t think of a situation where I would be happy to wait three months for a result. The children’s phlebotomy clinic was set up with good intentions: its staff are highly skilled, and children are less likely to develop a needle phobia if the blood is taken there, rather than by a rushed GP. But it’s another example of an underfunded service that has failed to keep up with demand.

There was a letter from the chief medical officer reminding me that the NHS should not be providing any pre- or post-operative care for people seeking private surgery abroad. The diminution and degradation of the NHS means that health tourism is booming – but so is the cost of fixing foreign hospitals’ mistakes. The NHS doesn’t have any reliable mechanisms to bill overseas private providers for the follow-up required when British people fly abroad for procedures that go wrong.

Only after looking at my emails did I examine the list of the morning’s patients. I’ve been a GP for 18 years, a partner in this practice for 13 of those, and about half of the 14 names were familiar to me. It’s the enormous diversity that I love about the work. From the names on the screen, I knew I’d be dipping into training in psychiatry, paediatrics, orthopaedics, gynaecology, dermatology and geriatrics. The morning would bring problems that, at one end of the spectrum, seem fleeting and trivial (though they may not seem so to the patient), and at the other, life-threatening and desperate. Both extremes can be satisfying to treat: in its essence, the practice of medicine is about using medical knowledge to ease suffering, and its best manifestations are a strange alchemy of science and kindness. Even the most seemingly trivial encounter would require me to sift through the patient’s story and symptoms for worrying features, exclude scores of potential diagnoses before arriving at the most likely, then formulate a plan that acknowledges the limits of the service and the patient’s own preferences.

Doctors are obliged to train for a great many years, because as a society we expect them to hold a wealth of knowledge about the body and mind, and to exercise wisdom, kindness and professionalism in how they apply it. The enormity of 21st-century medicine, with its increasingly unwieldy power to diagnose and treat, but also to complicate and overtreat, looms over every encounter. Sometimes it seems absurd to me that so many expectations have to be attended to in less than 10 minutes. One of my patients that morning, for example, wanted to discuss two different medication changes, a new rash, worsening hip pain and palpitations – all in a consultation booked for a cough. But though my days are always pressured for time, it still feels as if the job is worthwhile, and usually that it’s possible to do a great deal of good.

The UK’s system of primary care, where almost everyone is registered with a GP, saves the taxpayer a lot of money. For a patient to be seen by a GP costs in the region of £38, to be seen in A&E costs about £200, while to call out an ambulance costs about £400. A year’s worth of GP care per patient costs less than a single visit to A&E. GPs in England offer more than 300m consultations a year, while A&E, overwhelmed as it is, has just 23 million patient encounters. If even a fraction of the patients currently seen by GPs end up at the doors of the hospitals, those hospitals will be swamped.

The current algorithms used by NHS Direct trigger about double the number of ambulance call-outs as GPs do when taking the same call – computers don’t make good doctors. Another reason the ambulance service is overwhelmed is to do with patient expectations of what is a real emergency: one paramedic I know told me recently he was called out for a “bleeding wound” that when he arrived on the scene proved to be a paper cut.

The National Health Service is an amazing institution. It was chosen as the centrepiece of the London Olympics opening ceremony in 2012, though in terms of the quality provided by the service, 2012 now feels like a very long time ago, and it’s difficult to imagine an Olympic opening ceremony in 2024 doing the same. That we still have a system the same for everyone, free for all at the point of contact regardless of means, is something worth celebrating and protecting. But the NHS is not working the way it was intended to.

A nurse walks past a portrait of Aneurin Bevan, the architect of the NHS, in Cwmbran, Wales, in October 2021.
A nurse walks past a portrait of Aneurin Bevan, the architect of the NHS, in Cwmbran, Wales, in October 2021. Photograph: Huw Fairclough/Getty Images

With each year that goes by, I have fewer patients that remember life before the NHS. One woman remembers her mother keeping a jar of money “for the doctor” – they never took holidays, and any spare cash was put aside for medical fees. Illness could ruin a family’s prospects, and frequently did; healthcare for the poor was distributed through churches and charitable foundations with patchy coverage. In 1800, one in three babies born in Britain would die before the age of five; by 1930 that figure was still as high as one in 10. Public health improvements have led to a steady downward trend for infant mortality ever since – one of the steepest drops was between 1945 and 1950 when the introduction of the NHS saw child mortality drop by 32%.

When Aneurin Bevan inaugurated the NHS on 5 July 1948, he wrote to the whole medical profession: “My job is to give you all the facilities, resources, apparatus and help I can, and then to leave you alone as professional men and women to use your skill and judgment without hindrance. Let us try to develop that partnership from now on.”

The partnership between politicians and clinicians about how to make the NHS work in the interests of the British people has now been developing for three-quarters of a century and has at times made the NHS one of the most admired health systems in the world in terms of accessibility, value-for-money, innovation and outcomes for its patients.

In 1950, the UK was in the top six countries for life expectancy worldwide. By 2015, the UK had slipped to 21st, and, by 2021, it had fallen to 29th, because of political decisions about the funding of health and social care. By 2022, more people were dying from being unable to access hospital care than were dying of Covid.

Practising medicine within a national health service is fulfilling because clinical decisions can be made on the basis of need, rather than on the basis of ability to pay. Doctors in an NHS should be able to spend more time with patients, and less time sitting in management meetings or poring over spreadsheets, than doctors in commercial or insurance-funded services. But political pressure to cut costs also cuts the time each doctor or nurse has with their patient – which is why I’m often grappling with three or four significant problems in the absurdly short space of a 10-minute appointment.

For the founders of the service, it was the responsibility of the community to provide all the infrastructure – hospital wards, laboratories, health centres and clinics – in which medicine could be practised, so that the profession could get on with developing high standards of care, rather than developing ways of making money. Most high-income countries have a different system, topping up government spending with a mixture of insurance cover and a range of fee-for-service options. In those systems there is a basic level of healthcare for those who cannot pay, and a sliding scale of possible interventions depending on the nature of the insurance cover you’re prepared to pay for, as well as a catalogue of optional treatments for those who wish to fund treatments that insurance will not cover.

A truck carrying a Save Our NHS campaign message seen outside St Thomas’s hospital, London, in 2022.
A truck carrying a Save Our NHS campaign message seen outside St Thomas’s hospital, London, in 2022. Photograph: Amer Ghazzal/Rex/Shutterstock

Those health services are, as a consequence, far more expensive than ours to run, with a higher proportion of health spending going into management and administration. The idea that the NHS is bloated with managers is untrue, and tends to be repeated only in sections of the media sympathetic to private interests and keen to exploit the enormous potential of healthcare to generate profit: about 2% of the NHS workforce are managers, compared with about 9.5% in most industries. Finance executives within the NHS might wish the wage bill of the service to be lower, but those wages have been stagnant or falling now for many years. In 2022, nurses were being paid a fifth less in real terms than they were in 2010. There are more than 110,000 unfilled vacancies within NHS England, in part because better paid, less stressful work is available outside the health service. (I know of a ward that lost its clinical support workers because a coffee chain nearby was offering better pay.)

Because it is resourced from taxation rather than through insurance, the success of the NHS is always going to be inextricably linked to how well it is supported by government. For too long the UK has relied on the relative efficiency of the NHS, with very low overheads in terms of administrative costs, to justify lower spending on health than other countries. An international analysis of NHS finance and performance published in the British Medical Journal in 2019 concluded that we are falling way behind comparable countries in terms of the quality of our healthcare, but also that we are paying a lot less towards health than those other countries (the study examined Australia, Canada, Denmark, France, Germany, the Netherlands, Sweden, Switzerland and the US.) If we want better care, it concluded, we will need to spend more on health, just as those other countries do.

To say that the UK cannot match the healthcare spends of France, Germany, the Netherlands, or Denmark is to suggest that as a country, the UK is now too poor to have a 21st-century European standard of healthcare – that economically we have fallen too far behind our neighbours. Though successive politicians have voiced frustrations with the enduring public support the NHS enjoys, that very popularity has paradoxically permitted levels of underfunding and underperformance that the public wouldn’t have tolerated in a service that is less well loved.

So how do we save our service? As one consultant physician put it to me: “It’s surely not beyond our wit to come up with a better way.” Let us honour the principles that established the NHS, a healthcare service that’s free for all, funded by the people, for the people. The alternative is to return to the days of keeping a jar of money aside for doctors’ bills, and living in fear of illness. Let’s ask our elected representatives to benchmark the NHS against comparable European countries and insist that they commit to funding our service adequately, so that it can keep up. The voters are more unhappy with the NHS than they’ve been for 30 years, so let’s listen to them and change it for the better. To say that a functioning NHS is unaffordable is to admit to a startling lack of faith in civilised society.

Many frontline clinicians said of the winter of 2022-2023 that it was the worst they can remember, and we need to urgently expand hospital wards as well as community care capacity, to cope with the numbers that need help each winter. A system fit only for summer but unable to meet demand for the rest of the year isn’t a system that’s fit at all. If a plumber suggested installing a boiler that could keep your house warm only in July you would question their sanity, yet that’s exactly the situation we’ve allowed to happen in the NHS. Healthcare needs investment in people – not only by paying them fair wages but also by training them, and trusting in their professionalism. Morale among clinical staff is shockingly low, and there are hundreds of unexplored ways that the mood and working conditions in our hospitals and our clinics could be improved.

The chief medical officers of the UK and the CEO of NHS England now freely admit that the NHS can’t do all of what is being asked of it right now, so let’s start an urgent national conversation, perhaps through citizens’ assemblies, about what its priorities should be. What can the depleted workforce stop doing to free up capacity and time? And how much spending on drugs are the voters willing to support – the current budget allocated to the NHS means it’s not possible to have every modern treatment that every patient might want.

A Support the Strikes march in solidarity with nurses, junior doctors and other NHS staff in London in July.
A Support the Strikes march in solidarity with nurses, junior doctors and other NHS staff in London in July. Photograph: James Manning/PA

Aneurin Bevan said he had a “warm spot” for GPs. “The family doctor is in many ways the most important person in the Service,” he wrote in 1952, after just four years of the NHS. “He comes into the most immediate and continuous touch with the members of the community. He is also the gateway to all the other branches of the service. If more is required than he can provide, it is he who puts the patient in touch with the specialist services. He is also the most highly individualistic member of the medical world.”

Bevan knew that having a trusted generalist at the centre of the service would save it money, and it’s urgent that we find ways of supporting community care, which sees 90% of the patients with less than 10% of the funding. The former CEO of NHS England Simon Stevens said in 2016: “If general practice fails, the NHS fails,” and general practice in many parts of the country is now shockingly close to disintegration. The current situation is dire: I receive desperate emails every day begging me to work, and those practices are places that even three or four years ago had no difficulty in recruiting. We need to find new ways to cherish generalism, and ask of the specialists, what standards are “good enough” to get the best level of care to the greatest number of people? Because by focusing on stratospheric standards in some areas, we have let others fall to appallingly low levels.

Don’t be fooled by the brochures and promises of private healthcare companies, whose profits are bolstered by a struggling NHS, which also helps them manage their failures. Private companies take their doctors from the same pool as the NHS, and so outsourcing NHS services to private companies just makes it harder for the NHS to recruit, and costs the taxpayer more in the end. Clinicians need more time with their patients to have conversations about what the marginal benefits of many drug treatments really are, and whether giving a formal diagnosis is always appropriate. If we could have honest discussions about the benefits, risks and alternatives to many prescriptions and procedures, there’s a good chance we would do fewer of them.

Until the downturn in life expectancy caused by Covid and by policies of austerity, people were living longer than ever before. In a caring, civilised society, having an ageing population needn’t be a burden, but something worth celebrating. Let’s build a network of home care teams and intermediate care hospitals that can keep the frail and elderly people away from trolleys on corridors and queues in A&E, finding ways of looking after them closer to home with dignity and compassion.

At a teaching session recently at my local medical school, a disconsolate and anxious group of students asked me about falling standards in the NHS and dismal morale, and whether there could be any hope for their own careers. “We look at the junior doctors,” one said, “and wonder what it is that we’ve signed up for.”

I told them that in the mid-90s, when I started out in medicine, the feeling in the NHS was the same: a burned-out, exhausted workforce was fed up with working in a failing, underfunded service. Patient dissatisfaction was at an unprecedented high when, in 1997, there was a change of government. The voters demonstrated decisively that they wanted their politicians to put the NHS back at the top of their priorities, and taxpayers’ money flooded in. Morale among doctors, nurses and allied professionals began quickly to rise, and patient satisfaction, too; within a few years of the change, studies were being published that put the NHS among the most effective and efficient healthcare services in the developed world.

“The disenchantment in the NHS now won’t last for ever,” I said to those students. “The fortunes of the NHS will improve again, they have to.” I told them that despite all of the challenges of the service as it is today, caring for others remains the most rewarding of jobs; to work in medicine or nursing is to engage your intellect, your curiosity, your humanity, your compassion, and there’s no other job I’d want to do.

The principles on which the NHS was founded are still widely revered – good-quality healthcare for all based on need rather than on means. Bevan said: “No society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means.”

Whether its founding principles can continue to stand up against the costs of a 21st-century world of gene therapy, robotic surgery, innovative biologic treatments, stem-cell transplants and a population that’s living longer (and with more frailty) than it has ever done, remains to be seen – but I’m optimistic. The alternative is to admit to a lack of imagination and compassion. A health service free for all at the point of use, paid for by everybody, for everybody, is an expression of what’s best in our society. I hope you’ll agree it’s worth saving.

Free for All: Why the NHS is Worth Saving by Gavin Francis is published by Profile Books & Wellcome Collection on 31 August. To order a copy, go to guardianbookshop.com

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