Turning up the heat on the NHSBMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n2618 (Published 29 October 2021) Cite this as: BMJ 2021;375:n2618
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I read with interest your recent “Turning up the heat” editorial (1). Although I very much respect the author, as a concerned citizen and a consultant in Public Health Medicine who has been watching the recent developments in the health sector with some dismay and sadness, I wish to put forward an alternate perspective. The question I ask myself is who is turning up the heat on who? I must say both the parties, the government and the health system are turning up the heat on each other. With winter fast approaching turning up the heat at offices and homes might be comforting and provide health dividends but the current cold war or what can be seen as open confrontation between the government and unions representing the clinical workforce can only have disastrous consequences for our patients and communities we serve.
Threat of industrial action (3) is looming large from the gate keepers of the NHS without whom the NHS will be overwhelmed in no time. Consultants who provide clinical leadership and are ultimately responsible for the quality clinical care the NHS delivers are very unhappy with the government with 91% of expressing the view that they are not being valued (4). Those who run the NHS have expressed serious concerns (5) about their ability to deliver care this winter; “84% of trust leaders were very worried or worried about their trust having the capacity to meet demand for services. Just over half (51%) of trust leaders rated the current quality of healthcare provided by their local area as very high or high. A recent survey (6) of over 3700 consultants reported that nearly half of the consultant posts are not filled due to lack of suitable applicants and the consultants estimate that they work 11% more than they are contracted to work due to their clinical load. According to a recent NHS confederation survey (7) “Nine in ten NHS leaders say that current demands on their organisation are unsustainable, with just under nine in ten saying that a lack of staffing in the NHS as a whole is putting patient safety and care at risk”.
Royal college of nursing whose members form the backbone of the NHS has listed 10 unsustainable pressures facing health and care system in the NHS (8) with the top 3 being high NHS bed occupancy rate, sickness absence in the nurses and high NHS nurse workforce vacancy rate. A King’s fund blog paints (9) a gloomy picture of NHS waiting list for elective care equalling the population of Denmark at 5.6 million. We must reflect on the potential suffering, agony, and pain of waiting for care of the millions of our fellow citizens and residents. Pharmacists who are the most accessible parts of the NHS might take industrial action according to their journal (10). The recent report (11) by the Association of Ambulance Chief Executives titled “Delayed hospital handovers: Impact assessment of patient harm” makes very disturbing reading. The key findings of this clinical review which looked at samples of handover delays over an hour that occurred across the country on 4th of January 2021, is that the proportion of patients identified as potentially having experienced harm is significant. The report found 8 out of 10 whose handover was delayed having experienced some level of harm with just under 1 in 10 being classified as potentially experiencing severe harm. None of these is good news for the public who depends on the NHS to cure them when ill and comfort them when they suffer. All these publicly available exchanges show a system under pressure with potential consequences for patient care and safety and could significantly hurt the morale of staff and the public.
We are just coming out of a pandemic and the government has taken some bold steps and there are many things to celebrate together and as a country we managed the pandemic reasonably well (12). Our vaccination rates of over 88% first dose and 80% second dose are envy of many of our European neighbours who are currently facing civil unrest (13) due to the COVID control measures they had to introduce due to their low vaccination uptake. We achieved success in managing the pandemic by collaborative working and adopting the mantra “we are all in this together”. In the pandemic landscape we are not out of the woods yet. We face a dual epidemic of COVID and those waiting for elective care. In the land of primary care, the issue face to face or remote consultation has been the area of contention with media highlighting some of the perceived or real adverse impact (14) of lack of opportunities for consultation in person with GPs. With such headlines any responsible government need to address this and seem to be acting (15). Integrated Care Systems (16) are seen as the panacea by some for all the NHS ills, but these structural and functioning changes will take time to bed in. NHS is like a huge tanker which takes a long time to turnaround, and we need to solve the problems right now including this winter which is weeks if not days away.
If I am the government minister (thankfully I am not) I may feel I am under constant attack from all sides and heat is turned up on me. My humble view is instead of turning up the heat on each other which will only lead to an explosion causing huge detriment and distress to our patients. The need of the hour is to avoid using inflammatory language like turning up the heat and work together collaboratively to steer us all through this winter safely with minimal loss of life and suffering. No doubt we must find solutions on how best we look after our increasingly aging population and this can only be found with an open and honest dialogue between different players in the health and care system, government of the day and the great British public.
Dr Padmanabhan Badrinath, Lead Consultant for Health Protection & Lead for enhanced COVID Specialist Team, Public Health Suffolk, Suffolk County Council & Associate Clinical Lecturer, University of Cambridge.
Directorate of Public Health & Communities, Endeavour House, Suffolk County Council, Ipswich, IP1 2BX firstname.lastname@example.org
Disclaimer: The views expressed here are the personal views of the author and in no way represent the views of his employer, Suffolk County Council or the University of Cambridge.
Conflict of interest: The author works in a local authority Public Health Department and is a member of the British Medical Association, (BMA) the trade union and professional body for doctors in the UK.
(1) Edwards N. Turning up the heat on the NHS. BMJ 2021;375: n2618. Available from: https://www.bmj.com/content/375/bmj.n2618
(2) Nuffield Trust. Evidence for better health care. Available from: https://www.nuffieldtrust.org.uk/our-priorities
(3) Haynes L. GP industrial action ballot over access plans to end mid-November, BMA confirms. Available from https://www.gponline.com/gp-industrial-action-ballot-access-plans-end-mi...
(4) Mahase E. BMA refuses to engage with consultant pay review process amid call for reform. BMJ 2021; 374: n2192. Available from https://www.bmj.com/content/374/bmj.n2192.full
(5) NHS providers. State of the Provider Sector 2021. UK Health Security Agency. November 2021. Available from https://nhsproviders.org/media/692535/state-of-the-provider-sector-brief...
(6) Trudgill N, Phillips C, Nagamootoo D, Newbery N. Life in the time of COVID-19: the 2020 UK consultant census. Available from: https://news.rcpsg.ac.uk/wp-content/uploads/2021/11/Life-in-the-time-of-...
(7) NHS Confederation. Under pressure: NHS priorities this winter. Available from: https://www.nhsconfed.org/publications/under-pressure
(8) Royal College of Nursing. 10 Unsustainable Pressures on the Health and Care System in England. November 2021. Available from: https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/public...
(9) Ward D. King’s Fund. NHS waiting lists: how big is big? 11 November 2021. Available from: https://www.kingsfund.org.uk/blog/2021/11/nhs-waiting-lists-how-big
(10) Wickware C. Union warns of potential industrial action as Boots pharmacists reject pay rise offer. The Pharmaceutical Journal, PJ, October 2021, Vol 307, No 7954. Available from https://pharmaceutical-journal.com/article/news/union-warns-of-potential...
(11) Association of Ambulance Chief Executives. Delayed hospital handovers. Impact assessment of patient harm. November 2021. Available from: https://aace.org.uk/wp-content/uploads/2021/11/AACE-Delayed-hospital-han...
(12) Badrinath P. War on COVI19 - State authority, social responsibility and saving lives this Christmas. BMJ 2021;375:n2773. Available from: https://www.bmj.com/content/375/bmj.n2773/rr-0
(13) Sky News. COVID-19: Austria starts new national lockdown as protests against coronavirus restrictions spread across Europe. Available from: https://news.sky.com/story/covid-19-austria-begins-another-covid-19-lock...
(14) Independent. Student would not have died if he’d seen GP face-to-face, family says. 18 October 2021. Available from: https://www.independent.co.uk/independentpremium/uk-news/gp-appointments...
(15) Haynes L. GP online. Patient choice should determine whether GP appointments are face-to-face, says Javid. 2 November 2021. Available from: https://www.gponline.com/patient-choice-determine-whether-gp-appointment...
(16) NHS chief announces next steps for local health systems. 11 November 2021. Available from: https://www.england.nhs.uk/2021/11/nhs-chief-announces-next-steps-for-lo...
Competing interests: The author works in a local authority Public Health Department and is a member of the British Medical Association, (BMA) the trade union and professional body for doctors in the UK.
It is clear that the politicians' views of the NHS, their short-sighted “fixes”, are not going to help rebuild the enormous and old structure that is the NHS, to respond to the advances in medicine and the
expectations of society. On the contrary, they are destroying the bit of good left.
The NHS was built in a different environment, post-second world war, and the spirit of sacrifice and dedication that many put into it is long gone. Decades of erosion for political gain, bullying into absurd performance tasks, recurrent organisational changes, and waste of resources, have led us to the current situation. The significant workforce crisis is not new, it is endemic, and it is far from a solution in sight.
It is a pity there is such criticism of primary care, for example, where there are now more consultations than ever before while each year the number of GPs decreases. There is an unrecognised larger workload per individual. Unfortunately, rather than complementing the efforts and sacrifices made trying to keep the service functioning, there is only criticism. It seems that only face to face consultations are now valid. Primary care was looking for different ways to improve access to services before the pandemic. In 2014, many Clinical Commissioning Groups engaged with their practices looking for new models of care, for better technology use .
There is a need to work more efficiently, to look for new ways to deal with the current demand. There is an urgent need to change, not to waste time always thinking the past was better, that we need to move back. It is time to build new models of care using the XXI century technology at our disposal, it is time to progress, to support and encourage people to be part of it.
1. NHS England (2015). About wave two pilots. Primary Care 2.0 – West Leeds.
Competing interests: No competing interests
A third of the hospital beds of France and a fifth of Germany tell you all you need to know about a health service run by politicians since 1948. Perhaps the BMA were right all along you can't trust politicians with your health service.
Competing interests: No competing interests