Whither Our UK NHS ? Consultation Responses

Editor's note: I can now confirm from personal experience that the situation with respect to availability of 'routine' appointments is truly dire. 

I attempted to book one at our local GP practice over the counter yesterday and was told '...sorry, there are no available appointments on my system'. An attempt today to book an appointment online via the SystmOnline software our practice uses for bookings showed no appointments available in the period where booking was available, ending mid-September (i.e. at least an 8-week wait!).

This is clearly unacceptable and confirms that a policy of 'Rationing by Availability' by the NHS is in force. On the basis of recent media reports, I suspect this is country-wide and not just an isolated case.

The government has emphasised the need to keep the population healthy to help the NHS, and we are regularly encouraged not to delay if we detect anything 'out of the ordinary' with our health, as this could indicate a serious underlying problem. 

How on earth does this square with a complete unavailability of any opportunity to provide this information to our GPs ? 

It's one way of reducing the 'excess' elderly population, I suppose.....

Self-treatment would therefore appear to be the only option. Hope I'm successful......if not, this blog may finally go quiet....

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The NHS has never been more ripe for reform. I published my ideas on this initially in a 2022 blog, and the content has been updated periodically to take into account such progress as was made by the previous government.

The present government has accepted that the service is 'broken' (all the fault of the Tories of course!) and decided to request input from the public and NHS staff before attempting to implement any major reforms. This was a welcome development and did the new minister and his department credit. However, in the interests of openness we need to ensure the responses are actively considered, and where appropriate, acted upon. There needs to be a mechanism for providing confirmation of this, and feedback on ideas suggested /implemented.

In my previous blog, the main message that emerged from a hard look at the current system was that a new funding model will be essential if our NHS is to become fit for purpose again, and remain so. We have only to look at those of our nearest European neighbours with similar population sizes and demographics to convince ourselves of this. Although our healthcare spend as a proportion of GDP at 10.9% is comparable to other developed countries, the difference is that we fund this entirely out of taxation. Demand is projected to increase by ca 2.5% p.a., so the problem is only likely to get worse.

Unfortunately, a projected UK population of 75 million plus by 2030, with its ageing demographic and poor general state of health, cannot be provided with effective modern healthcare via public taxation alone – at least not at the levels of overall tax burden that our electorate would tolerate. This will inevitably mean involving private finance, some form of Government-sponsored health insurance,  and commercially-funded hospital/community facilities. The arguments for this are quite compelling, and I’ve already considered them in depth elsewhere, so will not repeat them in this blog. Please use the link above to the original 2022 article for more details.

I’ll use this new blog to consider some suggestions about the detailed changes to the various parts of our healthcare system proposed by government. I’ll also attempt to assess their merits, and provide some caveats on the practicalities of implementation.

1)       Shifting healthcare from hospitals to the community. This is a laudable aim and one which will be key to effective reform of the system. Most patients would welcome treatment in a friendly local setting they’re used to and can access easily, rather than in a noisy, overcrowded and impersonal large hospital setting, already on its knees trying to cope with demand. Traditionally, in the early years of the NHS things were done much more locally, with GP surgeries dealing with most of our ills, and relatively few patients even being referred to their local hospitals, which were smaller and more locally-based than today's centralised behemoths. Unfortunately, between the 1960s and 1990s as we got older and more numerous, and medicine became more centralised, costly and tech-oriented, the emphasis shifted to large regional hospitals, with the old local District and Cottage hospitals being scrapped on grounds of cost and inefficiency. This, coupled with chronic overload on GP surgeries and a lack of UK in-house medical training of sufficient new hospital doctors and GPs, has resulted in the system we have now, which is clearly not fit for purpose. The transition back to more localised healthcare will not be easy, as it will require new infrastructure and a radical change in organisation of the system. The key feature for it to work must be integration of services.  The idea of collecting all healthcare services under the same roof locally is a good one, but could lead to large and unwieldy conglomerates, and will require much new building. This may not be easily affordable in the short term, (or indeed practicable, given the chronic shortage of skilled labour in the building industry and competition for it by Labour's requirement for 1.5M new houses by 2029). Funding for the infrastructure needed for these new facilities is also likely to be resource-hungry….and subject to both cost and time over-runs. There must therefore be a more pragmatic interim solution to integration to help ‘get things off the ground’. Above all else, we must also ensure, as do our EU neighbours, that Adult Social Care (including hospice provision) is properly integrated into the new system - see below for more detail on the importance and practicalities of this. We will also need to provide adequate funding, and of course the well-paid, motivated and skilled staff, to make all this happen – which brings us back once again to the need for a sustainable funding model.

2)       Centralisation of digital records: As with any growth process, keeping tabs on, and interpreting,  all the data the system generates as it grows and reforms is an essential requirement. The NHS will be no exception. What we have now is a ‘hotch-potch’ of historical IT systems extensively patched together and barely functional. This type of arrangement provides an easy target for hackers, whether state-sponsored or seeking ransoms, as we have seen on a number of occasions recently. Any new system must at its core consider security first – the next world war will probably be fought largely in cyberspace and we need to ensure our healthcare system is as resistant as possible to external attack going forward. Any new system is only as good as its weakest link, and for the 'new' NHS we must ensure that link isn’t its IT infrastructure. It’s also essential that all elements of any new digital healthcare software are exhaustively tested before ‘going live’ – I’m well aware from my own efforts in writing code for software applications intended for use by others in the pharmaceutical industry how important this is. Always ask naïve members of your organisation, or better still the public, to test your program or app before releasing it – if it can be broken, you can be sure they’ll break it for you – and also tell you in no uncertain terms where your design is going wrong! The new IT system must also take into account that it will also need to be accessed by people with a wide range of digital experience and skill, from the highly ‘tech savvy’ to someone in their 80s or 90s who has never used a computer and doesn’t want to start now…(one particular issue that has already surfaced is access to the new 'all-singing-all-dancing' NHS app. Looking at its applicability, the latest version of the app appears only to be available to devices running Android v8 or Ios v15. Many of the NHS's older 'clients', will have older devices runing significantly earlier vesrions than this, so will be excluded 'at source'. Since these are likely to be the service's most frequent customers, this particular planning error does not augur well for 'digital integration'....the only solution is to ensure that the app is downward compatible (at least to Anrod 5.0 or Ios v10)).

3)       Holistic approach to medicine: Our western European neighbours have long realised the importance of keeping their populations healthy, particularly the Scandinavian countries, where holistic medicine now forms the backbone of their healthcare systems. Our own population is now acknowledged to be one of the ‘sickest’ in Europe…and is getting sicker. This is not just a result of the natural ageing process, but reflects our increasingly sedentary and unhealthy lifestyles and eating habits, and our lack of understanding of the implications. It is also rooted in the poor availability of healthcare; access to GP surgeries is now severely rationed 'by availability’, thus making rapid diagnosis, and treatment where necessary, a thing of the past.  This has already had major implications in outcomes and survival rates for potentially fatal conditions such as cancer. Various attempts by governments and healthcare professionals have been made over the years to address our population's poor general state of health, but fundamentally change will only occur if we change our own attitudes, and can also get access to, and support from, our GPs when we feel we need it (and not months later, when we've either died, or forgotten what we made the appointment for !). We will also need to ensure everyone has the opportunity and funds to afford healthier foods, jobs and living conditions. To do them justice, most GP practices are already embracing the idea of keeping their patients healthier, with many already offering periodic health checks to the over 65s, blood pressure and cholesterol checks, etc. but the impression is that this may be adversely affecting availability of routine appointments. It’s also important to ensure that patients don’t find this new approach intrusive, or feel they are being told how to run their lives…or even spied upon. Persuasion is the key to patient ‘buy-in’, rather than compulsion – it will simply not work otherwise. An important part of the process will be patient education, with easy and unfettered access to their records by patients when they need them to understand and follow their own treatment programmes. Patients must also have the opportunity to contribute to the treatment planning process when and if they want it. As a reasonably ‘tech-savvy’ pensioner myself, I can confirm that the current online access system is unnecessarily difficult to navigate at the best of times and does require a degree of ‘digital tech competence’, involving as it does multiple levels of registration  and security, and of course access to a smartphone with an internet connection. Any new system must be reliable, seamless…and accessible to all on request. ‘Wearable Tech’ has been suggested as a way of monitoring patient health remotely – again a nice idea, but fraught with potential implementation problems and cost implications. Patients will certainly not want to feel they are being ‘tagged’ and spied on, as is done with some offenders released into the community.

4)       Adult Social Care (ASC): As discussed, this must be integrated fully into the ‘new NHS’. The arguments for this are overwhelming, and are supported by the success of our EU neighbours in managing the health needs of their own elderly citizens. At present in UK we have the entirely unacceptable situation of inadequate residential placements and a chronic lack of home support, largely due to Local Authority budget cuts. This has led to extensive hospital bed-blocking, ambulances queuing to release their patients to A&E wards, and patients spending days in hospital corridors....and sadly sometimes even dying there! The only way of alleviating this lamentable state of affairs is to focus on keeping the elderly supported in their own homes for as long as possible, and providing sufficient residential places for them to go at the end of their lives when they can no longer cope. The role of unpaid carers is particularly important and needs to be recognised, and adequate support provided for them to continue in their vital support to the NHS. Hospice care is also seriously underfunded and largely run by charities. Their provision also needs to be enhanced, given the change in demographics and increased demand for end-of-life care. The debate about assisted dying may also figure in decisions on future healthcare provision. As discussed, a well-funded ASC system with well-paid and motivated staff is also key to efficient functioning, and would solve many of the problems our hospitals are facing today, by keeping as many of us as possible out of expensive and scarce hospital beds. 

F     Final Thoughts

I hope this blog provides some useful ideas on the reform of our NHS, which cannot come soon enough. If the current government, with its super-majority, does not 'grasp the nettle' and engineer radical change, the system will continue to teeter on the brink of collapse, and may actually go over the edge at any time. Amongst other implications, this would effectively break the government's contract with its NI contributors, who have paid for a healthcare system which is free at the point of need, and could lead to legal challenges in the courts.

The key message still has to be the need for a change of funding model – only this will enable the changes discussed to be fully and sustainably implemented. Meanwhile, dissatisfied and often desperate patients are turning to private medicine for relief in droves, and the NHS itself is calling on (and paying through the nose for!) private facilities in an attempt to fill the gaps in public provision and reduce the now colossal waiting lists. 

Reform of funding now could actually save the majority of UK healthcare provision from 'going private by default', and leaving a substandard and ailing 'bottom tier' for those who can't afford it.....given their socialist ideology, and the obvious current dissatisfaction with their progress so far, one for our political masters to consider carefully, I would think. 

Update 9.7.25:We now have sight of government's 10 year health plan for the NHS. See link to the executive summary. Although this document does provide some evidence of useful developments in the pipeline, it is disappointing in that it makes very little mention of how our adult social care system, which is ackowledged to be close to collapse, is to be dealt with. 

Much is made of the intention to move medicine into the community via 'all-in-one' health centres. These new setups could not possibly be expected to deal with the rump of patients in their last years who are not mobile enough to attend appointments and need regular care at home, and then residential care when they can no longer cope - there are just too many of them. I suspect the size of the problem and its cost is deterring any real attempt to deal with it. I appreciate a 'first things first' approach is necessary, but sorting this one out this is fundamental and needs to be addressed before we can progress in other areas (e,g hospital bed-blocking).

The other issue is 'digitisation'. This is a laudable aim, of course, and has to work if the integration of services proposed is going to be possible. Sadly, one major error in the practicalities of implementation has already surfaced - that of so-called 'version creep'. The latest 'all singing, all dancing' version of NHS app, which planned to be at the centre of things, can now only be accessed by those with smartphones or tablets with operating systems (OS) of recent vintage (minimum Android v8.0, Ios v15.0). It's necessary to go back as far as v2.30 (March 2023) to find anything compatible with Android 5.0, and this version will probably not work with existing HS databases. Many of the NHS's 'frequent fliers' i.e. those in their 70s onwards will either have no access to a device at all, or will have a older one which would probably not be upgradeable. Thus the 'IT team' have already fallen into the trap of disenfranchising a substantial proportion of their intended 'customer base'. Not a particularly auspicious start, then. 

If NHS digitisation is to work at all, it must cater for the whole population, not just the 'tech savvy' few. If it's not possible to make the NHS app downward-compatible with earlier versions of OS (I'd recommend Android 5.0 and Ios 10.0 to be sure of capturing most users) then those without the appropriate equipment should be provided with a suitable device AND sufficient training in its use for them to be happy using it. This is the only way the project will have any real chance of success....

First Published 23.10.24; Revised 9.7.25

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