The Prime Minister insists that the only way to increase health funding is more taxes for the NHS.  Of course UK health care is under funded but it is crazy to think that just throwing more money at the NHS will help.  Spending up to the European average won’t solve anything.  Scotland already has exactly the EU average, and longer waiting lists and worse health outcomes even than England. 

We need to find ways to encourage staff to follow the needs of patients, rather than their own priorities and interests.  In my hospital we had a discussion the other day about offering the morning-after pill in casualty, but the plan got held up because staff were fearful of the demand!  Imagine if Sainsburys only stocked sliced white loaves, for fear that if they offered crusty French sticks everyone would want one!  If there’s a queue in the supermarket a manager moves over and opens another till.  Why can’t the NHS be more like that?  Why can’t we have a health service where staff are pleased rather than dismayed to see a busy clinic?

We won’t do it by having more league tables, inspections and guidelines.  They divert staff from patient care.   Nor can we do it by blaming the managers, and saying we need more hard-working doctors and saintly nurses.  Doctors, nurses and managers are no different from the rest of us.  Some work very hard indeed, and some are bone-idle.   They follow incentives like everyone else.   Every patient has a story of queuing while staff arrive at the clinic late, or linger in the coffee room.  Stories of minor rudeness, of failure to pick up rubbish or mop up bloodstains are no longer newsworthy.  We’ve become so inured to them that it’s only when we fall ill in France or Germany that we realise how far behind the NHS has fallen.

The problem is the system.  The NHS is a monolithic nationalised industry that makes life comfortable for its senior staff at the expense of patients.  It doesn’t need to be like this.  In Europe government, private and charitable hospitals all chase patients who are insured either by themselves, their employer or the state.  The system looks messy but it serves patients better.   If the waiting list is six months you walk down the road to the next hospital.  Since the fee for your operation goes with you, the doctors and managers have an incentive to get their act together. 

Waiting lists are a life and death matter for patients with cancer and a huge inconvenience even for people needing minor procedures.  I recently came across a single mother of three who had waited nine months for a sterilisation operation and conceived twins while doing so!  However, waiting lists are not a fact of life.  European hospitals don’t have them. 

They result from a vicious cycle of inefficiency.   If a woman has heavy periods and needs a hysterectomy in Germany she goes to see a specialist who checks her out and does the operation.  The whole thing can be sorted out in a few weeks.  A simple hysterectomy is not rocket science!   Things are different in the NHS.   Her general practitioner often delays referring her and it may be weeks before she eventually gets seen.  Often she sees a junior doctor who, rather than making a final decision, orders tests and further appointments. These are never on the same day.   Unlucky patients may spend years coming back for tests, locked in a Kafkaesque bureaucratic nightmare, before finally joining the waiting list proper.  Sensible patients, go to the doctor early in the hope that they might actually get an operation when they really need it.   If they get better while waiting, all their appointments are wasted. 

The NHS pays doctors and nurses more or less the same salary whatever they do.   The consultant who sees 20 patients in a clinic gets the same as her colleague who sees ten.  The NHS even rewards consultants who skip off early to sit on lots of committees.  They often get a special salary supplement called a “Merit Award”.  This is why the staff doing the life and death work, dealing with strokes and heart attacks are so desperately busy.  Their bosses have found a good reason to be elsewhere. 

My field is pregnancy and the most dangerous part of pregnancy is labour and delivery, particularly if there are complications.   You might think that this would be the time when the consultant would be most involved.  In the rest of Europe you would be right.  In Holland for example it is almost unthinkable for a consultant not to be present for a Caesarean birth, certainly a complicated one.   Not so the NHS.  Last year the Royal College of Obstetricians became worried about this and set a standard for consultant attendance at complicated Caesareans births.  They didn’t expect NHS consultants to come in every time but they set a target.  What did they choose?  90%, 50%, 25%?  No. The target for consultant presence even at complicated Caesareans was 10%.  Although this sounds awful, fortunately things are not quite this bad in practice.  Many of my colleagues are working valiantly to improve things, and three quarters of hospitals in England manage to beat the target.  Nevertheless, talk about the poverty of low expectations! 

Many NHS midwives are playing the same game.  You might think that the central job of a midwife would be to deliver babies.  But labour wards often have too few staff to provide the one midwife per patient that everyone agrees is ideal.  Now this is odd, because there are a lot of midwives.  Over 18,000 whole time equivalent qualified midwifes were employed by the NHS in 1998, one for every 32 deliveries.  So where are they?  They’re on counselling courses, designing health care plans, and have gone into management to talk about how we need more midwives on the labour ward.  A system that followed patients would be very different.  Ask mothers whether they want consultants and midwives in the antenatal clinic doing preventive medicine or in the labour ward when serious complications occur. 

What should be done?  I support the NHS.  I work in it and believe in it, but it needs a shake up.  It should not be the only health provider in the country.  It should compete with private doctors, and with private and charitable hospitals.   Nor should it get all its money from the taxpayer.  That’s too easy.  It should have to earn a substantial portion from other sources, from patients paying themselves, or those with private, employer, or government insurance.  Let the patient decide where they want to be treated and let the hospital that treats them get paid for doing so. We need a diversity of competing hospitals to keep each other up to the mark.  What Blair has offered is more of the same monopoly.  

 Jim Thornton Leeds 22 Feb 2002

 Jim Thornton is a consultant in Obstetrics and Gynaecology working in the NHS