The NHS could do better

The National Health Service (NHS), mostly free at the point of need, is greatly valued by the UK population and is admired in many other countries. Lengths of stay in NHS hospitals have fallen and outcomes have markedly improved, even though there are fewer hospital beds, doctors, nurses and funding than in comparable countries. The continuing triumphs of the NHS should certainly be recognised. However, the gigantic machinery of the NHS is out of control, and the good intentions of Government and management to maintain quality of care and contain costs have failed. Thus, it continues to stagger from crisis to crisis. Advances in medicine and the increasingly elderly population make it likely that the financial demands will always exceed the available funding and so compromises will be needed. When the NHS cannot afford a service, then patients and the health professions, as well as management and Government, must all be involved.

We make a number of suggestions to improve the NHS, which together could improve patient care, often at less cost, improve management and raise professional staff morale without any major new legislation.

To put patients first

The primary focus of the NHS is to serve patients in need. Thus, the mutually trusting relationship between the patient and doctor becomes critical.¹ Continuity of care should be a smooth pathway for patients between primary, secondary and tertiary services, but many complain of disjointed care between hospital, community and primary care.² Integration would also allow general practitioners (GPs) and hospital consultants together to improve transfers of care, exchange information and postgraduate experience and provide supervised experience for those in training.

Patients want early diagnosis and referral for treatment, which can save short- and medium-term costs.³ Often, specialised clinical experience and diagnostic facilities can only be organised cost-effectively in hospital centres. Current misguided attempts to save costs through limiting the number of referrals from primary to secondary care are fruitless and morally wrong. GPs should be facilitators rather than gatekeepers for access to secondary care.

A serious and unresolved problem is the tight restriction on the working hours and rotas of trainee doctors imposed by European law⁴ and by the so-called New Deal contract negotiated with the British Medical Association.⁵ Clearly, tired doctors should not work excessive hours, but the restrictions have forced ‘shift work’, which damages the continuity of acute care.⁴

Patients also recognise many distressing examples of poor care in both primary and hospital settings, many due to multiple failures of systems, equipment and staffing, rather than to a single individual. A more open culture of recording and learning from errors would help.

Successive governments have been frustrated because they have little influence on what goes on in the workplace. Therefore, they fall back on unhelpful public criticism of the overworked professional staff, rather than partnering with them to protect the quality of the service. Concerns or complaints from staff (whistleblowing) are often treated by local managers as a disloyalty, rather than as a valuable contribution from experienced people on the front line.

Reporting of concerns by staff should be mandatory and encouraged by being discussed during each annual appraisal, so that staff can reflect with their appraiser on any failures of standards of care that they may have seen and action that was taken.

The role of trainee doctors in recognising poor care is especially important. Hospital management should make real efforts to gather reports of concerns from trainee doctors, and so together develop ideas for improving care.

Poor care by inadequately trained healthcare assistants (HCAs) is often due to poor leadership, rather than poor individual practice. It should be mandatory for them, and most people working in the NHS, including managers, to be registered and undergo annual appraisals of their practice; this would drive up professionalism and standards of practice.

To improve the medical profession’s care of patients

Further problems may have arisen when primary care widely relinquished out-of-hours responsibility for emergency care, putting extra pressure on local Accident and Emergency (A&E) departments,⁶ which are usually open 24 h. Where else can an ill patient go to ‘out of hours’? While extending hours of work by GPs for less urgent conditions should reduce pressures on A&E departments, it will not reduce the needs of seriously ill patients. A&E departments must be adequately manned and pressure on their services reduced through relieving the ‘knock-on’ effect of ‘bed-blocking’ in hospital wards by increasing the resources of community services.⁷

The limitations of the working week have also compromised the training of junior doctors.⁴ They have disrupted clinical teams so that senior and junior doctors are often no longer able to work together, and have reduced the opportunities for junior doctors to learn and gain supervised experience and support; they must be made more flexible.

A seven-day 24 h hospital for acute care is theoretically desirable and is generally accepted by the medical professions;⁸ however, it will only succeed if there are full back-up and diagnostic facilities with inevitable increased costs. More information is needed to understand the cause of the often quoted excess weekend mortality, and so identify the measures likely to keep these costs to a minimum.⁹

Both managers and government must recognise and respect the contribution that only the professionals can give to individual patients. The current increasing attempts to de-professionalise clinicians must be reversed; they cannot be treated as technocrats, and until this is recognised and implemented, we believe that professional staff morale, and hence standards of care, will remain low.¹⁰

Many of these recommendations will be effective only if there is good clinical leadership supported by both local management and government. The professionals are no longer allowed to exert the leadership influence needed to improve the care of patients.^10,11 The Medical Royal Colleges have good links with their members in the workplace, and have produced reports, such as ‘The Future Hospital’¹² and ‘A blueprint for building the new deal for general practice in England’,¹³ audits, guidelines and service accreditation systems that improve standards of care. They must be allowed to work more closely in equal partnership with both management and Government.

To help management and government improve patient care

As in any public service, there must be an equal and mutually respecting partnership between the professions and management; this must be established at all levels of the NHS.

The Chief Executive of the NHS, Simon Stevens, has issued his ‘Five Year Forward View’ on the management of the NHS.¹⁴ We add some practical and cost-effective ways to achieve many of his broad principles.

Managers at a local level are under pressure, and even threat of dismissal, should they fail to achieve well-meaning central targets. Central directives on targets, financial incentives and, even worse, fines, are counterproductive, demoralise staff and often take money away from a local hospital or practice where it is most needed. Savings could be made without loss of standards of care, if the fruitless imposition and monitoring of many of top-down targets were stopped.

Economists argue that some costs of clinical care can be saved through competition, exposing the NHS to cold draughts of new ideas. However, competitive healthcare is expensive to organise and, as seen in the USA, over-investigation and over-treatment of patients follow.¹⁵ A centrally driven policy of a competitive market in clinical care fails because it cannot adapt to many ‘unprofitable’ illnesses, although competition can reduce some costs of non-clinical care. The NHS is thus in the difficult position of trying to be business-like, even though the care of patients is not a business! On the other hand, the transparent sharing of results of comparable data between hospitals, units and practices can be a strong professional motivator for improvement, efficiency and cost.¹⁶

Medicine is increasingly complex, and no clinician can remain an expert in all conditions; the consequence has been greater specialisation, so that patients, especially those with multiple diseases, are not always treated holistically. This cannot be corrected simply by transferring them back to the overworked generalist in primary care. The highest quality of modern medical practice cannot be provided by every area of the UK. Tertiary care based on supra-regional centres provides optimal care for many rare diseases and for difficult types of common conditions. This is a well-tested solution in the NHS to minimise regional inequalities in the NHS in a cost-effective way.¹⁷ To achieve this, when necessary patients are usually willing to travel for the best opinion, investigation and treatment, but these centres must work with more local services to minimise travel.

Very large sums are spent on agency doctors, especially GPs and nurses, in response to local crisis management. Money could be saved if the real number of professional staff required to be trained and to run the NHS is implemented.

The experience, wishes and concerns of patients (and staff) can be a valuable influence on standards of local Services. Patients and relatives should be routinely asked for their opinions when leaving the ward or clinic. One or two patients should sit on each Trust Board who, together with an independent clinician, could oversee how the hospital handles patient and staff concerns, encourages staff morale and balances these against considerations of finance.

Not least, patients and doctors also know that the clinical roles of the unappreciated and poorly rewarded clinical ward ‘sisters’ are crucial for the care of patients in hospital, but their retention is poor. This must be addressed.

As Simon Stevens points out, prevention of disease should reduce the workload on the Service, at least in the short and medium term.¹⁴ Evidence-based public health measures to prevent disease such as those relating to alcohol, smoking and obesity can be effective, but probably require some legislative actions.

Conclusion

Implementation of these practical proposals could improve patient-centred care, often at minimal cost, and raise staff morale; all without major legislation.

Declarations

Competing interests

None declared

Funding

None declared

Ethical approval

Not applicable

Contributorship

Both authors equally conceived and wrote the manuscript.

Provenance

Not commissioned; editorial review.