Reimagining the NHS

So, as GP, and with the NHS all over the news right now, I wanted to throw some thoughts into the ring.

Firstly, I am so glad of the NHS. I am so glad that no matter who you are or where you come from, no matter how poor you are, you can get truly excellent free healthcare in this country.

You can read all about the proposed changes that Andrew Lansley is suggesting and why he thinks they are a good idea. You can read all about why Clare Gerada, chair of the RCGP, the RCN, Physios and numerous other health bodies are now vehemently opposing the changes he suggests (or rather the ideological objective behind how these changes might be implemented). You can read Andy Burnham MP’s tweets. You can listen to podcasts, you can watch question time or tune in to radio debates. All very interesting and some huge issues to tackle. In the main it boils down to: misuse of the service, overspending, affordability in the future and the role of private companies in providing ‘services’.

For me, all of this is slightly missing the point. I’m tired of all the political point scoring that is going on, and that one idea or another is going to solve the enormous issues in front of us (though I do agree that the proposed changes – the result of a non-listening, listening exercise would be detrimental to the nhs). I think we need to reimagine together what the NHS is about and what it needs to look like in the future. The NHS is an organisation which exists to serve the health needs of the people, not the other way round. Having worked in the NHS in lots of differing environments over the last 12 years, as a student, then a hospital doc and now a GP, I genuinely don’t believe that structural organisation will make any difference at all unless we start with a change of culture.

I would love to see a culture of: service and humility, honour and affirmation, dignity and integrity, going the extra mile, kindness and
gentleness, excellence and learning, integration and partnership,
people not paperwork, respect and love! I’m not just talking about how
we treat patients, but how we treat each other as workers! I have too often encountered people being treated like dogs, burnt out staff, staff who’ve got burnt out and stopped being able to care like they used to. Lying to prove unrealistic targets are met and other crazy performance driven behaviours. I don’t know anyone who didn’t go into the caring professions because at some level they love people or want to make a difference in other people’s lives. We need to recover this. The foundations need restoring.

With the right culture, a caring community of people together caring for the community, we could have something that brings an enormous amount of life and excellent care. To me it looks like treating people like royalty, having an attitude that no job is beneath me (so no more crazy stories of people being left in their own faeces for hours or not being fed their dinner – not sure there is much more important stuff than nutrition in helping a person on the road to recovery)……It looks like every member of a team from consultants to cleaners knowing that they matter and being thanked for what they do. It looks like community and hospital teams working in partnership, with seamless transitions. It looks like joined up thinking between allied professionals (with better partnership and respect with therapists of all descriptions and the social services). It looks like communities being able to participate in budget decisions, so that the services make sense for the communities they are serving (this might also lead to less abuse of available services and things being taken less for granted). It means sharing patient records across various settings with patients having access to these records so they can understand about the conditions they have and good communication with them about what their options are in treatment and management. It looks like those in positions of power, not lording the power over other people, but emptying themselves out in order to serve and build up those who work for and with them.

It means more than just a culture change within the NHS. Most of the health needs in our country cannot be solved my a nurse or doctor. Most of our problems are to do with how we live, the things we eat, drink and smoke, the ways our communities function – or don’t; the advertising we allow, the cost of healthy things in the super markets, the amount of exercise we’ve lost in our schools, the way we handle relationships, the way we parent our kids, the way we pollute the environment, the crazy working patterns we have that leave us little time to rest and recuperate. The NHS is breaking because we are breaking……the answer doesn’t lie in privatising the NHS so it can all be done more cheaply (because poor people with chronic ill-health, don’t make good business sense)……..we need to change the way we are thinking and living. A change of culture in us and in the NHS will lead to a sustainable future. Please stop all the talk about which political options will save the day. The answer is none of them.

Jesus said something very interesting. He said that if we seek first the ways of God – that is caring for the poor and marginalised, making sure the children, elderly and most vulnerable are looked after, loving on people – no matter who they are or what they are like – without judging them, working together for what is good and brings joy and peace, then everything else we need will be given us. Whether you have faith or no faith, that’s a pretty incredible statement. If we take care with how we live and what we do, to make sure that everyone who needs it most is looked after, then everything else needed will fall into place……pie in the sky thinking? I don’t think so, but I think it’s worth a go! So, what can we change in how we think and live that will enable a change in culture? A new culture of love and kindness that will breathe life into our communities in a way that looks after our holistic health needs and helps us to have an NHS that is sustainable, life-giving, dignified and excellent? What can we reimagine together?

14 thoughts on “Reimagining the NHS

  1. The NHS you describe reminds of the NHS I trained in in the 80s. Hospitals working together as a team instead of ward against ward;staff always willing and having the time to muck in. í remember sitting with my arms round the shoulders of a mother who’d just been told her baby had a cardiac problem for over an hour with no one nagging me to get up and do something to meet targets. It’s a fond memory of a long dead NHS.

  2. You’ve hit the nail on the head. More and more the NHS is being used as a mop to clear up the flood while we leave gaping holes in the dam. The only thing I would say, before everyone goes all misty eyed about the good old days is that you have to allow for change in living patterns as they are not all bad and some are inevitable anyway.

  3. A thought provoking article that makes more sense than most of the rubbish churned out by those who should know better. What has been suggested applies to society as a whole and not just the NHS. It should be required reading for every member of parliament.

  4. 100% agree on pride of the NHS. Nothing I’ve seen in SA (where private teats roughly 20% of the patients with 80% of the money spent on healthcare) has changed my mind. I’m proud to be working in the public sector here and am excited to come back too.

    While I accept that targets have led to some unscrupulous behaviour where the target has been put ahead of individual patient care overall I can’t accept that they have not been a bad thing. The NHS is a financial black hole. When Blair/Brown threw all that money at the NHS from 1997 onwards they needed to be able to have something tangible to show for it – they are politicians – so they chose to pursue the things that pissed the majority of the population of in the 1990s – waiting 6 months+ to see a specialist/waiting hours in A&E with simple fractures/elderly patients sat on trolleys for 24 hours to get a bed. I’d have done the same – otherwise they would have been wide open to criticism for splurging cash without anything to show for it (inefficient “old labour” behaviour – just what they were trying to avoid). While their motives were understandly primarily political I think targets also gave the staff a kick up the backside to improve/streamline patient “flow” (sorry for a dirty word) through the hospital. So basically what I’m saying is that I think that yes targets have caused some collateral damage along the way but they were necessary politically to get the investment needed, overall the NHS is an infinitely better condition than in the late 1990s AND most patients have seen a net benefit. And while we’re on the subject you can’t seriously tell me that QOF hasn’t had a massive net positive effect – both for patients and GPs.

    I have no wish to go back to the 80s – I’ve heard old timer consultants talk about how “in the good old days” they were served their lunch by waitresses in their own doctors only canteen! WTF?! Give me a League of Friends toastie or even a posh sandwich from a branch of Costa that got the LofF closed down instead of that any day of the week! May be hospitals were subjectively cleaner and patients given a few more hugs but that was a different world. A lot of the inpatients back then (I think – I was only born 1980) were so well they wouldn’t even qualify for a district nurse home visit nowadays! What was it: 5 days bed rest after an NVD?? The reality today is that patients are older and sicker than ever before – that’s not going to change – trying to imagine yesteryear in a fantasy and a perverse one at that.

    Bottom line is we’ve had a golden age of investment in the NHS and the money has dried up. I’m not going to lose a whole lot of sleep over what the politicians do about it. I’m going to focus on doing the best job I can AND improve on it with whatever resources I’m given. Can’t speak for Primary Care but I strongly believe that BIG improvements can be made without any extra investment. Too many hospital doctors sit back and winge about the governement but then treat the Department’s audit day/afternoon each month as an opportunity to skive off rather than take a serious look at quality improvement. The golden age of investment has made a lot of people lazy as well as some disenfranchised by the perceived culture of targets. We are quick to whine about financial mismanagement but quietly avoid offering to do something about it.

    100% agree on change of culture. A US guy Peter Pronovost has written a book on quality & safety in hospitals and transforming culture is one of his key principles – he has good data to back up his approach. His primary objective is improving patient safety but he is quick to point out the cost savings this creates and his approach to change is what has really captured my attention. ( – not the best written book ever but I think his main message is spot on). I intend to put this into practice on my return to the UK. His approach also adds some concreteness to what the concept of culture change actually might mean in practice.

    I’m actually looking forward to cutting my teeth in the age of austerity – maybe we’ve had it easy for too long?! Better healthcare for less money is readily achievable. May be we need to worry a bit less about the politicians and concentrate on what we can change from the bottom up…. or in Pronovost’s words try transforming healthcare from the inside out.

    Wow – epic comment – probably longer than your blog 😛

    • And that, dear Mark, is why I love and respect you so much! I really agree with you. I think there is so much good going on and so much that has changed for the better. There is so much to be thankful for and so much that is already fantastic. Love what you say and challenge about attitudes towards our work. I really am with you 100% that we can make a difference by who we are, how we behave, what we speak, how we treat people and what we model.

      I love this quote: “When the forms of an old culture are dying, the new culture is created by a few people who are not afraid to be insecure.” Rudolph Bahro. I don’t have a problem with much of the restructuring that has gone on – much of it has been good, and greater focus on community medicine and patient centred care is excellent. It’s awesome that people don’t wait as long as they used to, but there are a lot of cover ups going on because we’ve forgotten why the target was introduced in the first place. Targets can be good, but must not replace good care!

      But I do think there needs to a cultural shift in terms of how we all approach the nhs, a greater sense of corporate ownership of it, rather than an abuse of something we consider to be a human right…..and a rediscovery, for those of us who work within it of how to partner together better for the good of the people we serve. Sometimes, when you have inherited the hard fought work of previous generations, it’s easy to become lazy and take stuff for granted. That is why I think we need to reimagine the future so that we know what we are heading for. When vision fails, we lose hope. So, bring on good changes that will further enable good care, though I think the current suggestions are a nightmare. But no amount of structure can deal with the issues of our hearts! So, let my heart change, let my attitudes change and with the right culture in our wider communities and within the hs, I think we can build something really special!

  5. Pingback: The Future of the NHS « Mike Winter's Blog

  6. Love it Andy! Love it.

    It can be hard to imagine how the NHS can become great again without trebling it’s budget… Unless there is a massive cultural shift across the board. Not just how politicians drive it, and how managers manage it but also how front line staff believe in it and patients thankful for it. It’s time for us all to take a bit of responsibility.

    However, maybe structural change could also be great. Management theory generally agrees that structures work best when pretty small. I expect the Chinese Army is pretty effective but can the NHS seems too big to facilitate change when needed and too fragmented to enable a cohesive approach.

    Further, just to throw the cat amongst the pigeons, is free healthcare for all, delivered by independent organisations such a bad thing? After all, partners in GP practices are for all intent and purposes their own enterprise, NHS trusts fight over attracting the most profitable patients and I doubt there are many in the NHS that would do there job for free (in essence we are all our own little business with our own P&L transacting our services for a fee).

    I have worked with people in the independent
    sector that care for all their patients as much as those in the NHS… and they get paid less.

    Before everyone labels me i need to point out that I post this without knowing what I think is right but I just want to challenge people to consider that it is not all black and white or good and evil… The world is full of grey and I am swimming in the middle of it.

    • Wowzers! Great comment, and some salient points, Jon! I get to hang out with alot of intelligent, great thinkers, but there are few who match your good self and Mark Dunham in how deeply you guys think about issues and the humility with which you communicate…..

      I maybe overstated some things in my initial blog (imagine!), in saying that structural change/remodelling of services is not the answer. I still stand by that as I believe the wider cultural shift by all of us at every level is far more necessary, but you’re right, without some changes to how things are shaping up we will be both bankrupt and in an even bigger mess.

      Some of this discussion is about idealogical objectives of big vs small government and whether or not business and a caring service (one of which is primarily/traditionally about making money and the other about genuinely caring for those who make no financial sense, but simply cost alot!) can be bed fellows…..

      I think it was Maggie T who said that the problem with capitalism is capitalists….the over riding fear with giving the free market, with share holders wanting profit margins, more control in NHS services is that it will be those who need it most, who make the least financial sense, who miss out. However, I do think that it is possible to be a good and caring businessman (like yourself!), who is actually more concerned about the service than the money. I think that is where the rubber hits the road. I think it is also the flip side of the argument with a free service – people take it for granted and that means a lot of wastage!

      I would rather that clinicians were able to decide where money needs to be spent…I think that many changes haven’t occured because of people in positions of power playing dirty political games…I think that the NHS must remain a service rather than becoming a business…where we think of people as people and patients, not users or commodities…but I think we need to challenge some of the waste and find a way of shifting the focus away from traditional ways of thinking to a more radical community focussed approach to healthcare.

      But in all honesty, I think that no matter how much reorganisation and restructuring goes on, unless we recover and reimagine what it’s all for and what we are about, we are wasting our time…it’s a both and not an either or…so massively appreciate your comments! Thanks.

  7. It may help to achieve a ‘good’ result for the caring services if we look at them as a whole instead of individual departments of local and national government. For example, my local authority has just cut the subsidy they previously offered to the over 60’s when using the swimming, sports and exercise facilities provided by the local authority. Many of these faciliites are used during the daytime when the kids are at school and adults at work, by the over 60’s and, in many cases, by the over 70’s and over 80’s. If we over 60’s can keep ourselves fit and well helped by swimming, sport exercise etc., that in turn will have a positive effect on the NHS budget, the greater part of which, I understand, goes currently on healthcare for the over 60’s. A relief on a local authority budget is now going to present a strain on the NHS budget. ‘Joined up thinking’ is called for!

  8. Nice blog Andy – Not bad for a Tory-boy!

    Can I 100% agree with everything Mark said. We’ve seen huge improvements in healthcare even in our short time in the NHS. The ‘good old days’ were awful – unless you were a consultant at the top of the pile and got to play a lot of golf. Thousands of patients died of treatable/preventable conditions and hospitals were full of terrifying matrons and doctors who you weren’t allowed to talk to

    Working outside of the NHS, (in the under-developed world, the developing world and the private sector) has made me so much more proud of the NHS. 21st Century care for all patients – free of charge! That is an un-believable achievement!

    The NHS’s has three main problems –

    1. Healthcare is expensive and getting more expensive
    2. A tsunami of old people
    3. The Daily Mail (inciting a culture of dependency and criticism)

    I don’t think the NHS can afford to offer all services to all people. Sooner or later, we will have to admit that we aren’t going to be able to pay for the super-expensive cancer drugs that will flood the market, and we are going to have to make some extra space in our hospitals for all the elderly folk that have been propped up by expensive cardiac drugs and free swimming lessons for the last 10 years.

    Your right about Public Health needing to be nearer the top of the agenda – but I think you’re wrong to say we are neglecting it. We are seeing some positive change (smoking ban/minimum alcohol pricing etc.

    I also completely agree about the change in attitudes and behaviours – but I’m searching your blog for how you hope this will happen. Other than leading by example, I don’t see how you/we can push this policy forward. We can give everyone a bit more time off, so that they achieve a more sensible work – life balance, but we would have to accept, that this will cost a bit more and we’ll need to cut back somewhere else. At Stepping Hill we had a trust policy that included ‘Going the extra mile’ and ‘respecting patient’ – but somehow we still ended up in the newspapers!

    We need to ignore half the ‘crazy stories’ about people being left in their own faeces. It almost never happens in an NHS hospital – even when patients attempt to bite the poor member of staff who has to clean them. If you want to see a real area that really needs some care, attention, joined up thinking and a big pile of cash – then we need to look at nursing homes and residential care homes. Hospitals (on the whole) are doing ok.

    ‘Joined up thinking’ (Isn’t that a new buzz word for ‘common sense’?!) partnerships, communication, respect. This is all lovely – but it isn’t policy. It’s been used as policy (‘Back to basics’ & ‘Big society’ etc) but we still need people to make decisions about how the money should be spent. At the moment, we (mainly led by the media) don’t offer suggestions; we just wait for something to go wrong and then attempt to annihilate the person that was asked to make the decision. (For Andrew Lansley – you could read Fabio Capello).

    The NHS doesn’t need massive reform. It needs evidence based policy that is clinically led and doesn’t change every 5 years. It will surely benefit from a change in attitudes and a shift in culture – but this comes from society as a whole (and we the church need to be at the forefront of that), but it won’t replace the politics.

    Disclaimer: I don’t have much of an opinion of the current health bill – I’m a long way from home and I don’t know enough about it. I think the concept of allowing the G.P. to hold the purse strings is sensible – most of them will do a good job – but I doubt most of them are ready for the scale of criticism and abuse that comes with the job. I don’t believe that privatising parts of the NHS is a good thing. It might offer small improvements for those that can afford it. It will be detrimental to the organisation as a whole

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