NATIONAL HEALTH SERVICE

PROFESSOR Stephen Smith, Dean of Medicine at Imperial College London, has been making his professional views known on the state of the NHS. The leading medic says that the service will never improve until the entire system has had radical surgery. In a brilliantly argued prognosis, Professor Smith has seen first-hand how the rest of the world almost always delivers better health care and says it is not about the money.

As a consultant gynaecologist and professor, he once advocated a change in the appointments system at one of the best hospitals in the country – the Rosie Hospital which is part of Addenbrooke’s in Cambridge.

The existing arrangements saw one batch of women called in at 9am, another at 11.30am. The medic became increasingly tired of seeing these patients sitting in the waiting area, often agitated and fed up.

He cites a woman who comes through the door having been made to wait for more than two hours and who is understandably angry, tired and resentful, especially as she’d been trying to entertain a screaming three-year-old. The clinician says you’re not going to get the best account of someone’s medical history in those circumstances.

He thought individual appointment times would be better: say, one every 15 minutes. Every doctor and patient he spoke to agreed.

You would think it easy to get things done for someone who is a professor in the NHS. Senior doctors are revered: their opinion and judgements count. But try to actually change anything and it’s a different story.

Naively, Professor Smith thought the switch to a 15-minute appointment system would be easy. Instead, he had to argue his case in front of at least six committees who each have a separate chairman and differing agendas.

That instance was just the first of many of his battles with the staggering bureaucracy within the NHS.

Next, his unit pioneered a scheme whereby pregnant women would carry their own medical records to appointments instead of looking up their records on the central database. The opposition to this was ferocious.

TWO

PROFESSOR SMITH’S unit pointed out that 17 per cent of central records could not be found. And once women were trusted with their own notes, only 5 per cent turned up without them.

He also mentions another arduous battle in which post-appointment letters are sent to the patient, with a copy to their GP – instead of the other way round.

At the heart of this chaos, he says, is a system that doesn’t put the patient first. The hurdles placed in the way of reform are designed to shore up the NHS – and are not in the best interests of the people who need it.

After Cambridge, Professor Smith became Dean of Medicine at Imperial College London, then CEO of the Imperial College Healthcare NHS Trust. He has also worked in Singapore and Australia.

Having had a view of our healthcare system from many perspectives, today’s NHS, he says, is simply not fit for purpose.

The additional funds the Government is about to direct to the NHS – some £36 billion over three years thanks to a new “Health and Social Care Levy”, including £5.4 billion to help clear the backlog caused by Covid – is well intentioned. But throwing money at the current system won’t get us anywhere.

We have been furnished with yet more stark reminders of the eye-watering sums the NHS is capable of wasting. It reportedly paid around £400 million a month last summer to block-book private hospital care for non-Covid patients.

A good idea, many might think. But astonishingly two-thirds of that went unused, perhaps for ideological reasons. Many NHS staff have an aversion to private medicine.

Meanwhile, waiting lists have grown. About 5.6 million people are waiting for hospital treatment, and that number looks set to double in the coming years.

Some £9 million of the new money is already earmarked for salaries of up to £270,000 for executives who will be expected to “actively champion diversity, inclusion and equality of opportunity”.

The medic says he has no quarrel with high salaries if they help to attract highly competent people. These are, after all, important jobs. When Professor Smith was chief executive at Imperial College, he was responsible for a £1.2 billion-a-year budget and had people’s lives at stake.

His prognosis says it’s time we had a major review of the way we run our health service. The NHS was born from such a review: the famous 1942 Beveridge Report, which looked at health care, social care and education. It was marvellous and set up an NHS that was suited to life 80 years ago.

We need now to set up a new Beveridge review. A national debate should be had about how to best fund and run our health service for the 21st century.

The review could be a Royal Commission, it could be an inquiry led by a judge. But, he says, any inquiry should typically involve medical personnel, economists, social-care experts, politicians, and patients, while avoiding childish, political squabbles. And we need to ask: what do we want, and how do we pay for it?

Professor Smith’s analysis says there are other, far better ways in which we can pay for healthcare in this country. The best would be the social insurance schemes seen elsewhere in the developed world – which would offer a vastly superior service than the one we have now.

The biggest obstacle to bringing in social insurance is actually the English language. When you mention social insurance, people in Britain almost freeze. They think: “I can’t afford medical insurance!”

But it’s not at all like private medical insurance – that’s completely misleading.

Under a social insurance scheme, the Government “hypothecates” – that is, promises – the money to go on healthcare. The scheme is then run-on insurance principles, but it’s paid for by the state out of taxation. And the money cannot be used for anything else.

Be wary of the objections from the Department of Health and the Treasury that social insurance is complicated and difficult to manage. We know through international comparisons that it provides a high standard of care – often higher than the NHS.

Many will have been cheered to see that the levy the prime minister announced last week will be hypothecated for health and social care. That’s a small step towards a proper system of social insurance.

THREE

THIS has nothing to do with “privatising” the health service, nor is it a criticism of our health professionals who have shown – especially over the past two years – selfless dedication. It is about dramatically improving healthcare in this country.

The great myth about the NHS is the belief that, because it provides for everyone, it is exceptional. But do people here seriously think the citizens of Belgium, Holland, Germany, New Zealand, Australia, Canada, Sweden, Switzerland, Denmark, Norway, Spain and Italy all go around worrying about whether they will get treatment for any condition they may have? Of course not.

All these countries have slightly different systems, so our NHS review could look at the right mix of options, taking ideas from several countries, perhaps, to get the best for the UK. 

Professor Smith highlights the Dutch system, which has a small number of sickness funds which patients can switch between without penalty.

As a nation, the medic says, we’ve set the bar far too low: grateful to see a GP after several weeks’ wait, grateful to have surgery, if only after the millions ahead of us on the waiting list have had theirs.

The truth is, he insists, is that we can do better.

Explaining that when he was a young doctor, the clinician was filled with fervour for the NHS. He had the fiercest arguments, insisting our system was the best in the world. Then he began travelling to other countries as part of his academic research into menstrual dysfunction.

Much of his early research was done in Sweden. That was his first eye-opener: the Swedish system was outstanding.

One of the first things that impressed him was that consultants went outside their hospitals and held clinics in GP surgeries.

That was enlightening and certainly new to him. In Sweden, the consultant was expected to go to the patient, not the other way round. That is still a feature of Swedish medicine and we should look at it closely.

Right now, too much in healthcare isn’t right for the patient but persists because “we’ve always done it this way”.

And as for privatisation? When people talk of “mixing public with private”, there’s a widespread suspicion that evil American corporations will descend and make huge profits from “our” precious NHS.

But – and here’s the key point – large parts of the NHS are already private.

In the many years of working in hospitals, Professor Smith has never understood why so many people haven’t realised that GPs don’t actually work for the health service. They are small businesses. So are dentists, including those offering NHS care.

The first criticism from the Left is always, “Look at the American system!”

Professor Smith acknowledges that the American system is atrocious – not to mention terrible value for money. Many people live in fear of not being able to pay their medical bills and care costs twice as much as anywhere else in the world. Nobody wants that. What would improve Britain’s healthcare is a system like those of many of our European neighbours.

The biggest challenge for the UK health service now is how to integrate primary care (GPs, dentists and opticians) with secondary care (including hospitals). This comes naturally in a less “top-down” social-insurance system.

FOUR

SOCIAL CARE has long been neglected, but it is key to making the whole system work. It’s about getting older and vulnerable people home from hospital, rather than leaving them stuck there when they no longer need to be.

If Mrs Jones, 95, is ready to be discharged but social care can’t ensure she will be looked after at home, she must stay in hospital. Then the bed she would have vacated is not available for the next person needing an operation, and so on…

Lack of integration in the NHS is systemic: most patients are astonished, the professor says, at the difficulty of sharing records between a hospital and general practice.

The clinician says that if you are assessing someone’s health needs, you should be able, with their consent, to access their primary care records, operation notes and anything else that is relevant. But this is very difficult – although technology is slowly improving matters.

Professor Smith poses a final question. Should we now change the role of GPs to focus more on long-term care?

The medic says that if you are a woman with problem periods, say, why shouldn’t you access an app, put in your medical history and refer yourself to a consultant whose team will be able to look at the problem and decide if you need to come and see them? Why should your GP be the only port of call?

This final point brings Professor Smith back to his key point. The NHS as we have it was designed for life 80 years ago, when your GP was the person – invariably a man, in those days – who acted as a gatekeeper.

That was then, he says. What we need now is an NHS for the current and modern era.