I go to see a woman on the ward to tell her that, again, her procedure is cancelled. I see, written in the resigned expression on her face, the effort and emotional energy it has taken to get herself here: arrangements she made about the care of her household, relatives providing transport from her home over 70 miles away and now unexpectedly called to pick her up. A day waiting, the anxiety building as a 9am appointment became 10, then lunchtime, then afternoon. The tedious arrangements to be necessarily repeated: COVID swabs, blood tests, anticoagulation bridging. All wasted.
She smiles at me as I apologise. She is kind, rather than angry, understanding rather than belligerent. And yet she has every right to be furious. This is, after all, the second time this has happened. And she knows as well as I do that my attempts at assurance that we will prioritise her bed for the next appointment she is offered are as empty and meaningless as they were last time she heard them.
Such stories are the everyday reality for patients and clinicians within the NHS, repeated thousands of times a day across the country, each one a small quantum of misery. At least my patient got an appointment. Some don’t. Ask anyone with a condition that is not life threatening or somehow subject to media scrutiny or an arbitrary governmental target about their access to planned hospital care and you will likely get a snort of derision or a sob of hopelessness. Benign gynaecological conditions (for example) can be debilitating but frequently slip to the bottom of the priority list, suffered in private silence, without advocates able to leverage the rhetorical and emotional weight of a cancer diagnosis.
This is not all COVID related. Yes, COVID has made things worse but really all the pandemic has done is cruelly reveal the structural inadequacies that we have been working around in the NHS for years and years. ‘Winter pressures’ have reliably and predictably closed planned care services even if it took until winter 2017 for the NHS to officially recognise this and cancel all elective surgery for weeks. Estate is often old and not fit for purpose. Departmental and ward geography does not allow for the patient separation and flow demanded by modern healthcare. Staffing rotas are stretched to the limit with no redundancy for absence. Old infrastructure and equipment requires inefficient workarounds. Increasing effort goes into Byzantine plans for ‘service continuity’ to deal with operational risks, while the fundamentals remain unaddressed.
Efficiency requires investment. You cannot move from a production line using humans to one using robots without investing in the robots to do the work and the skilled people to run them. You cannot move from an inpatient to an outpatient model of care for a condition without investing in the infrastructure and people to oversee that pathway. You cannot manage planned and unplanned care via a single resource without adversely affecting the efficiency of both. You cannot expect a hugely expensive operating theatre or interventional radiology suite to function productively if the personnel tasked with running it spend a significant proportion of their day juggling cases and staff in an (often vain) attempt to get at least a few patients ready and through the department. Modern healthcare requires many systems to function optimally (or at least adequately) before anything can be done. Expensive resources frequently lie idle when a failure in one process results in the entire patient pathway collapsing.
The moral hazard encountered by people working in this creaking system is huge. How can we feel proud of the service we offer when failure is a daily occurrence? When we, the patient facing front-of-house, are routinely embarrassed by – or apologetic for – the system which we represent. We can retreat into the daily small victories: a patient treated well, with compassion, leaving satisfied; an emergency expertly, efficiently and speedily dealt with; teamwork. But these small victories seem to be less and less consoling as the failures mount. Eventually staff (people after all) lose belief, drive and motivation. Disillusionment breeds diffidence, apathy and disengagement. The service, reliant on motivated and culturally engaged teams, becomes less safe, less caring, less personal and even more inefficient as staff are no longer inclined to work occasionally over and above their job planned activity. A bureaucracy of resource management develops and teams become splintered. Process replaces culture and a credentialed skill-mix replaces trusted professional relationships.
The moral hazard is compounded by the seemingly wilful blindness of our political masters, the holders of the purse strings, to comprehend the size of the problem. Absent any real prospect of improvement, we learn to accept the status-quo, the cancellations, the delay, the waiting lists. And our patients accept this too: how else does one explain their weary stoicism. Meanwhile our leaders cajole us to be more efficient, to embrace new ways of working, to do a lot more with a bit more money. It remains politically expedient to disguise a few percent increase in healthcare revenue spending as ‘record investment’ but I argue that most people working at all levels in the NHS recognise the need for transformative generational investment on a level not seen since the inception of the service. Such investment requires money and money means taxation.
More than that, there needs to be the political bravery to open a considered debate about what we mean by healthcare, where our money is most efficiently targeted and what we, as a society can (or are willing to) afford in amongst other priorities for governmental spending. Shiny new hospitals providing state-of-the-art treatment may make good PR but are meaningless without functional well funded primary care. Investment in complex clinical technologies will not improve our nation’s health if the social determinants of this (poverty, smoking, diet, housing, education, joblessness, social exclusion) remain unaddressed. Such a discourse seems anathema to our current politics with its emphasis on the individual, on technocratic solutions and on the empty promise of being able to have everything we want at minimal personal, environmental or societal cost.
Until our leaders start this debate, and until we, as members of society, understand the arguments and elect politicians to enact its conclusions, ‘our NHS’ will continue to provide sometimes substandard and inefficient care in a service defined by its own introspection rather than by the needs of the community it should serve. Our healthcare metrics will continue to lag behind those of comparator nations. And I will continue to find myself, late in the afternoon, apologising to women and men for the inconvenience and anxiety as I speak to them about cancelling their procedure, hating myself for it but helpless to offer any solution or solace.