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A doctors perspective on the causes of NHS failings


We used to have Hospital Administrators, now we have managers. The difference (apart from the huge escalation in salaries), is that Doctors used to arrange matters to best suit their delivery of the service to their patients and the best way to run their units. Now the Managers dictate what happens, when it happens and how it happens. Rather than doctors deciding on the allocation of resources, we have managers with no hands on experience in treating patients telling doctors how to organise their services.

As with any corporate structure, those at the top define how the system should work and the organisation is arranged to best suit the needs and priorities of those in charge. We see this in a number of ways.

  1. Training is geared to what managers deem important. Thus we have the situation that doctors receive two hours of training at induction on CPR, (restarting stopped hearts and keeping the collapsed patient breathing and supporting the circulation.) It used to be two days of training. Instead, we have 40 hours of mandatory training in Equality and Diversity, Heavy lifting, GDPR and Lone Worker Policy etc. These are the priorities of the managers.
  2. Medical secretaries no longer type letters, reports and case notes for doctors but are sequestered to the needs of management. In consequence, doctors write up their own letters and reports etc. The effect of this is that I was expected to see 4 patients a day as a Consultant in Old Age Psychiatry as time had to be allotted to typing up the day’s work. In private practice, where I have arranged my own administration, I see a patient, dictate reports, letters etc, after each patient and, at the end of the day hand them to my PA who types the dictation, sends the reports, send the invoices and arranges the next days visists. I see 8 to 12 patients a day privately. I am able to see so many more patients as I have the proper admin support. We are not short of doctors, we are merely using them inefficiently.
  3. In General Practice, the referral system is so complex that fully 20% of referrals fail as they are written on the wrong computer system or do not meet the management criteria. This extra work load detracts from seeing patients. As a GP BC (Before computers), I could see a patient, on average, every 7 ½ minutes, now, because of the more complex admin, I am down to one pateient every 15 minutes. If you halve productivity, you need double the number of workers, which we do not have and cannot afford.
  4. GP Surgeries are over managed in other ways. In happier times we had an NHS contract and were answerable to the GMC (General Medical Council) if we misbehaved. Now we have Primary Care Networks, Clinical Commissioning Groups, The Care Quality Commission and the list goes on. When the CQC visit is pending, the surgery works at 50% capacity in order to check there is a “hot Water” sign over the hot tap, that the secretaries hypoallergenic soap is removed etc. All this ruins productivity.
  5. By tying GPs to a computer run system that, of necessity, requires rigid adherence to the systems in place, doctors are burnt out and move overseas.

The collapse in General Practice throws the workload onto A & E Departments, which are unable to cope with the workload.

Again, Management are frightened of mistakes and protect their corporate entities. This has lead to Junior Doctors not being allowed to function to their full potential. All decisions are now refered to the Consultant in A & E. You would think that this is very proper and safe. But it leads to ever long waiting times in A & E. Patients are left in pain and deteriorating for longer before treatment can be started.

To reduce the workload on Junior doctors, we now have ECG technichians and Support staff who take blood. In consequence our Junior doctors are becoming deskilled, leading to further deterioration in productivity.

The NHS used to function on the work of Junior Doctors whose work was overseen by the consultants. Now that oversight is so absolute only the consultant can make the decisions.

At Aberdeen Royal Infirmary, the first year Junior Doctors were used primarily to manage the computer systems and rarely got to examine a patient. They would race between the ward round and the computers to request X-Rays, ECGs, Bloods etc. Each request had its own different computer system, login details and password. You can imagine the flurry of unproductive work that did nothing to train juniors in medicine.

if you are upset at the lack of money available for Ambulance services, consider we wasted £10bn on IT systems that don’t work. That money could have been spent on ambulances.

The NHS is not short of money but the current corporate structure swallows and misdirects recources.

Doctors themselves are not without blame. The usual carrer path for a GP would have been a year a a Junior House Officer, (a pre- registration or probationary position) flowed by 4 x 6 month rotations in different specialities to gain experience as a Senior House Officer. This was followed by one year as a GP trainee. Thus a GP was a very senior, senior house officer.

GPs were unhappy at this “lowly status” and wanted to become “Consultants in the Community”. Thus new exams were divised and the Trainee became a GP Registrar. Great! This improves the quality of GPs, but it also limits their numbers. This is why you can’t get a GP appointment.

There is also the Demand side of the equation. By making the service free at the point of use, demand becomes unlimited. Do you remember when there was a 20p charge for Carrier Bags? The use of carrier bags dropped by 80%.  If we had a charge of £10 to be seen by a GP, it would only be a minor cost for most patients, but would make people think a little harder and perhaps seek advice from the local chemist. Probably not politically acceptable, but much time is wasted on bee stings and simple coughs and colds.

One further thought on the NHS.

Most surgeons don’t operate at full capacity. Probably as little as 20% of their time is spent using a scalpel. The problem is a shortage of beds.

Rather than build expensive hospitals, why not adopt the approach used during WWII? We built temporary hospitals, ( many still in use today), concrete base, linoleum floor and pre built concrete walls. Each ward the same. Each ward a separate building ( great for infection control). Cheap, quick and able to deal with thousands of casualties. Why build massive temples to health? £30 to £60million or a £2 million set of prefabricated units? The money saved could support social care and get patients who are stable but unable to return home out of hospital beds.