Part of our Life in the front line series
The NHS is a highly valued institution that the British public proudly defend. As a doctor, I’ve witnessed a number of systemic problems that the NHS has faced over the last decade: inefficiencies, staff shortages, strikes, budget rationing and top-down restructuring. However there is one increasingly common but often overlooked theme that seems to contribute to all of these challenges: the disenfranchisement of the voices of NHS staff.
Alienation within training and work environments
Where once we simply had hospitals we now have Foundation Trusts. Where once doctors and nurses attended meetings they now attend “interactive stakeholder workshops”. During my “integrated academic training pathway” to become a Consultant I must navigate the “workplace based assessment competence framework”. I am not only being trained in medicine, now I am being encouraged to partner with managers heading up “clinical business units” to better understand management positions and processes.
No doubt there are benefits in encouraging interactive working with colleagues and in creating assessments that ensure medical professionals have the skills necessary to perform well. However, in recent years the NHS training and working environment has become dominated by corporate acronyms and strategies so that one almost needs a glossary to unpick what is actually being said and done. The fracturing of existing systems and breakdown of clinicians’ training programmes has led to what feels like a splintering of what was once a cohesive and truly integrated team of healthcare professionals caring for patients. This has been replaced by a series of anonymous shift workers focussed on ever-moving targets and boxes to be ticked. The reality is that the processes that NHS are now immersed within have created mass disaffection and disengagement. Low morale amongst NHS staff is now a serious problem.
Disenfranchisement by obfuscation
Problems of staff disenfranchisement and low morale are epitomised in the current proposals to shake up the NHS through introducing “Sustainability and Transformation Plans” (STPs). These will bring about some of the biggest changes the NHS has seen for many years and yet most of my colleagues have never heard of them and those few who have feel completely unable to influence them. This week it has emerged that in order to find the billions of savings required nationally to implement STPs a “Capped Expenditure Process” will be introduced. It is only through leaked information that we are discovering what this is likely to mean: huge reductions in access to service across the country, blocking of hospital referrals and further caps on the use of desperately needed agency staff. We have been told that these plans are what NHS staff asked for as “key stakeholders” engaged in a local conversation. (4) Yet conversations should be a two-way interaction. As a “key stakeholder” I must confess that I, and most of my colleagues, have found what dialogue there has been about STPs to be at best opaque and decisions regarding outcomes have been taken unilaterally. This has been reminiscent of the public statements from senior NHS officials during the junior doctor contract dispute last year where thousands of my colleagues were described as “being misled” by the BMA. Many of us now find ourselves in an excluded position, appealing desperately to be involved in the critical discussions about the future of the NHS while being publicly assured that we are an integral part of it. The whole process seems to be yet another masterclass of disenfranchisement by obfuscation.
Concerns over Sustainability and Transformation Plans
Having taken time to read my local STP in South West London I am left none the wiser. In fact, I now have many more questions as to how the sustainability of our health service will be achieved given the astounding number of cuts, closures and downgrades these plans propose to introduce. Are these plans based on evidence or wishful thinking?
At first glance, the proposals present some very positive sounding goals. There are some fantastic info-graphics developed to show how the £828 million “financial challenge gap” will be closed by a combination of “business as usual” savings (£371 million) and “transformational savings” (£187million) to be achieved by reducing 44% of “avoidable” inpatient bed days. (6)
However, closer scrutiny suggests the proposed solutions risk falling seriously short of addressing the reality of need on the ground in multiple areas. At a time of increasing shortages of frontline clinical staff (there was a 50,000 shortfall of clinical staff in the NHS in 2014) STPs are being implemented by management consultants at a cost of many millions. Moreover, there is growing concern that STPs will widen health inequalities in communities that are already seriously struggling. NHS managers are now being urged to “think the unthinkable” about savings and ever more of us are concerned these plans will undermine fundamental principles of universal healthcare delivery for the first time since 1948.
As an Oncology trainee I have seen A&E waiting times soar and elderly patients languishing for weeks in hospital beds because community social support has vanished. I find it impossible to comprehend how 44% of inpatient bed days can be reduced without compromising patient safety. As a result of losing 50% of inpatient beds since the 1980s, the UK now has fewer beds per head than the USA where nearly 30 million are deprived annually of access to healthcare, and fewer than half the ratio of other comparable economies. I am gravely concerned that yet fewer beds will seriously compromise patient safety.
A major premise on which STP savings are to be achieved is through more effective “prevention” of ill health and greater treatment of patients “closer to home.” I do not disagree that patients should have care near home wherever possible. However, speaking as someone working on the frontline it does not seem credible that by 2020 the infrastructure, resources and community support will be in place to significantly raise illness prevention. Moreover, these plans say little about tackling the ever increasing incidence of cancer, cardiovascular disease, sepsis and organ failure: the most common causes of treatable death in this country. Closing inpatient beds, reducing surgical lists and merging units so that patients must travel extra miles in emergencies will certainly not facilitate this.
Speaking up for a Public NHS
Given these concerns, I believe STPs can only be understood as driven by a political commitment to economic austerity and an increasingly marketised NHS. I know I am not alone in thinking this, or in believing that our NHS should retain a commitment to the founding principles of a Beveridge model. The Health Foundation recently found that 88% of the population want a publicly tax funded, provided and delivered healthcare system. The recent gains by the Labour Party in the General Election with many voting on the basis for their pledge for a public NHS is testament to the widespread support this has. Indeed 250,000 people took to the streets only recently to join the largest demonstration in history in support the NHS to voice their agreement.
As an NHS junior doctor and patient, I – alongside many others – can no longer tolerate being excluded from the vital public conversation about the future of the NHS. That’s why I am working with Health Campaigns Together, the TUC, the People’s Assembly and health workers’ unions to collectively put across our case for a public NHS. We celebrated the 69th birthday of the NHS on the 5th July in a series of events at hospitals up and down the country. There are 60 million “key stakeholders” in our NHS in the UK who need to be listened to: we would like a genuinely sustainable, publicly provided and universal NHS to be around for the next generation.