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The word of 2016, according to Oxford Dictionaries, is ‘post-truth’.
Whatever your political views, it’s not difficult to see the dangers of a world in which – as the dictionary puts it – ‘objective facts are less influential in shaping public opinion than appeals to emotion and personal belief’.
Now, there is no shortage of emotion or personal belief in the National Health Service, and it would be a much-diminished place without it. I’ve known patients whose treatment was so technologically advanced that at the time I qualified it would have seemed like a fantasy – but it was the reassurance and empathy that they most remembered.
But that reassurance would not have been so kind if given in the face of a devastating prognosis. Knowledge matters. Facts are not the opposite of feelings – you need both – and basing our actions on sound clinical evidence is both a necessity and a kindness. And we will never ‘have had enough’ of experts, thank you very much.
We have, however, had quite enough of post-truth politics. Remember that promise, daubed on the side of a bus, of an extra £350 million a week if Britain voted to leave the European Union? A promise made by leading politicians which was never meant to be kept, and which they had themselves disowned within days of the referendum.
That sparkling gem of mendacity aside, I think the biggest threat to the NHS comes not from conscious deceit, but from the persistent, blinkered denial of a truth that is obvious to anyone outside government.
For years now, the very enormity of the deficit faced by the health service seems to have made it easier to ignore, rather than a matter of national importance. We could all conjure images of columns of pound coins reaching up towards the moon, but it was to the government just another large and depressing number to dismiss – one amongst many.
Ministers spoke blithely of efficiency savings, but found those ‘efficiencies’ only in penalising staff with real-terms pay cuts and reducing payments to providers that plunged hospitals into record deficits.
This year, health and social care providers across England were charged with finding a solution. Their STPs (sustainability and transformation plans) have revealed a health service that is in fact unsustainable without urgent further investment, and with little capacity to ‘transform’ in any meaningful way other than by closing services on a drastic scale.
Our own analysis has found they must cut £26 billion from health and social care costs within five years. Greater Manchester, north-west London and Hampshire and Isle of Wight face falling into the red by more than £1 billion each.
More big numbers, but they are much harder to ignore or deny when attached to the names of hospitals and GP practices that thousands of patients use every day.
As we have made clear, STPs will only succeed if they are realistic, properly funded and have patient care as their priority. Although still in draft form the majority do not appear to meet these objectives.
The health secretary speaks of ‘challenges’ and ‘bumps in the road’ with STPs. Something of an understatement perhaps. The councillor charged with scrutinising health in Birmingham puts it rather differently: ‘Although the social care financial gap is included within the plan, which is welcome, there is no indication of how this gap will be closed.’ This was precisely what STPs were supposed to do, but it is too often an impossible task with current levels of funding.
STPs are meant to bring health and social care together, and in a grim kind of way they do. It is clear from many STPs that each is desperately trying to prop up the other, their crutches cracking under the weight.
We have recently analysed social care’s share of the impending shortfall. In many areas, this is more than a quarter of the total, with combined deficits running into billions of pounds. It comes as social care is being cut in real terms, and the situation may worsen.
When social care is on its knees, patients suffer delayed transfers, and the personal and financial cost is vast. We have found a correlation – as you’d expect – between the STP areas with the highest social care deficit and those with the highest proportion of delayed transfers for social reasons. With several STPs, including Nottinghamshire and Staffordshire and Stoke-on-Trent, proposing to cut hospital beds these problems are only going to be exacerbated.
The British Geriatrics Society describes delayed transfers as ‘personally disastrous for elderly patients who are frail’. And it is not only older patients who are affected.
Hospital doctors know that the surgical wards can fill up with medical patients because there are no other beds. So, the medical patients do not receive optimal care, and the elective patients are postponed. Two sets of patients facing needless suffering.
Throughout the UK, it is the same story. An Audit Scotland report in October found that, as in previous years, NHS spending was not keeping pace with demand. Most performance targets had been missed.
In Wales, the Health Foundation predicted a £700 million deficit within three years – more than 10 per cent of this year’s NHS budget. The Welsh Government’s increase in health spending was therefore welcome and necessary, but is unlikely to be sufficient.
In Northern Ireland, there is an unprecedented number of unfilled consultant posts due to a lack of investment and proper planning.
This is not the counsel of despair. There are solutions at hand. In Northern Ireland, my colleagues have welcomed the findings of the Bengoa review which sets out key ideas for a more sustainable, patient and population-centred model of health and social care. They will be monitoring very closely whether their government implements the changes for which it calls.
The problem is that all too often, politicians slide sinuously past the truth for the truest thing they have to say without it being provably false. Let me give you an example. The chancellor, health secretary and prime minister have, at various points referred to a £10 billion increase in English NHS spending in this parliament.
As we have demonstrated, the ‘£10 billion’ actually equates to a £4.5 billion increase in overall health spending.
The health secretary said ‘whether you call it £4.5 billion or £10 billion, it doesn't matter’. I disagree. While any increase in health funding is welcome and desperately needed, this is the government taking credit for work they haven’t done and money they haven’t found. It corrupts the public debate. You also never hear them acknowledge how much of the ‘new’ money is being used to bail out trusts which are crippled by unworkable efficiency targets.
We need a government that is willing to own its share of the challenges, not one that is obsessed with owning the headlines.
It is just possible to see positive change here. At the beginning of the year, the government was still lumbering on with its self-defeating rhetoric that doctors were a ‘road block’ to improving the consistency of care across the week. It was an argument that should never have happened and that the government was never going to win, as it pitted a baseless accusation against the reality of tens of thousands of doctors delivering high quality care every evening and weekend.
The tone of recent discussions has been more constructive. At a symposium we held last month, I set out the efforts, led by the profession and over many years, to improve clinical standards throughout the week and ensure the right care, to the right quality, is delivered by the right people at the right time. The health secretary, who was at the event, acknowledged these efforts. We agree about the high standards of care we want to offer patients – how, indeed, could we not be?
What we now need the government to accept – and this should be equally uncontroversial – is that, if it truly wants consistently high standards, it will get the health service it is willing to pay for.
A recent BBC report found nearly half a million patients in England waiting for more than four hours after emergency admission, an almost five-fold increase in five years.
The beds they are waiting for have been taken away in the name of cost-cutting and efficiency. According to the OECD, the UK has fewer than half the beds of France and a third of Germany’s, per person – a difference in magnitude that cannot be explained away on definitions. That means daily, around the country, we have bed occupancy figures touching 100 per cent, one of the few NHS statistics that does. It’s a measure of ‘efficiency’ that is anything but efficient, and wreaks havoc with efforts to control infections and ensure patients are given the care they need.
The Nuffield Trust has linked high bed occupancy with longer waiting times before admission, distress for patients as they are more likely to be moved around a hospital, and a greater risk of infection. Governments that take responsibility, that consider the evidence and act on it, enable patients to receive better care. It’s easy to be cynical but I’ve never known a government in any part of the UK that didn’t ultimately want to achieve that.
Sadly, this lesson is more often proved in the negative than the positive. GPs in Northern Ireland, like GPs across the UK, are facing an ever-increasing workload, reduced funding and an out-of-hours system under great strain. Their government has failed to respond with the appropriate level of resources, in a country which already has the lowest number of GPs per head than any in the UK. The result – hundreds of GPs indicating they would be willing to submit undated resignations. As every doctor knows, ignoring an acute and worsening diagnosis rarely makes a situation better.
In England, we have seen a government refuse to meet its responsibility to provide a working environment for junior doctors in which they have confidence. A clear majority of junior doctors voted against its plans for a new contract, and the government’s decision to impose it is a self-defeating squandering of goodwill on an unprecedented scale.
If the government thinks it can press on regardless without worsening the long-term damage to the morale of the medical workforce, it is living in a fantasy world. Indeed, recent surveys from both the Royal College of Physicians and the GMC have confirmed that junior doctors are being left demoralised, sleep-deprived and forced to miss essential training.
During the contract negotiations, there were many areas where the government could not be persuaded of measures that were in the best interests of both junior doctors and patient care, but we were able to achieve a new system of exception reporting.
This enables junior doctors in England to raise any instance where their actual work varies from what they are scheduled, and paid to do. It includes one-off situations and more systemic problems.
As a foundation doctor, Martha Martin, recently wrote on our website, ‘statements about working over hours or while under-staffed will no longer be anecdotal but rooted in hard evidence’.
This has the potential to be a safeguard and an early warning system, and shock employers or the government out of any delusions about working hours to which they may succumb. The more that junior doctors use it when their hours are in variance, and report those inconvenient truths, the more effective it will be. And senior hospital doctors must encourage and allow this to happen. It’s also about employers showing junior doctors the respect they deserve when they raise concerns.
Another large and highly committed group of doctors who deserve a similar respect are the 30,000 who received their primary qualification in another European Economic Area country.
In October, they were described by one cabinet member as one of the government’s ‘main cards’ in Brexit negotiations. So, to their patients they save lives, relieve pain and bring kindness and reassurance, but, to this politician at least, they are just negotiating chips.
It’s a government that seems more interested in telling a bemused public whether its Brexit is hard, soft, red, white or blue than in looking its own health workers in the eye and telling them they’re valued, and that it will do everything it can to make them welcome and secure in their jobs. It is putting ludicrous slogans ahead of real people.
This has been a profoundly unsettling time for all overseas doctors. Mr Hunt, to his credit, has been supportive of doctors from EU countries, but offers much less security to the tens of thousands who trained in other countries. Instead, in his speech to the Conservative Party conference in October, he created the impression to many that, while their contribution was welcome, they were now just a stopgap until the extra 1,500 medical places he has announced leads to self-sufficiency.
There are so many practical problems with that plan that he has left unanswered but even more important is the basic truth he has overlooked, which is that the contribution of overseas-trained doctors to the NHS is so very much more than numerical. Without them, I doubt we would even have a functioning NHS, and even if we did, I wouldn’t want to work in it. We are all enriched by the wonderful diversity of the NHS workforce.
The BMA is currently surveying international medical graduates to ask about the impact of the referendum result and to help us enhance the services we offer them as members.
When we talk about evidence, and good data, it’s all too often from the perspective of arming ourselves against the opposite, and the harm that supposition, prejudice and hollow rhetoric do to our profession and the care we provide.
But if you want to see what clear, evidence-based information can achieve away from these tiresome battles, then I’d urge you to consider one of the many achievements of our company, the BMJ.
You’ll know of course of the British Medical Journal, which, for more than 175 years, has established itself as one of the world’s leading sources of medical education and informed decision-making. But the journal is just one part of a global information group which supports the improvement of medical standards worldwide.
Recently, with the University of Cape Town, it has launched the PACK (Practical Approach to Care Kit) Adult Global. Designed to be used by primary healthcare workers in developing countries, it includes a guide for managing symptoms and diagnosing conditions, and is based on WHO guidelines and the best available evidence.
Previously used in South Africa, it is now hoped that this clear, rigorous approach can empower healthcare workers and improve clinical standards in other parts of the world too.
It really is very simple. Evidence saves lives. The only place you can go without evidence – or ‘post truth’ – is one where patients are harmed. We’ll stick with the facts – they serve our patients well.
Watch a video version of Mark Porter's message.
Excellent thought provoking message from Mark Porter, dedicated Chair of Council. I wish a Happy New Year to officers, council, fellows, members , associates and staff of the BMA. Keep up your good work in 2017. Good luck. Dr Bashir Qureshi, Life Member of the BMA.
Really good message, touching a lot of key issues.
In particular, we aren't going to get out of this hole without using facts and experts, and squeezing data until it bleeds to support ideological decisions will make things worse.
so true. yet so depressing. We should not forget all the good things that go on in the NHS and that most patients do value us and all who work in the NHS.
Another rant from Mark Porter, full of complaints about the government and hardly a word about what can actually be done to improve the situation. This is the man, it should not be forgotten, who shamefully was in favour of junior doctors going on strike earlier this year - and who then had to make an embarrassing climb-down when he realised patients might be harmed. The only way to solve these problems (insofar as they are solvable) is to negotiate in good faith and without threats. Mark Porter has shown he’s unable to do this. I think he should resign.
Really good if thought provoking message. I agree we need to stick with the facts and use evidence rather than indulge or be indulged in what has been termed motivational reasoning. It might win voters, for a time, but will not effectively address the problems that the NHS is faced with and it runs the increasing risk of alienating the workforce which the NHS so heavily relies upon. I fear that a critical effect could be reached where any demoralisation can start to snowball. Being of continental European origin, I have found the NHS a rewarding and great place to work in and believe it is a great asset that should not be eroded. The NHS is a very diverse place, which is also reflected in the patients that we treat every day, and I am heartened to hear that Dr Porter positively welcomes that diversity. Here in Scotland, a dialogue has begun about realistic medicine, a concept which has resonated with doctors and I feel that it should be incumbent upon our political task masters to make a serious contribution to this debate.
Happy New Year to everybody at the BMA!
I did not intend to post the comment in which I said I thought Marc Porter out to resign, anonymously, but there seems to be no simple way on the BMA website to identify yourself: my name is Gabriel Symonds.
Well put Mark. It must be difficult indeed when faced with politicians' routine deflection of problems using dishonest numbers. I was going to say disingenuous but I think calling a spade a spade might be more effective. Perhaps it's part of the art of medical politics but you seem to pull your punches: "One cabinet member" describes European doctors as Brexit cards. Which one? Why no shame? £10 billion is not provably false and yet you have demonstrated it to be so. So they lied? Who lied? Statistics are indeed complex, so such simplicity is not straightforward but perhaps we could try harder to stop politicians wriggling off the hook. As a union we have no means of applying meaningful pressure in disputes. It is only by being better at getting the Media to spotlight to the public the dishonesty of politicians and health service managers that we can gain any traction.. We would also need to make sure that we're not gilding the lily (sorry, lying) on our side too. Perhaps we should start by putting our own names on the posts?
Steven Lawrie, Ayrshire
This website doesn't refresh very often does it?
Mark ,all you ever do is moan. You never actually do anything. You are still batting on about the junior doctors contract which you allowed to be imposed with no further oppostion ,for which you should hang your head in shame. I suspect all the other misguided government plans will be allowed to go through in the same fashion.
Of course the NHS needs more money but looking around at the acute needs of other sectors and the burden of national debt, where is it to come from? We can hope for substantial economic growth and we can urge that no wealthy organisations and individuals should be allowed to avoid paying a fair share but the reality is surely that the country must accept that with an ageing population and radical advances in medicine it must limit its demands and expectations and concentrate on making the NHS efficient and always a tolerable place to work, even though not all that is desirable is possible.
The BMA is quite right to draw attention to underfunding, and there are things which can be done to cope with this, but the Sustainability and Transformation plans are reminiscent of Stalin’s 5-year plans for agriculture which led to the great famine in Russia of 1932. They all contain highly ambitious targets while at the same time making huge “efficiency savings”. Meanwhile the government answers every criticism by saying we are investing “more and more” money into the NHS and Social Services, and coming up with one untried and untested national initiative after another. No-one is ever held personally accountable when these fail, as they do regularly.
What we need to admit is that there are limits on what national services can provide, and to specify what these limits are. People who want more than that should be given adequate warning of forthcoming limitations, and advice on appropriate private insurance schemes. This would be far better than privatising the NHS. At the same time clinical staff should not take on more work than they can cope with safely, and they could do this by concentrating on the more urgent cases while allowing waiting times for the less urgent to increase. People who don’t like this can put pressure on their MPs to get staffing levels increased. Finally, local schemes for raising money could be far more acceptable and accountable to local populations than national increases in taxation. Richard Turner
The BMA should try to be more focused on the positives. These issues have long been in the making by successive Governments.
The biggest problem in our region is shortage of doctors. Mark Porter highlights NHS finances which are clearly in bad shape but these will be covered by some sort of fudge. There is no alternative. Our inability to fill medical posts is more intractable. International Medical Graduates are now 30-40% of the UK medical workforce and have done a great job. But we cannot continue to rely on other countries to train our doctors to such an extent. Jeremy Hunt may be a very unpopular Secretary of State (justifiably) but he should be given credit for increasing the number of medical students in England, albeit a long term development. In attacking this announcement the BMA risks damaging its own credibility. It is probably the best thing this secretary of State has done.