Addressing doctors at the BMA’s Annual Representative Meeting (ARM) in Bournemouth, Dr Mark Porter, BMA council chair, called on the government not to ignore concerns from patients and doctors about the future of the NHS.
Delivering his final speech as BMA council chair1, Dr Mark Porter, said:
Check against delivery
Friends and colleagues,
It is an honour to address you for the fifth and final time as council chair.
This year, it is a particular honour, because we have been given such salient reminders of the profession at its best.
The health service is not short of problems, but it’s not short of heroes either.
I want to pay tribute to the courage and compassion of the doctors, nurses and emergency service workers who responded to the many tragic incidents in London and Manchester.
They ran towards danger, as others were urged to run from it.
They responded to suffering with compassion and unity.
And they distilled years of experience into the vital minutes that mattered for their patients.
I am so proud to work alongside them in the health service. I want to thank them on behalf of the whole profession.
We meet in the wake of a general election, called by a government that wanted a stronger mandate.
We know how that turned out. If you tell a member of NHS staff whose pay has fallen that there’s ‘no magic money tree’, you might just discover that votes can’t be magicked out of thin air either.
However, I’m not here to talk about the government’s lack of seats, but its lack of perspective.
The prime minister said the election was about the Brexit negotiations. But elections, and governing this country, are about more than that.
I don’t underestimate the scale of the task ahead. Those negotiations will be as difficult as they are crucial to the country’s future.
But prime minister, you ignore the NHS at your peril. You say in your manifesto that the health service “should meet the needs of everyone, no matter who they are or where they live”.
And yet the scale of the challenge facing the NHS is greater than you, or indeed any politician, was prepared to acknowledge during the campaign.
The task ahead is immense, made harder by years of neglect by those who have come before you.
We still have one of the best healthcare systems in the world. It treats more patients than ever before, and deploys treatments of which I could only have dreamt when I qualified as a doctor. But after years of underinvestment, with a growing, ageing population, and despite the extraordinary dedication of its staff, it is failing too many people, too often.
It’s not just doctors saying this. According to research we have published today2, 62 per cent of the public think the NHS will get worse over the next few years. Two years ago, that figure was 39 per cent. Our research shows that the public expects waiting times to rise, the scope and availability of services to contract, and that the NHS will not receive the funding it needs to deliver high-quality care.
For the first time in our polling, more of the public are dissatisfied with the NHS than are satisfied.
So how can ministers have let this have come about?
It is because we have a health service that they view from high windows in Whitehall, or on a sanitised photo opportunity, but which patients all too often see from a trolley rather closer to the ground.
I’d like those ministers to imagine, just for one moment, what it’s like to be on one of those trolleys. To be one of those patients who hoped their needs would be met, no matter who they are or where they live.
Let them imagine what it must feel like to be that patient feeling vulnerable, frightened and in pain. Not knowing what’s wrong with them, not knowing if their life will be changed for ever. Not even knowing if they will get through the night.
Let them imagine what it must feel like to be the patient left in a corridor wondering if there was something that could have been done six hours ago, which cannot be done now to help them. Or their family member, trying to reassure them.
Many patients don’t have to imagine. This is their reality. How many people does the government think should have to suffer like this? Waiting more than four hours for admission to a bed?
Would 129,000 in a single year be too many? That’s what it was five years ago. Last year it was more than half a million, a four-fold increase. How many patients belittled and bewildered in this way is acceptable to ministers?
It’s clear why it’s happening. We have more patients, with more complex needs, than ever before and yet the financial pressures grow worse. We have lost more than 6,000 general and acute beds in six years. Average bed occupancy between January and March was at 91 per cent, and dozens of trusts had days when they hit 100 per cent.
This isn’t a measure of efficiency, as it might be at the Holiday Inn. It’s a measure of how hospitals are choked as doctors try to move patients through their treatment pathway to the care they need.
If your patient has mental rather than physical health needs, the situation is even worse. Thousands are shuttled around the country because of a chronic lack of beds. Isolated from their friends and family at their most vulnerable time.
Some have to languish in police cells for their own safety, while their clinical staff scour the country for placements and transport.
Their care suffers when communication breaks down between hospitals, and when they are so far from home. Like the young man whose parents had one day off a week to visit him, and spent seven hours on the road for one precious hour in his company.
He suffered. Any of us would suffer in those circumstances.
Doctors have raised these issues repeatedly. So too have coroners, in those tragic cases where patients have taken their own lives. We shouldn’t have to wait for an inquest before we tackle such patently unworkable and convoluted ways of caring for patients at their most vulnerable.
The government says it wants parity of esteem between physical and mental health. That seems a very distant prospect. Please. This is not just another target to be fudged and missed. It is a moral necessity.
The lack of beds, the lack of doctors, and the queues for treatment that grow and grow are not inevitable. It doesn’t have to be this way. It is the result of an explicit political choice.
We don’t have to spend less of our GDP than other leading European economies on health. Our government has chosen to do this. If we spent the average – the average, not the most – then patients would see £15 billion extra investment in the English NHS within five years3.
This would meet most of the gap in funding that the government accepts with half of its brain while the other half continues to spout that the NHS is ‘fully funded’.
The government wants a world-class NHS with a third-class settlement. So do the other main political parties. They share the failure of vision. Under all the plans set out in the election, the share of GDP spent on health would have actually fallen.
We’re not asking for the world. We’re asking for the average. For a fair chance to create the health service our patients need and deserve, and that we want to deliver. More than 70 per cent of doctors told us it has become harder for patients to access care, something familiar to every one of us here4.
Why, you might ask, is the NHS funding crisis so unmissable for us, and yet so invisible to politicians?
Well, just consider this for a moment.
This is the government that says it wanted to tackle the country’s deficit.
But it creates a deficit for medical students starting a lifetime of serving the public with £100,000 of debt, and the threat of conscription to follow graduation.
It drives successful and cost-effective public health services around the country into deficit or closure. In England alone they face £400 million of cuts over five years.
It leaves trusts with an £800 million deficit that would have been three times bigger without a bailout.
And when it comes to the existential challenge posed by its refusal to fund the NHS adequately, it ducks, it dodges and it passes it on.
The deficit is dumped onto the shoulders of communities who have no chance to fix it by themselves. They produce 44 grim little manifestos where they are invited to consider every option, except the one that stares them in the face – that the NHS is systematically under-funded.
So we have STPs that are about sustainability and transformation in name and name alone.
For how can they be called sustainable when they are forced to find £26 billion of cuts in health and social care?
How can they bring about seismic transformation when they need £10 billion of investment just to get off the ground? That’s more than twice the capital budget, even before it’s raided to pay off hospital deficits, and I don’t think loans and land sales will make up the shortfall either.
Millions of people could be adversely affected. Politicians know this, or if they don’t, they should. And yet during election campaigns they visit hospitals and surgeries, smiling for the cameras often in the full knowledge that the place they’re visiting is facing unachievable cuts in funding and growth in workload.
And when they’re challenged on this glaring double standard, they smile again and say it’s all about efficiency. We just need to be more efficient. A word of advice for politicians here – don’t just endlessly repeat clichés that are demonstrably untrue. That’s not strong and stable government.
Every year, our hospitals are shackled to a tariff system that cuts income as costs inevitably rise. Every year, in the name of efficiency, they have to waste time obsessing about money when they need to be obsessing about care.
It doesn’t work. It’s obvious to everyone outside Whitehall. The trusts themselves say they are being asked to ‘deliver the impossible’.
And when the clichés run dry, the tactics get ugly. The government blames the staff.
In January, in the midst of what the British Red Cross called a ‘humanitarian crisis’, with both GPs and hospitals working flat out, the prime minister chose to set one against the other.
Seriously? The prime minister sees a health service at breaking point and blames GPs? When almost a third of practices can’t fill GP vacancies, when they’re dealing with tens of millions more appointments than they did a decade ago, with a smaller share of NHS funding.
The prime minister blames doctors, when her own government is so conspicuously failing to keep its side of the bargain and recruit the much-trumpeted 5,000 new GPs by 2020. Three years ago, it was a pledge. Then it became an ambition. Now it seems more like a mirage.
The government creates excuses not doctors. And a language of evasion and failure. Its own version of the five stages of grief. Where promises become ambitions, and ambitions become excuses. Then we get the shower of contradictions before hitting the buffers of outright denial.
The government speaks of ambitions and it takes a certain ambition to run a health service by picking the pockets of its staff. Year after year, the government has cut the real-terms pay of doctors, nurses, and other NHS staff. Some doctors have seen a 17 per cent drop in salary5. And with it, a dose of emotional blackmail. You either accept the pay cut, or services will have to close.
This is a not a choice we should have to make. This is a choice that the government has made, to deny the NHS the resources it needs in the face of all available evidence.
It is the wrong choice. It is wrong for doctors, it is wrong for nurses, it is wrong for the legion of healthcare professionals who care for patients and their families, day in and day out.
Passing the buck is not a solution. Blaming staff is not a solution. Giving the NHS the resources that patients have told us they need - that’s a solution.
We give politicians our vote and our trust. It’s way past the time for them to step up.
They need to take responsibility, not just for how the NHS is funded but for those who staff it. Like the 10,000 NHS doctors who qualified in another European country.
Many came here as students. They wanted to give their working lives to the health service. They were drawn by the values of the NHS and now embody those values. But they have been left with fundamental worries and doubts about their employment rights and long-term future in this country.
Ensuring their rights, which has been the BMA’s consistent call since the referendum, will rightly be a priority in negotiations but the government’s fine words need to be turned into actions.
Treating these doctors with justice and respect is not a matter of charity; it is a matter of practical necessity and of moral obligation. We simply wouldn’t have a health service without them. And even if we did, I wouldn’t want to work in it.
Our research earlier this year found 42 per cent of EU-qualified doctors were thinking of leaving after the vote6 – thousands more than the promised extra medical students, who haven’t even started their undergraduate courses yet.
Colleagues, closing down our borders would close down our health service.
In Northern Ireland, co-operation between European countries isn’t a slogan but a day-to-day reality with patients benefiting from cross-border treatment. Patients who have suffered heart attacks in the south have had their lives saved in the north. And patients from both countries are treated in the same, excellent cancer centre.
During decades of conflict, doctors treated patients without fear or favour and won the respect of all communities. In peace, they have furthered reconciliation.
To put all this at risk and return to a world of border controls and mutual suspicion will harm our patients and damage the health service. I hear belligerent talk about who has the hardest Brexit, but while these words may be thrown around lightly in London, they will be lived in Belfast.
It’s time also that the government took responsibility for the legitimate concerns raised by doctors and particularly those with the greatest impact on safety – for patients and doctors alike.
Junior doctors are using exception reporting to highlight problems with their work and training, and they are being supported by their colleagues and BMA staff. Two thirds of hospital doctors report rota gaps in our latest survey. This growing mass of evidence must surely mean no-one in Whitehall can continue to ignore the true situation in an overworked and understaffed health service.
GPs are considering whether to close patient lists because of the overwhelming pressures they face. They don’t need the government to make unfunded promises or threats about extending access. They do need the government to listen to why they have been pushed into considering such a step.
In medicine we’re trained to listen to what the patient tells us. If we ignore what we see and hear, and carry on regardless, neither we nor the patient lasts very long.
Preventing patients getting sick in the first instance is as important. Yet, even the simplest ways to promote good health are run aground. While the Scottish government has stood up to the alcohol lobby, and now has just one hurdle left to clear with minimum unit pricing, it seems that an English liver is worth less than a Scottish one.
We welcome the Welsh government’s commitment to make health impact assessments a central part of decision-making, and congratulate those doctors in BMA Cymru Wales who campaigned for so long to achieve this.
And yet in England the government came up with a childhood obesity strategy that was like a box of frosted breakfast cereal. You grind down the content, and all that’s left is a spoonful of sugary dust.
The government’s tobacco strategy grinds down to even less than that – there hasn’t even been one for the last two years.
When governments lead and act, there can be big wins in public health. When they fail to act, they fail us all, and they make the pressures on the health service even worse.
Active across so many fronts, the BMA must be the organisation our members need it to be, in changing times.
Our members have told us it needs to be more locally focused, and the local engagement pilots we have run this year will lead to more staff closer to where our members work.
It’s essential that as an organisation we embody the values that doctors demonstrate individually, and abundantly. Hundreds of doctors have helped to shape the Living Our Values project, giving us their expectations and insight into how we should behave with each other.
Sometimes when people talk about our values, they hark back to a golden age, when we treated each other with unfailing courtesy and respect.
So can I briefly take you back to a previous ARM.
A certain doctor gave a talk on obstetrics. An extraordinarily talented and tenacious doctor. That doesn’t seem a controversial act, but it caused uproar.
What, asked your predecessors in 1875, could a woman possibly know of obstetrics?
This was our first female member, Elizabeth Garrett Anderson. The same ARM decided to call a vote on the admission of new female members. One thousand voted in favour. Three thousand voted against.
Perhaps we shouldn’t be surprised that a society denying women the vote and so many other rights, treated the idea of female doctors with such hostility.
But our profession was part of the problem. Dr Garrett Anderson endured 17 years of hostility and suspicion, until finally she witnessed the lifting of the ban. She led the way.
I want to say this in memory of Elizabeth Garrett Anderson, in this centenary year of the Medical Women’s Federation.
Firstly, thank you. For being ahead of your time and not giving in.
Secondly, it’s a lesson, RB, if it were needed, that we can get things wrong, and we can be too slow to realise when we are wrong.
And finally – this is unfinished business. Our profession is heading towards numerical equality. It is a long, long way off actual equality, 40 years after the Sex Discrimination Act was passed.
This is an urgent task for us all. It’s about challenging the structures that entrench inequality, but also about challenging both our own behaviour and attitudes, and those we experience every day. Until we are truly equal, we are all diminished.
I have been involved with the BMA for nearly 30 years. So much has changed, but I have been constantly inspired by the example of so many colleagues willing to stand up for patient care and the medical profession. I’d like to thank in particular Anthea [Mowat], Andrew [Dearden], Keith [Ward] and Ian [Wilson], and the many hundreds of representatives with whom I have served. I’d like to thank everyone here today as well.
Nothing would have been possible at the BMA without our expert staff, and nothing possible for me personally without the support of my wife Linda.
There was a BMA paper recently on why people choose this vocation, and what keeps them in it.
The reasons are familiar – the wish to help others, the variety and sense of fulfilment. That’s what I felt when I entered medicine almost 30 years ago and what I continue to feel now as I return to full-time practice. I’m sure it’s the same for you.
But what struck me even more is that so much of what we do here and in representing our fellow doctors is about trying to preserve that feeling, that promise you made to yourself when you qualified.
As a house officer 30 years ago, I wanted to help people but my ability to help them was compromised by 90-hour weeks. I didn’t mind hard work, but what I did mind was the risk to patient safety in the middle of the night.
That’s why I got involved in the BMA.
And we have changed things. Not as much or as quickly as we would like, but the work which every one of us does for the BMA makes a difference.
Colleagues, we have a government trying to keep the health service running on nothing but fumes. A health service at breaking point. Run by ministers who wilfully ignore the pleas of the profession and the impact on patients.
But we can make a difference. We can be a source of hope for our patients, a source of leadership for our colleagues, and a source of challenge for government when it fails the National Health Service.
That’s why we’re here. That’s what we do. And I know that you’re the right people to do it.
Notes to Editors
The British Medical Association (BMA) is the voice of doctors and medical students in the UK. We are an apolitical professional organisation and independent trade union, representing doctors and medical students from all branches of medicine across the UK and supporting them to deliver the highest standards of care.
- Dr Mark Porter steps down as BMA council chair on Thursday 29 June and will be replaced by Dr Chaand Nagpaul.
- BritainThinks conducted an online survey of 1031 adults living in England between 12 and 14 June 2017. The survey was conducted using the Populus Data Solutions online panel, and data were weighted to reflect the English population in terms of age, gender, region and social class. Some questions in this survey have been asked in previous surveys conducted by BritainThinks for the BMA in 2015 and 2016. A survey of 1,031 adults in England for the BMA reveals2:
- More than four in five (82 per cent) are worried about the future of the NHS
- Almost seven in 10 (69 per cent) believe the NHS is heading in the ‘wrong direction’
- More people are dissatisfied (43 per cent) with the NHS than satisfied (33 per cent). This figure has doubled over the last two years. In 2015 a BMA survey found that 21 per cent were dissatisfied, with 56 per cent saying they were satisfied. In 2016, 37 per cent reported that they were dissatisfied, with 41 per cent satisfied.
- Almost two thirds (62 per cent) expect the NHS to get worse in the coming years, compared to only 39 per cent in 2015
- The number of people who believe the NHS will get better has plummeted to half what it was just two years ago. Down from 26 per cent in 2015 to 13 per cent today.
- The top three concerns about the NHS were:
- A lack of funding (50 per cent)
- NHS will cease to be free at the point of use (41 per cent)
- Waiting times in the NHS will increase (35 per cent)
- Asked what they thought was likely to happen to the NHS in the coming years:
- More than four in five (83 per cent) said they believed waiting times will increase
- Three quarters (75 per cent) said they thought number of services will be reduced
- Three quarters (75 per cent) said they thought that getting a GP appointment will become more difficult
- Almost seven in 10 (69 per cent) believe that the NHS will not get enough attention because of Brexit.
- The BMA is calling for spending on the NHS to rise to match that of other leading EU economies. Using the most recent OECD data, this means that the UK would spend 10.4% of GDP on health instead of the 9.8%. By 2022/23 this would mean spending on the NHS in England would be £14.6bn more than currently projected.
- A BMA quarterly online survey of 422 doctors was conducted between 23 May and 13 June 2017. 71 per cent of respondents believe that it has become more difficult for patients trying to access NHS care over that past 12 months. Respondents were asked to tell us how they thought patient access to services had worsened over the past 12 months. The most often cited reason for the deterioration in access was longer waiting times for admissions and for GP appointments.
- In real terms, doctors’ pay has sharply declined in the past five years, with junior doctors seeing their income drop by 17 per cent. Over the same period consultants have seen their pay drop by 14 per cent and GPs by 13 per cent. More information is available here.
- For more information visit the BMA website.