Radical ideas to revolutionise a broken NHS. Your thoughts?

[Puffing Devil]

Do you have a link to the source of your chart because it does look strangely convient. The data I've seen is that between 2008 and 2012 the waiting list stayed quite steady at about 300,000.

They are extracted from an FT article, which is paywalled. The background/build-up is in this Twitter Thread: https://twitter.com/jburnmurdoch/status/1606223967903260673

Given the source, I don't doubt the veracity.

 

[Bletchleyite]

Out of curiosity why do so many Americans oppose the idea of a UK or Canadian based healthcare system. Our healthcare system is often mocked and ridiculed by Americans.

Because they're selfish and don't like the idea of their money helping others.

I doubt the current climate would allow the NHS to be introduced here if we didn't already have it.

 

[The Ham]

Do you have a link to the source of your chart because it does look strangely convient. The data I've seen is that between 2008 and 2012 the waiting list stayed quite steady at about 300,000.

My reading of the graph is that it does show that between 2008 and 2012 that there probably wasn't a significant variation (+/-10% would be about 270,000 to 330,000, although it's hard to judge where that range sits.

This is confirmed by this article which intimates that 2009 to 2012 was broadly stable:

Chart of the week: How has the waiting list changed over the years?

Each week we present analysis of data in chart form to illustrate some key issues and invite discussion. The waiting list in England recently topped six million people, which is the largest figure since the NHS was established in 1948. John Appleby looks back over the years to explore the...

www.nuffieldtrust.org.uk

As success in reducing long waits in the early part of this century continued, the Labour government raised the stakes by announcing a new, more comprehensive target in 2005 that no more than 10% of patients should wait longer than 18 weeks from referral by a GP to treatment in hospital. This meant another change in waiting list data in 2007 to better capture what would now become a more overarching measure of the complete waiting list/time experience. Within two years – by 2009 – the total waiting list had nearly halved to 2.3 million, and the 18-week target continued to be met up until 2017. But from around 2012 the waiting list started to rise, nearly doubling to 4.34 million by February 2020.

 

[duncanp]

The budget may not have been cut "in real terms". However:

• Beds have been cut, especially acute beds and those for the care of the elderly
• A&E Departments have been closed and/or downgraded
• Waiting times have spiralled for both elective and emergency cases
• Money has been diverted from the NHS budgets to external agencies -
  • Serco and Capita for example - with questionable records of delivery
  • Growing group practices of GPs and other providers

Budget notwithstanding, the current government has been managing down the provision of the NHS through culpable neglect, if not wilful action.

View attachment 126691

The Labour government of 1997 - 2010 fiddled the waiting list figures by not putting people on the waiting list even when their clinical situation justified it.

I know this because around 2004 I started to have problems with back pain.

My GP wanted to refer me to the local hospital (Whipps Cross in London) but said she couldn't because that would mean they wouldn't be able to meet their waiting list target of 18 weeks from referral to treatment. She probably wasn't supposed to say that.

In other words, waiting lists were "managed", with only a set number of people allowed to be officially referred per month. Anyone else just had to wait in a queue which was effectively a "waiting list to get on the waiting list".

It was the same with St Tony Blair's policy of being able to get a GP appointment within 48 hours.

You would phone the GP on Monday and be told there are no appointments left, as all appointments have to be within 48 hours of phoning.

Same thing on Tuesday.

On Wednesday morning the receptionist would condescend to give you an appointment on Friday.

Officially the appointment would be within 48 hours of phoning, but the reality was quite different.

 

[Bletchleyite]

The same fiddling happens with GP appointments. Rather than releasing a year's worth and ending up booked for 3 months, they release them a month at a time or daily so the "waiting list" is never more than that.

 

[DelayRepay]

That kind of fiddling happens everywhere - it's not just the NHS. It's a problem when you use targets to incentivise people - they naturally manage the targets rather than managing the underlying supply/demand/whatever. See the thread about Royal Mail delivering the most recently posted items first, in order to minimise the total percentage of letters classed as late.

One thing I would look at is whether 111 can be expanded to be the first point of contact for all medical issues, rather than the GP receptionist. They could triage you by phone/video call then book an appointment if one's needed. This appointment could be with a different surgery if the one the patient's registered at doesn't have any availability, or could in some cases be a direct referral to a hospital.

I think we have an inherent fear in restricting access to GPs in this way, because the media will always focus on the one case where the wrong advice was given, rather than the tens of thousands of hours of GP time saved through not having to deal with minor ailments that don't need medical treatment at all or are best dealt with elsewhere e.g. at a Pharmacy. You could go a step further and triage A&E attendance in this way; if it's an emergency, you'd rink 999 for an ambulance. If you're less sure you'd ring 111 who would have attendance at A&E (via an ambulance or under your own steam) as options available.

 

[Bletchleyite]

I think we have an inherent fear in restricting access to GPs in this way, because the media will always focus on the one case where the wrong advice was given, rather than the tens of thousands of hours of GP time saved through not having to deal with minor ailments that don't need medical treatment at all or are best dealt with elsewhere e.g. at a Pharmacy. You could go a step further and triage A&E attendance in this way; if it's an emergency, you'd rink 999 for an ambulance. If you're less sure you'd ring 111 who would have attendance at A&E (via an ambulance or under your own steam) as options available.

I think we need a system following IT Service Management style processes - multiple entry points to the same services triaged on need. So you could call 111, or you could go and log into a website and "raise a ticket" with the time to type in lots of detail on your symptoms and add photos* etc, or you could go to a receptionist or pharmacist but perhaps we'd upskill them with more triage ability and provide them a private consultation room - surgeries can sometimes be a bit like that Monty Python sketch - "who's got the pox?"

* Noting that we might actually need a law change to allow photos of certain conditions to be taken and uploaded, particularly of children - "indecent images" laws make no exceptions to doing so for the reasons of medical care!

 

[jfollows]

Out of curiosity why do so many Americans oppose the idea of a UK or Canadian based healthcare system. Our healthcare system is often mocked and ridiculed by Americans.

Because it's viewed by many as "socialist", which is anathema to many Americans who instead believe more in self-support, isolation and self-sufficiency, not all bad things in themselves.

 

[DynamicSpirit]

Out of curiosity why do so many Americans oppose the idea of a UK or Canadian based healthcare system. Our healthcare system is often mocked and ridiculed by Americans.

I would guess it's a mixture of:

• They hear misinformation about our system that is exactly as bad as the misinformation we in the UK tend to hear about other countries' systems.
• Mainstream culture and political beliefs in the US are much more focused on private enterprise and self-sufficiency, and opposed to 'big Government' doing this kind of stuff in a monolithic kind of way. That makes it much harder for any idea comparable to the NHS to fly.

 

[HSTEd]

In this respect, I am becoming increasingly convinced that the GP system is not particularly suitable for a modern healthcare system.

Scattering doctors in tiny premises all over the place with no in house diagnostic system and insufficient staff to practically arrange 24/7 cover seems like a bad plan.
So much medicine these days depends on diagnostic tools and equipment, and given how mobile the population now is (and yes I know not everyone can drive, but motorised transport is widely available in a way it simply wasn't in the 40s), having a dozen GP surgeries in a town seems suboptimal.

Need a diagnostic hospital that does GP stuff as well as A&E, and can provide proper facilities etc.

In addition, the lack of proper hospital welfare facilities (obvious stuff like usable canteens etc or even drivers to take exhausted staff home after a shift) reduces the efficiency of operation of our medical staff body, which was puchased through an enormously expensive training programme.

And definitely, do not put "Doctors in charge".
We should not pay for Doctors to spend years in training to do Administration, if anything we need a separate medical administration training pipeline.

 

[DelayRepay]

I think we need a system following IT Service Management style processes - multiple entry points to the same services triaged on need. So you could call 111, or you could go and log into a website and "raise a ticket" with the time to type in lots of detail on your symptoms and add photos* etc, or you could go to a receptionist or pharmacist but perhaps we'd upskill them with more triage ability and provide them a private consultation room - surgeries can sometimes be a bit like that Monty Python sketch - "who's got the pox?"

* Noting that we might actually need a law change to allow photos of certain conditions to be taken and uploaded, particularly of children - "indecent images" laws make no exceptions to doing so for the reasons of medical care!

Whilst I agree, you do realise that this will generate the same response as a suggestion that people buy their rail tickets online... we'll get the story about the elderly person who can't use a telephone or a computer. I agree that raising a 'ticket' online wouldn't work for everyone and every condition, but I bet it would deal with a good 80% of GP appointments and possibly a good percentage of A&E appointments too.

In this respect, I am becoming increasingly convinced that the GP system is not particularly suitable for a modern healthcare system.

Scattering doctors in tiny premises all over the place with no in house diagnostic system and insufficient staff to practically arrange 24/7 cover seems like a bad plan.
So much medicine these days depends on diagnostic tools and equipment, and given how mobile the population now is (and yes I know not everyone can drive, but motorised transport is widely available in a way it simply wasn't in the 40s), having a dozen GP surgeries in a town seems suboptimal.

Yes - it is inefficient, a huge waste of money, incapable of delivering the services patients need and inconvenient for most people too. I'd scrap the idea of a 'family doctor' - everyone would just be registered with 'The NHS' rather than a specific surgery. All admin and appointment bookings would be handled centrally and 'the centre' rather than the GP would be the gatekeeper of other NHS services.

My own industry, banking, is not without problems but I think the NHS needs to look at how we've moved away from having a physical branch in every small town to delivering services in a digital (and therefore more cost effective) way. In banking we have an arrangement with the Post Office for people who still need to do a physical transaction, the equivalent NHS partnership would be with the pharmacies.

 

[The Ham]

I think we need a system following IT Service Management style processes - multiple entry points to the same services triaged on need. So you could call 111, or you could go and log into a website and "raise a ticket" with the time to type in lots of detail on your symptoms and add photos* etc, or you could go to a receptionist or pharmacist but perhaps we'd upskill them with more triage ability and provide them a private consultation room - surgeries can sometimes be a bit like that Monty Python sketch - "who's got the pox?"

* Noting that we might actually need a law change to allow photos of certain conditions to be taken and uploaded, particularly of children - "indecent images" laws make no exceptions to doing so for the reasons of medical care!

In this respect, I am becoming increasingly convinced that the GP system is not particularly suitable for a modern healthcare system.

Scattering doctors in tiny premises all over the place with no in house diagnostic system and insufficient staff to practically arrange 24/7 cover seems like a bad plan.
So much medicine these days depends on diagnostic tools and equipment, and given how mobile the population now is (and yes I know not everyone can drive, but motorised transport is widely available in a way it simply wasn't in the 40s), having a dozen GP surgeries in a town seems suboptimal.

Need a diagnostic hospital that does GP stuff as well as A&E, and can provide proper facilities etc.

In addition, the lack of proper hospital welfare facilities (obvious stuff like usable canteens etc or even drivers to take exhausted staff home after a shift) reduces the efficiency of operation of our medical staff body, which was puchased through an enormously expensive training programme.

And definitely, do not put "Doctors in charge".
We should not pay for Doctors to spend years in training to do Administration, if anything we need a separate medical administration training pipeline.

I'd been having similar thoughts. The NHS app should also be able to be a route in.

Another option to consider is there's been a rise in private medical offering app based consultations, now whilst plenty prefer an in person appointment there's plenty who could deal with stuff online like this. The problem with then is that unless you're in an urban area of someone does need to see you it's not easy to get to them. The NHS, offering a similar service, could give you a range of options as to where you could go.

 

[Bletchleyite]

Whilst I agree, you do realise that this will generate the same response as a suggestion that people buy their rail tickets online... we'll get the story about the elderly person who can't use a telephone or a computer. I agree that raising a 'ticket' online wouldn't work for everyone and every condition, but I bet it would deal with a good 80% of GP appointments and possibly a good percentage of A&E appointments too.

Indeed. But also note that I said that you could "raise a ticket" in lots of places, perhaps a triage desk at a hospital, a pharmacy*, or a "good" old fashioned GP receptionist.

The one thing that'd need to change is the idea that you don't have to say anything about what it's for until you get to a doctor, as that's inefficient. Obviously for certain specific problems there'd need to be the option to "raise the ticket" with a male or female as desired. However I think I personally would always do it online in text/pictures form.

I think I'm with you in saying that the community GP surgery is as out of date as the branch bank, suiting only a small number of people, and has probably had its day. The idea that GP surgeries procure other services, as became the case 10 or so years ago, was about the most counterintuitive reform imaginable.

* I think the idea that if you don't want to do it online or by phone that the route in to all but emergency NHS care would be via a pharmacist has quite good legs, as it were. They're generally accessible in the community (far more so than GPs), keep longer hours than GPs, have consultation rooms and can route people to over the counter medication if appropriate, saving the NHS money.

 

[DelayRepay]

Another option to consider is there's been a rise in private medical offering app based consultations, now whilst plenty prefer an in person appointment there's plenty who could deal with stuff online like this. The problem with then is that unless you're in an urban area of someone does need to see you it's not easy to get to them. The NHS, offering a similar service, could give you a range of options as to where you could go.

I have access to an app based GP consultation through the Private Medical Insurance my employer provides. It's great - same day video appointments at a time that's convenient. I've used it twice for minor issues so that's saved the NHS two GP appointments. And I suspect the insurance company delivered the two appointments at a lower cost than the NHS would have.

 

[Bletchleyite]

I have access to an app based GP consultation through the Private Medical Insurance my employer provides. It's great - same day video appointments at a time that's convenient. I've used it twice for minor issues so that's saved the NHS two GP appointments. And I suspect the insurance company delivered the two appointments at a lower cost than the NHS would have.

One issue with these is that they can't route into an NHS prescription or similar, which can make them very expensive if your condition is ongoing, despite saving the NHS money!

If I could get an NHS prescription (they cost me a marginal £0 as I do the monthly thing due to needing a fair whack of pills already) or referral from them I'd use them, certainly. I'm not in a private scheme but I'd happily pay the £50 ish fee they charge if they could do what an NHS GP can.

 

[HSTEd]

I think I'm with you in saying that the community GP surgery is as out of date as the branch bank, suiting only a small number of people, and has probably had its day. The idea that GP surgeries procure other services, as became the case 10 or so years ago, was about the most counterintuitive reform imaginable.

It's ultimately the cult of "put the doctors in charge" writ large.

 

[DelayRepay]

One issue with these is that they can't route into an NHS prescription or similar, which can make them very expensive if your condition is ongoing, despite saving the NHS money!

If I could get an NHS prescription (they cost me a marginal £0 as I do the monthly thing due to needing a fair whack of pills already) or referral from them I'd use them, certainly. I'm not in a private scheme but I'd happily pay the £50 ish fee they charge if they could do what an NHS GP can.

That is true... I didn't need prescriptions but if I did I would have needed to either see my NHS GP or pay.

I don't think they can route directly to hospital specialists either on the NHS. They can route you to a private specialist if your insurance covers it or if you are willing to pay.