NHS Reform: what should future UK healthcare look like?

[TPO]

I took up the challenge from @SurreyCommuter in the COVID thread. https://www.railforums.co.uk/threads/nhs-awarded-the-george-cross.219472/

I have put in this thread although maybe it should be in the COVID thread? (Mods please feel free to move if in wrong place).

OK, this is a sensitive subject, so I ask that we approach this in a factual and balanced manner and without emoting. There's been a lot of good from the NHS over the years, but equally there's no doubt it has its flaws and also no doubt that as the future unfolds, healthcare will need to be flexible enough to respond to changing demands and challenges.

Funding is often presented as "the answer" but I am not convinced that is all of the answer. There's also questions such as what level of care should be provided and how best to do so (locally vs centrally for example).

For a starter, I suggest we need a "national healthcare" system that looks a bit like this:

- Funded through National Insurance (or a similar mandatory payment at PAYE level)
- User does not need to pay and claim back (with some exceptions)*
- 100% coverage as there is now
- retain emergency ambulance service

However, where I'd differ:
- Everyone has a "smart card" account with a basic level of credit on and covering A&E, GP visits etc.
- Anyone with a known condition requiring frequent GP visits has extra credit to cover this.
- Any extra services your front-line referring medic confirms as required, you get required credit added and help to find the most appropriate provider
- *Time wasters at A&E or GP surgeries run out of credit and a nominal sum is made for a visit- e.g. it'll cost you a flat £50 if you're in a Drunk Tank on a Saturday night. I know this is controversial but it's a sad part of life that free "entitlements" are often not valued, used to excess and not respected.
- More localised control of services, local hospitals setting priority in their areas
- "Health education" in schools from a young age, really shouldn't be having A&E and GP visits for non-issues which could be treated at home. Inculcate a level of personal responsibiiity and resilience from a young age.
- GPs funded when people do have an appointment rather than by how many on their list, the person can instead choose to use a "walk in centre" which is e.g. perhaps in a local supermarket and is open in the evenings
- Medical records follow the person around (OK, I know that needs proper secure IT)
- Streamline the process of CPD for medics and remove the govt incentive payments for certain tasks
- Referrals to specialists can be from either a GP or a walk-in centre, they would all be "primary contact" medics.
- Hospitals and treatment could be by public sector, charitable sector or private sector but cost controls in place (keep the effective parts of NICE etc).
- Remove number caps on university training places for doctors and nurses, reinstate vocational routes where appropriate, provide bursaries for students from poorer backgrounds linked to service in a UK medical setting for X years afterwards

That's not the details, just the overview, but the point is moving away from a monolithic national service to something more networked with payment systems modeled on the best European systems.

The outcome should be a system which is not a national religion, which values things like good convalescent care (e.g. feeding patients decent food and helping them eat it) and which is not needing to lock the economy down every winter to avoid collapse. It should also not need to constantly recruiting nurses and other medical staff from poorer countries which invest in training medics then see them tempted away by richer countries, and health sector employers should be place where people WANT to work. .

Social care will of course be a linked issue.

I'm sure there's different ways to achieve a good end, but I think some things are critical:.

(1) Getting away from the NHS being a quasi-religion or staffed with "heroes," and towards an understanding of a modern health service
(2) Pragmatism and use of modern IT
(3) Long-term development and retention of capacity and capability in the system (good base of staff, capacity linked to local need)
(4) A sense of responsibility on the part of users to go with the sense of entitlement already existing

There's no easy answer, but if the NHS continues to be a sacred cow and we avoid sensible discussion of reform, it will either collapse under its own weight or a govt will eventually change it by stealth and in that situation the outcome is unlikely to be the best possible one for the public (rather it will inevitably serve vested interests).

TPO

 

[WelshBluebird]

I think its a noble set of ideas, and certainly you do try to tackle some of the issues with the NHS and how people use it that do need to be looked at. But I think there some pretty big issues with what you suggest.

- Anyone with a known condition requiring frequent GP visits has extra credit to cover this.

What about people with unknown new conditions? Or even just conditions the GP refuses to deal with (a lot of mental health issues end up like that, or things like Fibromyalgia etc).
How do you judge how much "extra credit" to give? Whose to say that my condition doesn't need more "extra credit" than yours or whatever?
What happens when people run out of that credit but have medical issues they need seen to still?

- *Time wasters at A&E or GP surgeries run out of credit and a nominal sum is made for a visit- e.g. it'll cost you a flat £50 if you're in a Drunk Tank on a Saturday night. I know this is controversial but it's a sad part of life that free "entitlements" are often not valued, used to excess and not respected.

Who judges who "time wasters" are?
It is easy to use the fairly straightforward "drunk tank" example but even then what about people who have alcohol addiction issues (I know its a taboo topic but addiction really is a healthcare issue). And of course then you get the more complex examples - what about people who were injured whilst drunk through no fault of their own (were attacked, or tripped on some dangerous flooring, or just happened to have a separate medical issue when drunk)?
Would you extend that to other injuries where the person could have taken more responsibility to prevent it (obesity, smoking, taking part in sports, cycling to work etc etc)?
How would you deal with the fact that a potential £50 flat fee would probably put people off going to A&E even if they should go because that 50 quid could be difference between them eating that week or the next?

 

[gordonthemoron]

Too much admin, just stay as it is

 

[87 027]

Why not have a look at the following, compare them to the proposals above and where the NHS currently is now

Personalised Health and Care 2020

Personalised health and care 2020

Using data and technology to transform outcomes for patients and citizens.

www.gov.uk

Five Year Forward View (from 2014)

https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

These changes mean that we need to take a longer view - a Five-Year Forward View – to consider the possible futures on offer, and the choices that we face. So this Forward View sets out how the health service needs to change, arguing for a more engaged relationship with patients, carers and citizens so that we can promote wellbeing and prevent ill-health.
It represents the shared view of the NHS’ national leadership, and reflects an emerging consensus amongst patient groups, clinicians, local communities and frontline NHS leaders. It sets out a vision of a better NHS, the steps we should now take to get us there, and the actions we need from others.

NHS Long Term Plan (from 2019)

UK Government Web Archive

This Page is [ARCHIVED CONTENT] and shows what the site page https://www.longtermplan.nhs.uk/ looked like on 11 May 2025 at 09:12:43

www.longtermplan.nhs.uk

As medicine advances, health needs change and society develops, the NHS has to continually move forward so that in 10 years time we have a service fit for the future. The NHS Long Term Plan is drawn up by frontline staff, patients groups, and national experts to be ambitious but realistic.

These are all fairly long documents but have summaries at the beginning. The thrust of it is a greater emphasis on 'prevention' as well as the traditional 'repair' service

 

[johntea]

The trouble with NHS IT is it is far too fragmented (although having a 'central' solution didn't work out too well either!), I should know I've worked in it for the past 5 years now - and we're only just starting to get rid of the fax machines and Windows XP!...if one good thing has come out of Covid it is that there has been years and years of technology uptake in the space of just 18 months

I have seen absolutely millions wasted however on several systems that the powers that be have been blinded by the sales people into thinking they're the best thing since sliced bread and then they've quickly found they're about as much use as a chocolate fireguard

 

[PupCuff]

From my point of view, the biggest frustrations I have with the NHS are;

• We're expected to often put up with appalling service because 'it's free'.
• Until very recently one of the main services I used didn't have access to email - only fax. It's 2021.
• My hospital records don't link up with my GP records.
• Where private providers deliver NHS services, often this will be one provider with no competition so they have no incentive at all to provide a good service.

If I was in charge I'd look to:

• Upgrade the IT to be a modern, centralised up-to-date system that's easy to use by clinicians and easily accessible to the patient as well whether that's at the GP, the pharmacy, the walk in centre or the hospital across the UK. Half the time my name is spelled wrong, every time they correct it on one system the spelling error creeps into another. Things like that should be fed from one unique data source not multiple sources where data discrepancies can occur.
• Move away from the current referral system where you're sent to one specific provider and instead issue a 'referral code' or somesuch that you can take to any NHS accredited provider and get the diagnostics/treatment etc. The referral code would be how the service gets paid by the NHS so each provider has an incentive to make their service the best they can (customer service, availability of appointments, accessibility for the disabled etc) otherwise they won't get the patients through the door and won't get paid. I don't work in the city where I live, there should be no reason why the GP can't refer me for an ultrasound and I then take the referral and book this at a location near work then they sort the money out between themselves afterwards.
• Make it a condition of providing NHS services that medical providers have to meet minimum service standards, and regularly audit these - as an example, my GP in my last city, you couldn't book appointments at the front desk, you had to use the app, except between 08:00 and 09:00 in the morning. That's an unnecessary inconvenience for people who can't use the app and poor customer service.
• Increase training of clinical staff - we hear regularly about shortages of doctors and nurses, so I'd put in place schemes to train staff off the street. Every year we hear medical courses at university are oversubscribed, yet this translates to a shortage of doctors and nurses. Going down the applying to university route also disadvantages people from low income backgrounds who would make great doctors and nurses but don't want to be, or can't afford to be, lumbered with the cost of university. It's easier to retain staff you've trained yourself too, as you get their buy in from an early point, and there's also the option of having them repay training fees if they leave within a certain number of years.
• Push a culture where change happens because the people in front line roles feel empowered and supported to suggest and implement improvements to make their working environment or area of responsibility better and influence change up the chain of command. If a secretary is working 60 hour weeks because he's being told to do a job in a really inefficient way then clearly he's got an incentive to work to get the process more slick and in turn make him and the overall department/business more productive.

 

[DarloRich]

The last time the government tried to modernise the NHS IT systems cost about £10bn and didnt work!

 

[Wuffle]

The last time the government tried to modernise the NHS IT systems cost about £10bn and didnt work!

Made the private companies involved a few bob though I wonder how many donated to political parties ?

The problem is that the government is blinkered to "Wintel" solutions and doesn't think outside that box

 

[RuralRambler]

The last time the government tried to modernise the NHS IT systems cost about £10bn and didnt work!

If it's anything like the industrial/administrative computerisation I've been involved with, the problem is that the "users" want the system to mirror their shoddy/ineffective outdated working practices. Computerising a shambles just creates another shambles, just on discs rather than paper, and costs a fortune. What is needed is that the working practices are made more efficient in the first place, with proper organisation, and then that's literally a hundred times easier to computerise and costs a fraction. I always remember one manufacturing firm where the parts/products had a crazy/convoluted parts number system - about 20 digits long, a mix of letters and numbers, each digit meaning something, i.e. the last digit told you the angle/degree of the component part, the first digit told you the material, etc. It was a relic of manual, paper based stock control, and they first "computerised" it back in the late 80's with a simplistic DOS system. When it came to moving the databases over to Windows, they wanted to retain the parts number system, which literally couldn't fit into the industry-standard off the shelf manufacturing software databases. I had one hell of a battle with them to change the part numbers and use all the new functionality instead (built into the modern software), i.e. "tagging" parts with different fields to signify material, size, etc etc, so you could easily search by "ferralium" or "sd40" or "90 degrees" etc from drop down search screens and create all kinds of bespoke reports, i.e. stock lists/valuations by material, product type, etc. The trouble is that the actual users of systems often don't have the breadth of experience/knowledge/awareness of "better" or "modern" ways to do the job they've been doing for years/decades.

 

[87 027]

Made the private companies involved a few bob though I wonder how many donated to political parties ?

The reality is more nuanced than that. Some suppliers absorbed heavy losses and walked away to prevent even further losses

 

[HSTEd]

I've unfortunately come to the conclusion that government funded healthcare is incompatible with a free society.

First it was abhor the morally degenerate fat people or the morally degenerate smokers, now it is never ending restrictions to "protect ah enn aitch ess"

I wish it was not so, but I have not yet come up with a way of preventing government funded healthcare being used as an excuse for ever greater authoritarianism

EDIT:

On NHS IT, they should stop trying to build a single database or record system which is amazing and does everything.

They should just define data standards for interchange of data between systems, it doesn't matter if its old fashioned or inefficient, you just need a way of moving records around between disparate systems - and all future contracts would be required to support this interface no matter what else they do.

Even if it was some sort of silly HTML format on a 60mA current loop teletype!

 

[Ediswan]

They should just define data standards for interchange of data between systems, it doesn't matter if its old fashioned or inefficient, you just need a way of moving records around between disparate systems - and all future contracts would be required to support this interface no matter what else they do.

Even if it was some sort of silly HTML format on a 60mA current loop teletype!

The close relative XML might be up to the job. As you say, defining data standards is the key.

 

[87 027]

The close relative XML might be up to the job. As you say, defining data standards is the key.

And which standards and how many previous versions of those standards and how you persuade suppliers to adopt standards while they are still being developed and how you retrofit new standards onto pre-existing systems which on average are replaced at great expense once every 15 years or so and if you do interim releases how much time and effort you devote to confirming backwards compatibility and make sure any changes haven’t broken something that previously worked… (pauses for breath)

I invite you to look at material produced by the Healthcare Information Management and Systems Society and consider the difference between foundational, structural, semantic and organisational interoperability. Or to put it another way, you can very easily set up a Zoom call with someone in Russia, but if you don’t understand Russian and they don’t understand English, you aren’t going to get very far…

 

[HSTEd]

And which standards

The one an appropriate commission choses, just as has been used in previous instances of technological adoption by states throughout modern history?

how you persuade suppliers to adopt standards while they are still being developed

It's really quite simple - they either adopt the standard or they get no business.
And I'm not sure why it is necessary to start adopting a standard before it is finished?

That seems like it is asking for trouble.

and how you retrofit new standards onto pre-existing systems which on average are replaced at great expense once every 15 years or so

So you mean within 15 years we can have everything integrated?

At the speed at which NHS IT moves, that's still a dramatic advance on everything that has come before.

and if you do interim releases how much time and effort you devote to confirming backwards compatibility and make sure any changes haven’t broken something that previously worked… (pauses for breath)

Well you simply don't do interim releases because they are a huge waste of money most of the time.
The standard is produced, the standard is frozen and *then* implementation commences.

 

[Ediswan]

And which standards and how many previous versions of those standards and how you persuade suppliers to adopt standards while they are still being developed and how you retrofit new standards onto pre-existing systems which on average are replaced at great expense once every 15 years or so and if you do interim releases how much time and effort you devote to confirming backwards compatibility and make sure any changes haven’t broken something that previously worked… (pauses for breath)

Just suggesting that XML might be a suitable interchange format, rather than HTML. I am not attempting to address any other issues.

 

[87 027]

The one an appropriate commission choses, just as has been used in previous instances of technological adoption by states throughout modern history?

It's really quite simple - they either adopt the standard or they get no business.
And I'm not sure why it is necessary to start adopting a standard before it is finished?

That seems like it is asking for trouble.

So you mean within 15 years we can have everything integrated?

At the speed at which NHS IT moves, that's still a dramatic advance on everything that has come before.

Well you simply don't do interim releases because they are a huge waste of money most of the time.
The standard is produced, the standard is frozen and *then* implementation commences.

I invite people to consider the following and whether this is sufficiently well defined with sufficient certainty for a software vendor to code into a product to go on the market tomorrow

BETA - NHS digital, data and technology standards framework - NHS Digital

We’re the national information and technology partner to the health and social care system using digital technology to transform the NHS and social care

digital.nhs.uk

Just suggesting that XML might be a suitable interchange format, rather than HTML. I am not attempting to address any other issues.

That deals with foundational and possibly structural interoperability but I question whether it is enough for semantic interoperability

== Doublepost prevention - post automatically merged: 10 Jul 2021 ==

It's really quite simple

Nothing personal, but I suspect many a subject matter expert heaves a great sigh whenever they hear words similar to these. “Surely it can’t be that difficult to …” falls into the same category

 

[HSTEd]

Nothing personal, but I suspect many a subject matter expert heaves a great sigh whenever they hear words similar to these. “Surely it can’t be that difficult to …” falls into the same category

In this case the simplicity is not actually making the standard.

I am referring to the simplicity of forcing compliance - it's just use of the NHS's monopsony power.

 

[87 027]

I am referring to the simplicity of forcing compliance - it's just use of the NHS's monopsony power.

I come back to the point that a standard has to be pinned down to the point where it is implementable. I have attended numerous health technology conferences where suppliers have worked to implement a draft standard and complained it has subsequently changed, so the question of ‘moving goalposts’ does at least need to be acknowledged as a concern.

== Doublepost prevention - post automatically merged: 10 Jul 2021 ==

monopsony

You are right that this can be a powerful force

 

[HSTEd]

I come back to the point that a standard has to be pinned down to the point where it is implementable. I have attended numerous health technology conferences where suppliers have worked to implement a draft standard and complained it has subsequently changed, so the question of ‘moving goalposts’ does at least need to be acknowledged as a concern.

From my own experience with the nuclear industry, I despair at the desire of people to start building something before they've finished the design.

A standard should be nailed down before any significant implementation work goes forward.

 

[87 027]

A standard should be nailed down before any significant implementation work goes forward.

Completely agree!

 

[Worm]

Made the private companies involved a few bob though I wonder how many donated to political parties ?

The problem is that the government is blinkered to "Wintel" solutions and doesn't think outside that box

I studied the possibility of using a Xubuntu system instead in an NHS trust for my undergraduate dissertation last year with real NHS staff, the overwhelming opinion was that "it just isn't the same". The literature also showed the attempts at implementing whole FLOSS software systems in hospitals failed in every attempt, the most notable being a Belfast hospital in 2005, within 6 months they brought back XP desktops after staff complaints.

 

[87 027]

Also worth bearing in mind that medical staff rotate around the health service, so the greater the variety of systems and interfaces, the more potential unfamiliarity and additional learning there is for people on the front line. Particularly if the ambition is for a paperless NHS with everything electronic at the point of capture - rather than medical secretaries typing things up from handwritten notes!

 

[HSTEd]

The literature also showed the attempts at implementing whole FLOSS software systems in hospitals failed in every attempt, the most notable being a Belfast hospital in 2005, within 6 months they brought back XP desktops after staff complaints.

And that ultimately shows the issue.

Staff don't want to change, so the NHS slowly dies as a result.

It is essential that the NHS use software platforms that can be controlled by the state and can be maintained and upgraded indefinitely without the interference of third parties.

XP will never be ported to new hardware or receive new driver software.