Offline: Tackling the despair of England's NHS

Abstract

It is with exquisite sadness that anyone concerned with the future of health care in England now observes the present broken covenant of trust between government and medical profession. I cannot recall a time since 1980 (the year I became a medical student) when the confidence doctors and politicians have in one another has been so low, when the dialogue between them has been so bitter. Ever since the creation of the Royal College of Physicians in 1518, the profession has served at the pleasure of government. Five centuries ago a contract was struck between doctors and Henry VIII. In return for the freedom to regulate who practised medicine and how that medicine was practised, physicians would dedicate themselves to the health and security of the nation. That contract reached its apotheosis with the creation of the National Health Service (NHS) in 1948. Each party to the arrangement has honoured its promise. Andrew Lansley's health reforms stretched that promise to breaking point. But the contract did not break. Lansley's political party, the Conservatives, won a general election in 2015, and any thought of rolling back the Health and Social Care Act 2012 ended with that democratic choice. The junior doctors' strike of 2016 was a moment when the compact between government and profession was again threatened. Now, as another winter crisis engulfs the NHS, battle lines are drawn once more. Doctors point to the strain being felt by general practitioners (GPs) and hospitals. As Liam Brennan, a softly spoken consultant anaesthetist, told the BBC last week, “It makes us feel intensely distressed and unhappy that we're not able to look after patients to the best of our ability.” By contrast, the government argues that it has given unprecedented resources to the NHS. Theresa May, Britain's Prime Minister, now demands that GP surgeries open between 8 am and 8 pm 7 days a week, or else they could lose precious funding. The government clearly believes that doctors are not doing enough. The debate among politicians is no less rancorous. Jeremy Corbyn, the Leader of the Opposition, argues that 1·8 million people waited longer than 4 h to be seen in Accident and Emergency Departments in 2016. He gives examples of excruciatingly poor care—a 22-month-old sick child who was cared for on two plastic chairs pushed together and covered with a blanket. Theresa May replies that, in 2016, 2·5 million more people were treated in Accident and Emergency than 6 years ago. The Prime Minister agrees that “unacceptable practices” do occur in the NHS. But she suggests that these incidents are isolated and that the NHS is performing robustly. The present stand-off between government and profession cannot continue. It is already likely that there have been deaths caused by the current NHS crisis. Certainly, patients have been harmed and standards of care have fallen in places to pitifully poor levels, despite the very best efforts of health professionals. What is to be done? Is more money the solution? Or is the NHS model of care broken? Some commentators have called for cross-party consensus on the NHS. That will not happen. Others have proposed a Royal Commission to review the future of the NHS dispassionately and independently. That might happen, but probably only if an episode of calamitous injury proves that the NHS is no longer able to protect the public. There is, however, one opportunity for some optimism. Quietly over the past 6 months, a House of Lords Select Committee on the Long-Term Sustainability of the NHS has been gathering evidence. It has listened to testimony from health professionals, academics, managers, economists, regulators, trades union leaders, civil servants, politicians, and (even) journalists. The Select Committee is led by former obstetrician Naren Patel, a gentle but steely and determined Crossbench Member of the House of Lords. Lord Patel's compass has been wide: social care, public health, general practice, workforce, primary care, multimorbidity and an ageing population, the value of data and technology, and, of course, financing. His report will be published in March. It might be too much to say that his findings will be the last opportunity to save the NHS. But an opportunity it nevertheless will be. Doctors and politicians alike must hope that whatever he and his colleagues recommend will provide the basis for a new settlement between the government and profession to protect an institution that has, until recently, served the public in remarkable and extraordinary ways.