NHS at 75: Desert Island Discs | A word from the registrar

I’m a fan of Roy Plomley’s genius concept where people explore their lives through eight musical tracks, a book and a luxury. It’s longer running than the NHS itself! The highs and lows of desert island life mirror those of our most fundamental institution on its 75th birthday. So I’ve been reflecting on 8 organisational principles or ‘tracks’ for NHS ‘essential listening’: 

1. Workforce: skilled, motivated and appropriately resourced.
2. Clinician training: career-long learning and development.
3. Systems learning: safety and quality through innovation and improvement.
4. Productivity and process: streamlining, eliminating duplication, and embracing technological advancements to enhance productivity and enable efficient delivery of care.
5. Governance and ethics: strong governance structures and ethical principles, essential for transparency and public trust.
6. Global outlook: embracing international collaboration and research, tackling global challenges such as climate health.
7. Clinical leadership: empowering clinicians to design, shape and fully engage in NHS leadership.
8. Accountability and autonomy: promoting accountability while safeguarding clinical autonomy to provide individualised, patient-centred care.

Dan Wellings’ blog for The King's Fund says the NHS at 75 is still the institution that makes people most proud to be British. Despite this, the same audience rated the NHS its lowest ever rating for service provision in 2022. Of those who were satisfied, the top reason was because it was free at the point of use (78%).

There is an inherent conflict between the utilitarian principles on which the NHS was founded and the heightened sense of individualism that drove societal shifts in the late 20th century, and which sustain the demand culture of the 21st. No funding structure, however creative, can resource a system of free universal provision driven by unlimited individual demand. At 75, the NHS faces its own existential crisis. So how do we recreate a realistic, equitable and sustainable system of universal 21st century healthcare, which still meets the ‘needs of the many’?

This ‘national institution’ is already divided and defined by its devolved healthcare administrations, and by primary and secondary care sectors with separate funding principles. The historic gatekeeping function of primary care physicians is already crumbling, while new systems of commissioning and service delivery in England struggle to become established.

Some would argue that the gatekeeping principle is outdated, but removing it without identifying an alternative is already stressing the system and creating perverse patient outcomes. Not least of these is the widening gap between outcomes for those in poverty and those in more privileged groups.

The RCP continues to emphasise health disparities in terms of access to care and the inevitable poor health consequences of poverty driven by cardio-, cerebro-, and renovascular risk, obesity, alcohol and substance dependence, and long-term respiratory disease as a consequence of poor air quality and housing.  

COVID may have been the grim illuminator of the problem, but the problem itself is not new. Mortality (all causes) is predicted by social deprivation and arguably tackling the social determinants of health might be the single most important approach to a sustainable healthcare strategy for the future.

Back now to the NHS playlist! These eight essential ‘tracks’ hold not surprises and the RCP has published widely on their themes. Workforce remains central but is not the only solution to the impasse in productivity, which ONS data showed to be falling well before the pandemic.

Productivity is key and yes, we should acknowledge the obvious things: avoiding duplication of effort, reducing waste and guaranteeing a working IT infrastructure etc. but at the heart of falling productivity lies the fundamental issue of capacity.

Acute hospital beds have decreased by 44% in the last 30 years. In 2017, the NHS's own benchmark system safety was to run at no more than 92% capacity. The Royal College of Surgeons and Royal College of Emergency Medicine suggested that 85% was a more accurate figure, but capacities over 90% have been consistently exceeded since 2018. (Oddly, 82% is the suggested bed occupancy level for optimising the prevention of hospital-acquired infections). The Health Foundation reports that the NHS will need to add between 23,000 and 39,000 beds by 2030/31 just to maintain 2018/19 levels of care as the population ages. This is equivalent to 38–64 hospitals, or at least £17–29 billion of capital investment. This is well beyond the planned current 5,000-bed expansion in the Long Term Plan.

So what is the single essential track for our survival? A subjective choice, of course, but if we were to rush into the sea to reclaim a floating piece of vinyl as it’s washed away, for me it would be the one labelled ‘Autonomy and accountability’. This is the glue that binds all NHS professional activity together, and which should underpin all new structures and services.

The erosion of accountability and clinical autonomy explains much of the evidence for burnout and dissatisfaction in the current workforce. Only a third of consultants feel in control of their workload and arguably the erosion of wellbeing for our doctors in training links directly to a fall-off in autonomy. If daily tasks become meaningless and dissociated from patient outcomes, they fail to develop opportunities to build good professional experience that underpins our workplace learning.

I have written previously about autonomy and wellbeing and continue to believe that a key role for the RCP as a membership organisation is to be the reasoned voice of physicians ‘demonstrating compassionate, collective leadership for the wider physician community … supporting the principles of autonomy for the wellbeing of the profession.’

Finally, my favourite part of the radio show: the book and the luxury. What would we choose for the NHS at 75? Well, non-clinicians (and clinicians) wanting to understand more about clinical common sense and priorities would do well to select Being Mortal by Atul Gawande – a sensitive, moving account of the practice of medicine based on patient-centred rationale.  

As for a luxury (and I’m not really certain we can splash out on this) … 5 minutes to chat with a colleague over a decent up of coffee seems like serious indulgence these days!

Please stay in touch and find time, if possible, to enjoy the parts of the job we still love – according to the UK physician census, 84% of consultants still feel valued by their patients.

All good wishes.

Cathryn