Future of medicine

Journeymen: why aren’t doctors more loyal to the NHS?

The NHS is being dismantled, privatised, on that I think most are agreed. There appears to be a groundswell of resistance to this, at least there does if you spend time on Twitter. Here socially engaged, predominantly left wing commentators rally to the cause, but beyond the Twittersphere the story does not seem to attract much attention. The BBC is not interested, the press explore it fitfully. Anger is contained. It looks like a done deal. But what of those who work for the NHS? Surely doctors and nurses are fighting, demonstrating, complaining. I don’t see them. Do they have no loyalty? I’m not out there either. Do I?

The Luminous Bed Test
One way of assessing a person’s attitude to the NHS is to ask, in the manner of a market researcher, how they felt during the Olympic opening ceremony. You would assume that most health care professionals felt proud when those illuminated beds lined up to spell out the letters ‘N H S’ for the whole world to see. For me it was an abstract kind of pride. Perhaps that was because the Health and Social Care Act had already received royal assent, and many had identified it as the beginning of the end. Danny Boyle’s choreography seemed like a cheeky, even subversive attempt to signify national affection for a lost cause. The impression was not helped by the news (released before the Olympics were even over) that Trusts were being encouraged to export ‘the NHS brand’. It was that superficial term that caused me to ask myself – What does the NHS mean to me? To answer that requires an examination of my relationship with the NHS. And, like most employee-employer relationships, it’s complicated.

nhs beds

Aerial view of Olympic opening ceremony

Mixed feelings
Doctors, especially those in training, have not always been treated well by the NHS. Until recently the hours were hellish. Now the hours are better but the team-working ethos has been fragmented. Trainees struggle to find the time to study, and are forever cross-covering each other to free up days for essential courses. Some rotas allow no choice as to when holiday is taken, while others rely on the tradition of ‘internal cover’ by which on-call shifts that are ‘missed’ while on annual leave have to be paid back when the doctor returns. The MTAS debacle (a ‘deeply damaging episode for British medicine’ according to the man who led an independent enquiry into it, and one that I was fortunate to avoid) resulted in doctors leaving the country and the profession. Many complaints could be directed at administrative and academic bodies that are not part of the NHS: Modernising Medical Careers (MMC), Deaneries, the Royal Colleges or Medical Education England (MEE) – but the doctor in training who is struggling to progress cannot be expected to understand the subtle tensions that exist between these bodies, it just feels like the ‘system’ – the health service, the NHS.

Self-sufficiency
Doctors in training flit from employer to employer with great regularity. I think I worked for 9 trusts between qualification and consultancy. This unusual pattern of employment demands two qualities – adaptability and self-sufficiency. Adaptability is crucial, because you have to learn the ropes of a new hospital within days, sometimes hours, if your patients are not to be disadvantaged. Self sufficiency is equally important. The doctor who moves through an ever changing landscape of individual trusts seeks constant reassurance that their trajectory is correct, their educational development satisfactory, their emotional wellbeing monitored. They want to know that someone is keeping an eye on them. The system can meet these demands up to a point, but is designed to identify and assist outliers, the ones who are struggling. The majority will move forward, deal with their own problems and dig into their own resources to work through the crises they are bound to encounter…they will not be feel the warm hand of the ‘system’ at their back. So, when their training is complete and they find themselves reasonably happy with their lot, they will attribute their success to their own persistence and endurance. They will not feel grateful to the NHS for the help and encouragement that it gave. The pride that they feel will be personal.

Where does loyalty lie?
In a consultant interview one of the questions was “Will you work at XXXX, or for XXXX?” It was a good question, because it forced me to express the desire, in advance, to be loyal. I had not worked at the hospital and I did not yet know if it deserved such a commitment. Only a fool would have said, “Oh, well…ask me again in six months and I’ll tell you!” On further reflection the question suggested that there should be automatic loyalty to an employer. I asked myself if I had demonstrated loyalty to my previous Trusts? Had I defended them when they were criticised? Had I made an extra effort at work in order to strengthen their reputation? The answer was no. I had whined and whinged about the conditions as much as my colleagues in the pub after work. I had brimmed with frustration when I couldn’t get away for training days. My loyalty lay with my team, my mentors, perhaps with my department, but not with the institution itself. As the expiry date on my contract approached, as my ID card was automatically deactivated (sometimes a couple of days before I actually left), I recognised that I was another employee passing through. Close colleagues would say goodbye, emotions might run high (the most stressful jobs engender a ‘band of brothers/sisters’ feeling) but the hospital wouldn’t blink an eye. The NHS wouldn’t miss a beat. The day after I and my new friends left, a fresh group entered…and a smooth service was maintained.

We are loyal to people and to places. The great mobilization of energy by staff and community in Lewisham, south east London, to defend the downgrading of their local hospital, is a case in point. Loyalty is an emotional response, fed by proximity and constancy. Medical trainees are rather like journeymen of old, moving from Trust to Trust, trading their nascent expertise for a salary, and for the training that ensures ongoing growth, then moving on. Such journeymen do not develop loyalty easily.

Tangible and intangible rewards
Hasn’t the NHS rewarded its staff for the demands it has made? Of course it has…senior doctors are well paid, and risk opprobrium when they moan about conditions on salaries that approach or exceed 6 figures. But money is not the issue, because the changes that are being made will not take it away – and of course, doctors working in the private sector will not be excluded from the financial benefits that its expansion may present. There are deeper, more subtle rewards for working as a doctor in the NHS, but they require us to step back and appreciate how amazing our jobs are. It is easy to forget that working within the huge, impersonal structure has allows us to pursue a vocation. It facilitates the practice of skills that we competed to acquire, and provides the protections and guarantees that come with state sponsorship. Although progress through the system feels random and unplanned, it is at least guaranteed to those who pass their exams and maintain standards. Patients trust us with their lives. Why don’t these benefits engender loyalty? They do…but to the job, to the vocation. Not to the administrative structure within which we work. Perhaps we have been spoilt. Perhaps we will only notice how well we have been treated when that structure crumbles. To really appreciate that structure we need to look up and out, beyond the personal to the societal.

A higher level of concern
If the defenders of the NHS are not motivated by personal loyalty, what is it that gets them up in the morning? It must be because they are looking at it not as providers of healthcare but as sociologists. They are concerned about access, equality, disenfranchisement, the creation of two tiers… These concerns require a higher level of understanding. The problem, I feel, is that most of us are not influenced by these socio-political issues. We are relatively apolitical, we go with the flow, we allow changes to wash over us and hope that our lives will not be disturbed too much. Only social campaigners fight for others. The rest of us just get on.

The one thing that most healthcare workers would respond to is a threat to patient safety. No one can see into the future, no one knows if the gradual privatisation of the NHS will adversely affect the care that patients receive. The full NHS risk register was not published, but it is hoped that the very act of reading the warnings it contained allowed preparations to be made to minimise potential harms. Only as mistakes occur will the case against privatisation grow, but by then we will be reacting to downstream events, not reversing the cause. There are signs. Recently, NHS Direct pulled out of the 111 service for financial reasons. We have been reassured that patient care did not and will not suffer, although an undercover reporter said,

Halfway through the training a manager in the call centre admitted to me and the other trainees that on the weekends the service was ‘unsafe’ because they didn’t have enough staff to handle calls.’

Serco, a private contractor for out of hours primary care services in Cornwall,

falsified figures on its performance 252 times, making it look better than it was, so that serious failings in the service only came to light thanks to whistleblowers.

On the other hand we know that many harms were done to patients before the Health and Social Care Act came into being. The Francis report into Mid Staffs has demonstrated that all was not well with the current system. The NHS and safety are not synonymous. So I, as an individual doctor, with a small view, must accept that I am not in a position to know what is right . I am a worker. I see the decisions being made around me and I may feel comfortable or I may feel uncomfortable… but that is as far as it goes. I do not feel particularly sad to see the NHS changed. For the reasons explored above, loyalty to it is not woven into my DNA. But I do worry that the decision to take it apart was made for the wrong reasons. I worry that public representatives with vested interests voted in favour of privatization because they saw the opportunity to make profits. I worry that providers will walk away when promised returns to do not materialise. I worry that patients will be disadvantaged or put at risk… but these objections are hard to define and shrouded in uncertainty. Perhaps my middling, rather anaemic reaction to these changes is a typical one. That might explain the failure of the medical and nursing professions to rise up.

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The day assisted dying became legal: choices

As a supporter of assisted dying (AD) I ask myself  – ‘What will I actually do if it becomes legal?’ I haven’t travelled to Oregon or Washington state to see how it works, nor have I talked to doctors or nurses who are involved, but I think it is important to anticipate one’s response. After all, a recent NEJM paper described in a routine, academic, matter of fact way, how a ‘Death with dignity’ programme was rolled out in a Seattle cancer centre. If AD is legalised in the UK, any doctor who works in the field of cancer or palliative care will be touched by it in some way. The degree of involvement will depend on some of the thought process that I explore in this post.

For those who oppose AD it will be relatively simple – if a patient asks about AD you will make it clear that you do not ‘do that’. But it will be necessary to refer the patient on to a colleague who does. To refuse would be to obstruct the patient’s access to a legal therapeutic option. There are parallels with abortion here.

What about those who are ambivalent? This is probably the majority. When the day comes, will it be necessary to make a choice, to be an ADer or non-ADer? Will it be necessary to register that preference, for the sake of transparency? Perhaps it will be possible to avoid making that choice for a few months, a year…until a patient asks you to help them. If you are not completely ‘anti-’ but you have no wish to be involved in assessing them and certifying the terminal nature of their illness, you will again have to refer on. Over time you may be persuaded by the conviction of your patients, and begin to recognise that by referring on and leaving such distasteful tasks to others you are separating yourself from the patient’s journey too forcefully. You might conclude that it is cowardly, in a way, to ‘wash your hands’ of them when the going gets tough and they ask for your signature on the piece of paper, the document, the booklet…whatever it is. You may review your position, and change, finally accepting that ‘Yes, quite a few patients have asked me now, AD is a fact of life, why should I make their progress any more difficult than it is already?’ Others will remain intellectually neutral, but for good reasons they will continue to maintain clear blue water between their own practice and AD. That will be perfectly understandable. I can foresee many doctors adopting this approach.

And what about doctors like me who instinctively support AD? This is where I get nervous. If, a month after the law is passed, a patient whom I have recently diagnosed with terminal cancer (a common enough event) sits down in my clinic and says, ‘When the time comes I want an assisted death. How do I arrange it?’ – I will have to do everything in my power to facilitate it. To do otherwise would be hypocritical. So, I might have to decide that I am happy to be one of the signatories, but not so happy to prescribe the fatal dose. Or I might decide to push myself through that discomfort barrier, propelled by a self-imposed reluctance to abdicate my professional responsibility to care for the patient, and volunteer to be physically involved in the prescription and administration of the fatal dose. If I do that I must prepare myself for the experience of being with someone who is not imminently dying, who is still independent, in the last hour of their life. I will have to remain strong and unflustered (the last thing they will want to see is a nervous clinician) as they arrive, confirm their identity, take to a bed, gather their family around them, reach for the ‘milky drink’, and expire. Am I ready for that? Are you?

NHS2 in the year 2053 – a sideways look at the future

The Hub headquarters, glass clad and monolithic, glistened from its dominant position at the north end of the campus. I stared up at it, but was soon drawn back to the shabby, warehouse-like building to my right which appeared to have received little attention since the winter of ’45, the year I had worked in it as an intensive care doctor. We called it the ‘Lung’ back then.

A new influenza strain had swept through the country, the largest epidemic since 1918/19, and most of those infected developed respiratory failure. Because there was a national shortage of ventilators we relied on five powerful, central bellows A to pump oxygen via filtered tubes into fifty intubated patients at a time. It was hell. Two trainee doctors and eight nurses looked after each fifty patient cohort. It was one of the reasons I packed it all in. Each morning as I walked in, and each night as I walked back to the magnatram terminal, I saw the lighted windows of the other unit, where patients slept, artificially, to the sound of their own machine.

Six months later I gave up medicine to become a social historian. And that’s why I had returned, to the North Eastern Health Hub – to conduct research for my new book. The Hub had grown while its competitors in the region had closed down…or, more accurately, had been absorbed. The medical staff moved across, local managers evaporated, the bricks and mortar were flattened. The magnatram was jammed with patients arriving for their appointments. The Hub was massive now – a hospital town.

As the lift approached the executive floor I began to get nervous. Professor Sam Laszlo, or his PA, had put aside forty-five minutes. In that time I had to discover all I could about how his company had come to dominate the UK health market. I knew he would be coy about some things…but I hoped that pride would feed his honesty.

He smiled openly, his tall silhouette framed and blurred in window of bright blue sky behind him.

“Hello! Thank you for coming today. I’m sorry we don’t have much time…”

“Any insights would be gratefully received…it’s a bit of a coup to get to meet you.”

“ I understand you worked here once.”

“Yes. Intensive care. In the Lung.”

“The Lung?”

“Down there.” I pointed over his shoulder, for the roof was visible below us.

“Ah. Of course. I apologise. It’s got a quite different use now.”

“It looks pretty neglected to me.”

“Not on the inside. Not at all. It houses the fibreoptic data spine, and the refrigeration units to keep the hardware cool. Since the UniRecB scandal we have had to keep all patient data on-site. A pain, but there you go. Anyway, tell me, remind me, what is title of your book? You sent it to me but I don’t have it with me.”

“‘Two Tears: The Long Dying of NHS1’. But I might change it. That’s ‘tears’ with an E and an A.”

“Two Tears! Ingenious! But why not ‘In Pursuit Of Excellence: How NHS2 Put The Patient Back In Charge?”

“I err…come from a rather socialist background. I’m cynical about the changes…”

“But it was New Labour who let us in. You won’t remember personally of course, but after Cameron won a large majority for the Old Conservatives in ’15, on a welfare-immigration ticket, ably assisted by the nascent economic recovery, New Labour begged David Miliband to come back from the States. He shook them up, rode the economic recovery and promised a happier life free of austerity…and they won in 2020. Small majority mind you. The new health secretary, Burnham, was held by a few to the promise he had made in 2012 to repeal the Health and Social Care Act, but it was too late [1]. The benefits had become clear. It was the quality you see. New Labour didn’t even have to discuss health in their manifesto, there was no hunger for change anymore. People were happy.”

“The healthy majority were happy.”

“No, patients were happy. Qualified Providers came in, staffed their establishments properly, asked their patients about the experience, changed what they didn’t like, dealt with complaints promptly, sacked doctors and nurses in the lowest 5% on their real-time bedside compassion scores…how could Burnham dismantle it? Private companies were soon providing 25% of secondary care, it was growing at several percentage points per year. Trusts all over the country had budgeted for huge increases in income from privately ensured patients [2]. It was done.”

“But by that time there was evidence of inaccessibility…”

No-one was excluded. Remember, the state was still funding healthcare – and increasing it –  as it does now, no-one had to pay anything to get treatment…”

“Isn’t that disingenuous? State funding fell in proportion to national health needs estimates, provision became second class. This was described in the Scott review in 2024. There were already identifiable, statistically significant survival differences between NHS and privately insured patients…”

“In a few conditions only.”

“Cancer…”

“But cancer is no longer an issue, not in the era of vectorgen therapy. By 2022 that technology was already coming through. Successive governments saw that and planned strategically to account for a reduction in demand. A poor example…for your book. Don’t hang your thesis on cancer. The story isn’t in mortality, it’s in quality of life. Private companies were soon demonstrating a greater focus of quality of life…”

“…because those companies concentrated on the non life-threatening conditions. The routine, relatively safe stuff…non-urgent surgery for healthy people. That’s how you get great Patient Reported Outcome Measures.”

“How can you say that? What are we most famous for?”

“Hegemony.”

“We are dominant now, I agree. But clinically?”

“The HEPMatrix, I guess.”

“Yes! We poured resources into a group of patients with high mortality, very little hope, that no-one had tried to help before, and we changed the game. What happens now when alcoholics or Hepatitis QC patients decompensate? They are plugged into the HEPMatrix until they recover. It’s revolutionised the care of liver failure. My predecessor in this office was awarded the Nobel prize. I won’t accept this overwhelming negativity. We do benefit society…we make money yes, but we re-invest…”

“You have to re-invest, to create new markets. The HEPMatrix did that. It opened up a massive market, and the state had no choice but to pay you to provide the machines.”

“The HEPMatrix would never have come about without private investment. You must understand that. We ran research programmes from the outset. It’s altruistic, clearly.”

“Are drug companies truly altruistic? No. It’s their business. Health is your business. You wouldn’t invest in research unless, on balance, you made money out of it.”

“The two are intertwined. Healthcare has never come for free, somebody pays. Just as we pay for food, water, energy, CO2 removal…you grew up regarding clean air and a stable climate as basic human rights, but twenty-five years ago, when you were what – three or four years old? – we were all taxed for those electrolised graphene spongestacks you see on the horizon. Every industrialised country in the world did the same after the Mumbai Olympics were washed out and the European drought of 2026/27. Health does not come for free. Someone must make money out of it, but as long as that money is made ethically, and used well, what’s the problem? My shareholders are not evil men and women. They work. They too will get sick someday.”

“And none of them will go state.”

“It’s so lacking in objectivity, your line of questioning…”

“I have a responsibility to dig. In the time we have I’ve got to stress my sources a little bit…do you mind? I want to know about the separation. What precipitated the overt separation of state and private funded health streams? It’s not something you find written about much.”

“It’s convoluted. When the double-prion phenomenon began to reveal itself in the huge wave of pre-senile dementia, it became clear that disease progression could be halted if the diagnosis could be made within six months of disease onset and a course of three, 72 hour extra-corporeal cerebrospinal fluid fractionations. General practitioners were urged to screen their patients, and this led to a massive increase in referrals to neurology clinics around the country…”

“ …and the true two-speed nature of New Health Streaming (NHS2) was revealed.”

“Quite. It had been going on for years of course, that’s what the Streaming structure was all about…but the double-prion epidemic, Marshall’s diseaseD, showed up its…vulnerabilities.”

“You mean only those who were insured got seen and treated in time.”

“Only a condition with such a short window of therapeutic opportunity could have done it.”

“How thoughtless of it.”

“It could not have been planned for.”

“But it happened. New diseases occur all the time. Whatever system we have needs to be able to handle them, equitably.”

“NHS2 was doing just that, both streams were audited and proven to work within clinically acceptable timescales. Until then there were no real inequalities…”

“…until the McCartney report smashed that illusion. She showed, five years later, that among the uninsured permanent dementia was eight times as prevalent than among the insured. Because they didn’t get seen in time. Two streams…”

“New Health Streaming was developed democratically, in the oldest parliament in the world. The populace agreed, in principle, that those in work, and therefore insured, should be seen sooner, as their health was more important to the community. You think that’s evil…the voting public did not. How else do you think the Cameron government, the government that facilitated and welcomed the arrival of Any Qualified Providers, how else do you think they got voted in again in 2015? They had a mandate by then, and New Labour did not reverse it.”

“I don’t believe the populace always reach the right decision.”

“Ahh! So perhaps a Communist regime, ruled by wise oligarchs who know what is best for their people, would suit you better! That went well in the mid 20th!”

It was going a bit wrong by now. I glanced at my watch and saw that time was running out. The professor looked down at the glass surface of his desk. I watched his eye track a new message, but I could not read the words from where I sat.

“How interesting!” he exclaimed, looking up sharply, “I know more about than you realise. You do have an agenda after all. Care to tell me about it, or shall I tell you what I know?”

“What do you know?”

“Your mother succumbed to complications following the removal of her colon…an operation she asked to have after receiving the result of a LifeSpan assessment. You’ve been politically active since your late teens. Demonstrations, i-pamphlets…and then you worked here. In the ‘Lung’. If I had known all that I wouldn’t have…”

“Seen me?”

“I don’t know. How old were you when she died?”

“Seven.”

“That was what, early 30’s, we had just published the PicassoE paper. A little earlier and perhaps she wouldn’t have given Lifespan as much credence.”

“Well she did. It gave her an 89% lifetime bowel cancer risk, with a high chance it would be biologically aggressive and unamenable to early detection, curative surgery or vectorgen therapy. It’s understandable, what she did.”

“Our analysis of Picasso’s DNA gave him a 79% chance of a similar disease. And he lived to a good age. Tragic.”

“But your company owned LifeSpan.”

“We sold it after the first cohort of adverse prophylactic procedures.”

“Five years later. After thousands of unnecessary procedures.”

“Not all were unnecessary. Many people were saved. That’s a fact. Once again, your Manichean view is proved to be naïve. It’s all about balance. Society, which includes this company, wavers across the correct path, to the left and to the right, as it develops new technologies and discovers how to apply them, but the correct path can only be charted in retrospect. Don’t blame the innovators.”

Click

The tape recorder in my jacket pocket had run out.

“Tape! How quaint. Of course, your G-glasses would have been taken off you downstairs. The screener would never detect a tape recorder. But you should have just asked, the audio file would have been in your cloud before you opened the door to leave. It still can be. I’m not embarrassed.”

“Is that it then?”

“I think so. Don’t you? I hope it been useful.”

Notes

A – The bellows were steeped in irony. The Hub had brought them in a few years before the influenza epidemic  hit to manage the Guillaine-Barre outbreak of ‘42, itself caused by a faulty influenza vaccine. The chief executive in charge of the manufacturing company who signed off the use of cheap porcine substrates (leading to xenomyelinic cross-talk) is still in punitive re-profiling on the North Sea hulk-network.

B – The ill-fated attempt to provide a unified system with which to access the medical records of all patients, nationwide, had a promising start. UniRec rolled out in 2024 and received positive reviews from primary and secondary care. Patients too were able to access their medical details from home and on their smart devices. However the financial regulator, while investigating the stellar performance of a private insurance provider, Longevity+, in the financial year 2027/8 discovered that the confidential medical details of over 80% of their applicants had been accessed. All those rejected for insurance cover had early indicators, in their bio-informatics, of chronic disease susceptibility. After this scandal UniRec was dismantled and all physical and wireless connections between regional databanks were severed or firewalled.

C- Hepatitis Q was discovered in 2038. It was identified, retrospectively, in archived biological material as far back as 1987. Although blood borne, the virus did not appear to have been passed to blood transfusion recipients, probably due to its exquisite sensitivity to citrate, an additive used in packed red cell storage. In any case, since 2032 red cells have not been used for transfusion, the advent of Self-Terminating Oxygen Delivery Nanobots (STODNs) having made this practise obsolete. The Hep Q epidemic of the late 30’s and early 40’s was caused by a single infected narcotics developer who isolated and then mass produced a novel hallucinogen from his own bile.

D – The currently accepted explanation is that a new, equine prion (proper nomenclature PrPeq/valupak/2012) was acquired through contamination of processed meat and ready-made meals in 2012/3 (and probably for several years prior to this). This interacted with the highly prevalent but latent ‘new variant Creutzfeldt-Jakob’ (nvCJD) prion. nvCJD was related to Bovine Spongiform Encephalopathy (BSE) which entered the human food chain in the final decade of the 20th century. Cows, natural herbivores, had been fed meat and bone meal derived from  sheep infected with Scrapie, and calves which received protein supplements to accelerate growth.

E – Picasso’s DNA was extracted from a bone fragment, retrieved with the permission of his estate from his grave in Vauvenargues, Eurorealm Subzone 26 (formerly Provence-Alpes-Côte d’Azur, France). LifeSpan were criticised not only for driving people to unnecessary surgery on healthy organs, but for a number of suicides (2,347, proven association) that occurred in the weeks prior to a ‘likely date of death (natural causes only)’ that was provided, at extra charge and without guarantee, to their clients.

References

[1] Speech to Royal College of Midwives’s annual conference in Brighton, 16th November 2011

http://www.guardian.co.uk/society/2011/nov/17/labour-repeal-nhs-bill

[2] Freedom of Information requests in 2013 revealed that Trust (NHS1 terminology) planned to increase income from private patients by up to 200% or more in the first years following the Health and Social Care Act/Any Qualified Provider agreement.

http://www.guardian.co.uk/society/2013/apr/06/nhs-hospitals-increase-private-patients

Apologies and acknowledgments: Isaac Asimov, Philip K Dick, David Mitchell, Arthur C Clarke, and all serious health commentators out there.