The problem with the NHS? The soft bigotry of low expectations.

In many ways I’ve endured enjoyed a very fortunate life. Not least because, perhaps unusually, I’ve had almost no dealings with the National Health Service. I mean, apart from a couple of vaccinations before trips to heathen foreign parts I’ve hardly seen a doctor since I left school. This surprises me as much as it may surprise you.

So I’m never quite sure what passes for ‘good’ service on the NHS. What is normal in an organisation of its size, diversity and complexity? And how, in any case, do we measure ‘success’? I have a sneaking suspicion that we often do so by rebadging failure as normal.

As I type this, you see, my mother is confined to her bed, unable to walk on account of, quite literally, crippling pain in her back and leg. Her situation has been so bad that a doctor actually came to the house to see her. (This wasn’t always such a novel experience, I believe.) He recommended an MRI scan at the local hospital and marked the request for said scan ‘Urgent’.

It turns out that urgent means you might get an appointment ten days later. I had no idea if a ten day wait for what is, these days, a pretty routine kind of analysis is disgracefully lengthy, unusually short or, perhaps, both. Turns out it’s about normal.

And that’s ten days waiting for a mere scan. Then you’ve got to get the results and only then might some treatment be recommended. Lord knows how long that will take but it’s hard to avoid the suspicion that many cases deemed urgent are not actually dealt with urgently.

Anecdote, for sure, is not data. But my point is less about the detail of an individual case but, instead, about how we define success. I note, for the purposes of comparison, that urgent cases requiring an MRI scan in Canada are supposed to be dealt with within a maximum of seven days. Not as fast as some countries; still significantly faster than in this country.

Of course, we accept that healthcare is rationed in this country and that, unlike the United States where it is in large part rationed by finance, it is rationed by time here. We understand, too, that the health service is a vast and complex entity and that not everyone can get everything they want precisely when they want, or even need, it. We appreciate, as well, that there are many thousands of excellent doctors and nurses working in the NHS. We know that, once you get to the point of treatment, there’s a decent chance you will receive good, or even excellent, treatment. It’s just the getting to the point of treatment thing that’s a drag and a slog and, often, a wearying, frustrating, rage-inducing battle.

So much so that it reminds me of a Soviet joke Ronald Reagan was fond of telling: Ivan goes to buy a new car. There is a ten year waiting list for the car and you need to pay in advance. Ivan goes to the state-dealership and signs up for his Lada. Everything is in order. Come back ten years today and you’ll get your car. There’s just one thing, Ivan says, will it be ready in the morning or the afternoon? What possible difference does that make, the dealer says, it’s ten years from now! Well you see, Ivan says, the plumber’s coming in the morning.

Is it harsh to think that joke applies to the NHS too? Not really. Consider how we assess success. If you need to go to A&E you’re supposed to be seen within four hours. Let me repeat that: four hours. If you wait three hours and 59 minutes that’s fine. The hospital has met its target. No problem. But four hours is not a small amount of time. Not in those circumstances.

Or take cancer treatment. There’s a target (in England) that 85% of cancer patients should begin to receive treatment within 62 days of their GP referral. And, to be fair, most of the time in many parts of the country these targets are more or less met. (And when they are not, sometimes it is at least in part the fault of the patient who misses or cancels appointments etc.)

Again, the issue is less whether targets are met or not but the generosity of the target itself. We think you have cancer and most of the time we hope to begin treatment within two months. Two months.

As for less immediately pressing conditions? Well, in Scotland (for example), 90% of patients are supposed to receive treatment within 18 weeks of being referred by their GP. Eighteen weeks. That might not, with apologies to Tony Hancock, be half a lifetime but it’s hardly rapid service either. It doesn’t have to be like that and we know this because there are countries in which it is not like that.

But we tell ourselves that many people are seen much more promptly than this and, anyway, it’s a fiercely complex organisation and so, sure, we can’t really or realistically expect it to be any better.

Which, it strikes me, is precisely the problem. The NHS suffers from the soft bigotry of low expectations. We put up with waiting for the chance to wait some more because it’s the NHS and it’s the national secular religion and so observing that, actually, it’s often not as good as we would like it to be becomes an act of minor blasphemy. Why do you hate the brave doctors and saintly nurses anyway, eh?

Still, we kid ourselves. Deep down I think we know that the NHS provides a tolerably adequate service for a still just-about tolerable price. We know that it’s not as good as we pretend it is even if, of course, it often works wonders. It is to the left as the armed forces are to the right: a sacred, unchallengeable myth.

But the NHS is not the envy of the world and our armed forces are not the finest in the world. Not bad or necessarily disgraceful but not as good as we pretend.

Targets, for sure, are not the be all and end all but if we are to have targets – not a bad idea, incidentally, even if they can sometimes produce perverse incentives – it might be better to have targets that demand prompt attention rather than ones which, by virtue of their slackness, define and reveal the inadequacy of the service and the pitiful limitations of our expectations.

Of course it is a difficult and complex business, made more so by the dazzling, heroic, advances in medical science. But many other enterprises are also complex. There are always many, many reasons why something can’t be done but it’s reasonable, I think, for patients to demand better. I don’t care how it’s done, really, merely that it’s done. What works in practice is more important than what works in theory.

The noble ideal celebrated by Danny Boyle at the Olympics’ opening ceremony no longer really exists. That’s partly because society and medicine have changed but it’s also, at least in part, because the NHS has not moved with the times. To take but one example: it remains, in many ways, a five day a week operation in a seven day a week world.

We make a desert and call it health and congratulate ourselves even as we remain blind to the fact that our definitions of success actually reveal the paucity of our ambition. Is it so surprising, then, that we settle for something less than we should?


  • weescamp

    What you’re describing Alex is one of the consequences of economic and industrial decline. To afford the sort of service you seek requires investment and I’m afraid that the union that you adore is essentially bust.

    What’s more, government policies and those of the so called opposition give us no hope that this situation is likely to improve anytime soon.

    Now of course we all know that the Westminster govt is intent on privatising the NHS because it foolishly believes this will improve its quality of service. It won’t. It will only increase costs and make health services less and less affordable.

    • Shazza

      Privatising will go a long way toward stopping the International Health Service being run along the lines of treating the whole world, boob jobs, hymen replacement (to avoid honour killing), etc. etc.
      It will also go a long way in utilising the equipment/surgeries etc. 24/7 and prune all the unnecessary layers of management and put the needs of patients first.
      Having been a patient in both NHS and private hospitals, I can assure you that the private hospitals were far more efficient, clean, friendly and unlikely to treat you as a mere statistic.

  • Rhoda Klapp8

    Massie is right (!) and it isn’t about money, it’s about the will to do better. The headline is correct.

  • Alexander Lyle

    http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

    While I agree that there is a lot of room for improvement in the NHS, mostly around attitudes and ambition, we should not lose sight of what we have

    • HJ777

      Unfortunately, the Commonwealth Fund work contains no hard data. It is mostly subjective and there are no cross-country control measures. It doesn’t look at outcomes or the quality of medical treatment.

      The OECD and EHCI are rather less complementary:

      http://www.oecd.org/eco/healthcaresystemsefficiencyandpolicysettings.htm

      http://www.healthpowerhouse.com/files/ehci-2013/ehci-2013-uk.pdf

      • tjamesjones

        Good one HJ. Re the UK it says “The quantity and quality of health care services remain lower than the OECD average while compensation levels are higher”

        • HJ777

          Yes, and as it points out, we spend about the average, so we get less value for money as well.

          The more detailed reports on efficiency are particularly revealing. It says that, in Europe, only Greece and Ireland have less efficient medical systems.

  • HJ777

    “Of course, we accept that healthcare is rationed in this country and that, unlike the United States where it is in large part rationed by finance, it is rationed by time here.”

    Not sure that I agree with this. What the US and the UK have is excessive costs involved in providing medical care, caused by various rent-seeking behaviours. It is no coincidence that the US and the UK have fewer medics per head than similarly rich countries, yet they are paid more. In both countries eminently suitable people are routinely refused access to medical training and licensure prevents the emergence of alternatives.

    So in the US, there is plenty of medical care available but the total cost is astronomical because the supply largely isn’t rationed (only the supply of medics is). Here we control the total cost by rationing supply.

  • DavidL

    I used to work in the NHS, and now I see it from the other end of the telescope as a patient. The problem that strikes me hardest is that it exists in a state of permanent and constant chaos. The clinicians I meet are (for the most part) very good at their jobs, and very committed, if not always the best at communicating (the young ones seem to be getting better). But appointments are made without consultation, letters misaddressed, test results lost, files and patient notes ditto; different parts of the system seem not to be able to communicate with each other…. I could go on. And inefficiency costs money – missed appointments, needless repeat appointments, repeat tests, failure to pre-empt avoidable complications etc, etc.

    • HJ777

      Advocates of the NHS, and especially those who oppose any private sector involvement in the supply of any NHS services, always cite the supposed benefits of the NHS being an ‘integrated’ system and the hazards of moving away from this.

      But this ‘integrated’ system is too complicated to be run efficiently as your experience indicates. I’m sure that the East German car industry was planned and run as an integrated whole, whereas in the west we had competing suppliers and competing sub-suppliers which was much more efficient and responsive – without any central organisation.

      This is why the NHS should be broken up.

      • tjamesjones

        I believe you re your mum, and I agree with your diagnosis!!

      • starfish

        Agreed
        The NHS is far from ‘integrated’

      • Inverted Meniscus

        A breathtaking dose of common sense but the NHS is the most sacred of sacred socialist cows and is thus not a subject for criticism or debate.

    • suzy61

      I deal with hospital procurement departments as part of my job. Almost without exception their purchase orders come through with wrong prices or product codes. I patiently send them a list of codes/prices and wait for the amendment – which very likely will come back uncorrected. I can easily go through this farce two or three times before the purchase order is correct. Then what usually follows is a phone call from them asking for an impossible delivery deadline- otherwise they will have to cancel the patient’s appointment. This happens every day of every week. Sometimes I manage, with a lot of extra time and effort, to meet the deadline but quite often it’s just not possible and these poor patients will have their operations cancelled. Who cares? Certainly nobody in procurement – or at least that’s how it appears. Permanent and constant chaos is, I think, a most accurate description.

  • simon

    Why compare with Canada and the US, go closer to home in France, Germany and Switzerland. All of whom deliver better service than the NHS. I believe the problem lies with the fact that a) there are many more layers of management that other systems leading to higher cost and inertia b) users/patients are not considered sufficiently knowledgeable/aware to take control of their own results c) an innate and unquestioning attitude that health care professionals are always right and do their utmost to serve the patient interest.
    There are a myriad of models that could be used to improve the health service but until the belief that the NHS is the best in the world is dispelled and the national psyche changes you will sadly have to make the most of what you have.

    • telemachus

      The NHS has been declared the best healthcare system by an international panel of experts who rated its care superior to countries which spend far more on health.

      The same study also castigated healthcare provision in the US as the worst of the 11 countries it looked at. Despite putting the most money into health, America denies care to many patients in need because they do not have health insurance and is also the poorest at saving the lives of people who fall ill, it found.

      • HJ777

        No it hasn’t.

        I presume you are referring to the Commonwealth Fund report, which contains no hard comparable data (just subjective impressions) and ranked the NHS just about the worst on actually keeping people alive.

        The OECD and EHCI reports, which are far more comprehensive, and use hard data, rank the NHS poorly.

        http://www.oecd.org/eco/healthcaresystemsefficiencyandpolicysettings.htm

        http://www.healthpowerhouse.com/files/ehci-2013/ehci-2013-uk.pdf

        • Des Demona

          The OECD data says nothing of the sort and EHCI is funded by drug companies and medical insurance companies. Quelle surprise!

          • HJ777

            Wrong on both counts. It would appear that you aren’t even capable of reading what the OECD reports say in black and white.

            The EHCI reports are sponsored by the European Commission.

            The OECD says quite clearly (and I quote) about the UK:

            “The quantity and quality of health care services remain lower than the OECD average while compensation levels are higher” – whilst stating that we spend the average.

            The efficiency reports are particularly revealing – we are ranked one of the least efficient.

          • Des Demona

            I was looking at the actual data – not the subjective comment.

            And the EHCI report was funded by Pfizer Inc, USA, Medicover S.A., Belgium, and New Direction Foundation, Belgium ( an organisation dedicated to promoting free enterprise)- not the EU.
            I wonder what dog you have in this hunt?

            Here’s something you may find disagrees with your quoted ”sources”

            http://www.theguardian.com/society/2011/aug/07/nhs-among-most-efficient-health-services

          • HJ777

            The actual data in the OECD report is very clear – and the summary is entirely consistent.

            The European Commission regards the ECHI reports as the best comparators. What is your criticism of their methodology?

            As for The Guardian report – it is completely erroneous and a complete misinterpretation of what the study says. It’s an old one this one. Read the actual study to which it refers. It does not say that the NHS is one of the most efficient systems. It says it is one of the worst performing. The report looks at changes and asserts that the NHS has improved more from a much lower base, but is still one of the wors. Others haven’t improved as much but that is entirely to be expected because of the law of diminishing returns.

            Do learn to read and understand data.

  • Des Demona

    I recall back in the 80’s and 90’s when there were 2 year waiting lists for the likes of hip replacement operations. Things have got a lot better , or had, but I guess with the setting up of the NHS for privatisation they have to make it worse again,.

    • tjamesjones

      did you genuflect before you hit “post”?

    • HJ777

      Were you not aware that even after more than doubling NHS spending in real terms, average waiting lists in 2007 were longer than Labour inherited in 1997?

      http://news.bbc.co.uk/1/hi/health/7271772.stm

      Only after that did they begin to fall.

      All the data shows that the NHS in England – where there is greater, albeit still modest, private sector involvement – outperforms those in Scotland and wales.

      • Des Demona

        Did you actually read the link you gave? It is not average it is median.

        • HJ777

          You are making the mistake of equating average to the mean.

          The median is also a type of average and in this case it is the relevant one since it means that the typical person waited longer.

          As the report says:

          “The figures obtained by the BBC News website, from the NHS Information Centre, show that for some cancers average waiting has increased slightly, while big falls have been seen in more minor conditions such as cataract operations and treatment for dermatitis and eczema.

          Katherine Murphy, of the Patients Association, said: “These figures make us really question whether patients are getting a better deal.

          “What concerns me is that patients with serious conditions may be waiting longer than they used to be. That is wrong.”

          So what Labour did was to reduce the longest waiting times, which were often for relatively minor treatments at the expense of longer waits for treatment of other, often more serious, conditions.

          This is astonishing in the context of spending more than doubling.

          You can rant all you like about ‘privatisation’ but the data shows that the NHS in England is actually slightly better than in Wales or Scotland, where any private sector involvement in provision has been rejected.

          By the way, only one government has ever cut NHS spending – a Labour government in the 1970s. Margaret Thatcher’s increased spending substantially in real terms and as a proportion of GDP, contrary to popular belief.

          • Des Demona

            I’m not confusing anything. The median has been used in the link obviously because it is the only stat that can be manipulated to show a slight increase in waiting times. If the mean had been used it would show a dramatic fall, having eliminated the disgraceful former waiting times of two years or more.
            As the private sector can cherry pick their involvement in health care in a bid to make a profit it is hardly surprising that in certain areas they may show better figures than the NHS who have to cater for every illness and eventuality.
            And if Thatcher did invest substantially as you suggest then she was spectacularly unsuccessful.

          • HJ777

            I didn’t say you were confusing anything. I said you were mistakenly equating ‘average’ with ‘mean’ whereas ‘median’ is also a type of average.

            As the article makes clear, the median increased by about 20% – not a slight increase. You assert that the mean time would have shown a dramatic fall – based on what data?

            Your point about private involvement in providing NHS services is invalid since the data comparing England with Scotland and Wales shows that England does better overall.

  • tjamesjones

    Great post. I once had a debate with an NHS booster who reported that “most people are satisfied with their treatment in the NHS”, and I wondered, what does that even mean?

    It’s very hard to judge a service like the NHS because most people have no alternative benchmark. Further, for [50%] of people it’s a service they have barely if at all paid for, and people tend to be pretty happy with something they haven’t paid for. It might feel a whole lot different if you had just paid with real cash the cost of a treatment, to be stuffed around by a bureaucratic process that is surprised each time you reappear.

    • HJ777

      You make a very good point.

      People may think they have received the best treatment in the NHS. This may be true or it may mean that they simply haven’t been told about better treatments that the NHS doesn’t provide. Where there is a provider-purchaser split, and there is a choice of provider, as in the social insurance systems common in Europe, the provider has an incentive to inform you about the latest/best treatments because they want the funding to provide it.

      • Wessex Man

        Unfortunately, in these last two years I’ve experienced a BMI Private Hospital, A State Spanish Hospital by Ambulance and a NHS Hospital again by Ambulance. The medical care by all was first class in all three. When discharged from the Spanish Hospital I left with results from all tests and treatment in English, The BMI Hospital couldn’t let me have a shower because there was no hot water in the wing that I was on, re-instated the day before I came home. The care couldn’t be faulted in the NHS Hospital, until I was stranded laid on a bed in a freezing corridor after an MNRI Scan, when the Porter eventually turned up he stank of cigarettes.

        Then when as an out-patient, I found all the problems frequently quoted by my ex-sister-in-law an Ambulance Driver. the pure petty mindedness of the ‘backroom’ organisation is mind boggling in their offices, the last occasion, while a physio was trying to get a woman to book me ten appoints at one a week, she clearly was out of her depth, it took over 15mins to book in which time she had cone completely red faced and was shouting at the physio.

        The notices on the wall said it all in all departments about my fellow patients, missed appointments in all departments running into hundreds each month at every department.

        The adminstration in the NHS needs a brutal clear out and patients who can’t be bothered to turn up twice should be refused treatment unless they pay fines and pay for treatment.

  • davidofkent

    Yes I suppose that the NHS provides a perfectly tolerable service, especially for those who pay nothing for it. I don’t mean that it is ‘free at the point of use’. I mean that millions of people pay neither income tax nor NI (or very little of either) and thus contribute next to nothing for these public services that they consume. However, the NHS is not more or less tolerable for those of us who pay very large amounts of income tax or NI or both. The Welfare State is being funded increasingly on the money contributed by an increasingly smaller number of people. We know where this will end.

  • William Haworth

    Everyone has an NHS horror story. Apart from Labour politicians.

  • andagain

    It is to the left as the armed forces are to the right: a sacred, unchallengeable myth.

    Labour and the NHS always remind me of Terry Pratchett. Specifically, the bit in Small Gods where it says that people start off believing in a God, and end up believing in his Church. Loyalty to the organisation ends up overwhelming any interest in what it is supposed to be for in the first place.

  • paulme

    A few weeks ago I woke up and found I was almost blind and it took 48 hours for me to see a doctor. At the time I was a patient in the acute medical unit of a west London hospital.

  • Q46

    Competitive, free market capitalism ensures via market signals such as prices, demand, supply, competition, consumer choice – that prices, thus profits are lowest, efficiency is highest, resources best managed and distributed, innovation is continuous.

    Providers who respond to these market signals do best, those that do not go out of business to be replaced by new entrants who can do better: this ensures management and workers have an incentive to be market driven, not product driven; outward looking responsive to consumer needs, rather than inward looking preoccupied with their own.

    Any provider which enjoys a monopoly, guaranteed income which is not linked to performance, where there is no price system or any other market signals, will be inward looking, incapable of best allocation of resources thus inefficient.

    It will always be product driven not consumer driven… this is what we provide, take it or leave it; the staff come first; it has no need to innovate; nothing to be compared with; no consumer choice.

    Added to this a consumer base which loves to be abused in a manner they would not tolerate for a second by any other provider, consumers who have no idea how much they are paying for what they get, or often don’t get, and are such brainwashed ninnies, they have let themselves be frightened like little children by scary stories of not being able to afford healthcare if Nanny State wasn’t providing it.

    Do not know what they are paying, but know they will not be able to afford an alternative. What a bunch!

    The NHS is the way it is, expensive and bad, for all the reasons State monopolies are and why only North Korea and the UK have them.

  • http://batman-news.com The Commentator

    The reality is we are paying first world health costs for third world health care. There are some excellent clinicians and nurses in the NHS and no shortage of utterly appalling ones as well. This disgraceful old relic of post-war socialist Britain is, we’re told, the envy of the world, even though no other country has been stupid enough to copy it. A national religion we’re told, it’s either this or the American model, and you wouldn’t like that! No, but I would like access to the first world healthcare they enjoy in France, Germany, Switzerland, Austria, Netherlands, Sweden, Norway………

  • Andrew Smith

    Whenever I need a scan or an x ray (I live in Germany) I phone around the various radiology practices in my area and see whether I can make it the same day or the day after. Once I had to wait a couple of days. Now the system isn’t perfect here, but it is free at the point of service and quick. If you don’t like your doctor, you go to as many as you want until you find the right one. All paid for by a slice out of my earnings. Were I to become unemployed, the state would step in. This isn’t rocket science and can be emulated in GB. Whenever I have cause to speak of my NHS treatment, the doctor looks at me as if though I had just got off the boat from some African republic.

    • Bonkim

      But Britain has the best health free service in the world.

      • Andrew Smith

        If I have understood you properly, you mena the “best free health service”. Well that is untrue.

        The NHS is free inasmuch as it is tax funded, as is the German system. Every worker pays 15.5 % of their earnings in a sort of “health tax” instead of the service being funded by general taxation. So in essence, they are comparable in terms of funding. The difference is the light years better service due to the decentralized, patient-focussed form of organization. . So No GB has not got the best free health service in the world. Because a) it’s not the best and b) it’s not free – we pay for it with out taxation.

        I don’t wait 18 weeks for treatment I need just to prop up a bureaucratic nightmare which salves the conscience of the Left. It’s this sort of unthinking bleating that stops reforms and perpetuates unnecessary deaths.

  • Bonkim

    The NHS would have been better and faster if it cut out non-essential and cosmetic treatments and surgical procedures, such as fertility treatments, and cosmetic surgery instead concentrated on basic health needs to get the working population on their feet after an illness or life threatening illness. Social services and the NHS are supposed to be basic safety nets – not lifestyle choices.

  • FrankS2

    Going by the picture, Danny Boyle’s message to the world was, “Britain – a nation of sick children”!

  • Mark McIntyre

    The problem with the ‘blessed’ NHS ? – the inordinate amount of time, effort AND money it devotes to the decrepit, elderly, ‘coffin dodgers’ !
    People who have had a life – those over seventy years of age – should no longer receive life treatment. Those of working age and below should be prioritised – they are still / will soon be – contributing to the system.
    “Oh, but, we have paid into the system all our life” – so the cry goes from the Coffin Dodgers. NO THEY HAVE NOT ! – once they receive their State Pension – they no longer pay National Insurance. Those who no longer pay their car or home insurance are no longer covered – the same should apply to NI / NHS.
    The kind heart in Moi would allow them to receive minor treatments and pain killing treatments / drugs, but, not life saving treatment.
    Coffin Dodgers should prepare to ‘meet their maker’ – and come to terms with that prospect – GET USED TO IT, GET OVER IT, and while they still have it – GET A LIFE !