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Towards an eternal winter – can the NHS survive?

Longer but not healthier lives, rising hospital admissions, expensive new treatments and underfunding – is it over for the National Health Service as we have known it?

When George Farrelly finally made up his mind to study medicine, he did not so much make a choice as follow a calling. An intense, preoccupied young man who grew up in Cambridge and Rome, Farrelly had majored in history at Harvard and imagined a future as a writer. His epiphany came when he cloistered himself in a Benedictine monastery on Lake Geneva to answer no less a question than: “Does God exist?”

The kindness of a monk who nursed him through a bout of winter pneumonia made a literary life seem suddenly empty of meaning. Farrelly burned the novel he had been working on and resolved instead to devote himself to what he liked to call “street medicine”: a sincere but as then vague aspiration to minister to the broken-spirited, the out-of-luck and the poor. It was the late 1970s, and when Farrelly enrolled as a mature medical student at St Bartholomew’s Hospital in London, the path to prestige lay through such exalted fields as neurosurgery and cardiology – not the comparatively parochial world of the GP. Farrelly and his wife, Isabel Hodkinson, also a physician, seized their chance to live their grittier – if more romantic – vision when they took over a practice housed in a former council flat in the East End borough of Tower Hamlets. The switchboard was so rudimentary that when somebody called to book an appointment the phones in the rooms all trilled at once.

Twenty-seven years later, the husband-and-wife team are still treating patients in the area from the much smarter premises of the Tredegar Practice, a modern surgery sandwiched between terraced streets and newer estates near the Bow end of Roman Road. On a recent Wednesday morning, Farrelly grabbed his black medical bag from his consulting room and set off at a brisk clip. An energetic 64-year-old with wispy grey hair, Farrelly could easily pass for a compassionate but streetwise inner-city priest. He was visiting patients on the “integrated care list” – typically older people with multiple, chronic conditions who are too unwell to make it to a surgery and who are presenting in ever greater numbers to Britain’s GPs.

First up was Steve Blum, a former lorry driver who blamed his problems on a 60-a-day cigarette habit he had only managed to kick after it very nearly killed him. Blum had suffered his first stroke in 2006, while at the wheel of a 26-tonne truck hurtling through the Dartford tunnel. A second stroke several years later left him barely able to walk. Farrelly reached Blum’s second-floor flat, installed himself on the sofa  and produced a checklist and pen. It was time for the patient’s annual review, and the pair had much to discuss.

A heavyset man with a neatly trimmed beard, Blum had the worn-out look of a permanent patient who cannot remember being pain-free. His family had produced a laminated handout detailing all of his complications  – and the 16 types of medication they required – to serve as a handy cheat sheet to thrust into the hands of staff whenever he had to go to hospital.

Gradually, the pair worked their way down the list: memory loss; type 2 diabetes; arthritis in his hands, feet, knee and right hip; damaged nerve endings; depression (which had triggered two overdose attempts); anxiety; degenerative disease in the back; sleep apnoea; asthma; high blood pressure; high cholesterol and an enlarged prostate. Finally, they broached the question of Blum’s weight – which hovered stubbornly near 20 stone – before concluding with a goal-setting exercise. “What are your wishes – your dreams – over the coming year?” Farrelly asked. “To win the lottery,” joked Blum, who was born and bred in Tower Hamlets and found some solace in gallows humour. More gruffly, he added: “To go back 11 years and not have had my stroke.” The pair settled on a plan that included Blum using his mobility scooter to accompany his son and nephew to see his beloved Tottenham Hotspur play at Wembley. After all, Blum would soon have cause to celebrate. In two weeks he would mark his 56th birthday.

The National Health Service, which turns 70 this summer, is not that much older than Blum. But its litany of problems – like those of so many of its patients – can seem almost too much to bear. Midway through the worst financial squeeze in its history, saddled with the legacy of interminable reorganisations and ruinously expensive private finance initiatives, and grappling with the twin pressures of staffing crises and ever-increasing demand, the organisation’s future has never looked so uncertain.

At the start of this year, strains building below the surface burst spectacularly into view as the NHS suffered its worst winter crisis since the 1990s. With ambulances backed up in hospital car parks, A&E departments overflowing and elderly patients left languishing on trolleys, NHS England was forced to postpone more than 50,000 non-urgent operations to free up more beds. As standards of care began to unravel, staff expressed their shock and anger on social media: one A&E doctor apologised for “third-world” conditions.

“The big danger is that this is all going to collapse,” Farrelly had told me last summer, during a lunch break at a cafe near the Tredegar Practice. Wearing sombre colours and sandals, which enhanced his ecclesiastical aura, he spoke with the combination
of finality and resignation that has become a default setting among hard-pressed medics. “If you have increasing flow of work, decreasing people to do the work, and decreasing resources, it’s going to crumble  – you won’t be able to do the job.”

Dr Jackie Applebee, who works with Farrelly, is equally forthright. A vocal official in the British Medical Association, the doctors’ union, Swansea native Applebee is also an outsider who has learned to call Tower Hamlets home. Having worked in the borough for 17 years, she spends much of her spare time campaigning on behalf of the NHS, her stethoscope swapped for a megaphone. One rain-spattered Saturday afternoon, she stepped on to a stage at Chrisp Street Market, a drab precinct a couple of miles from the surgery, and delivered her prognosis.

“It’s going in the same way as the American health service where people die on the streets because they haven’t got insurance,” she said. “We have to fight to keep the NHS free at the point of delivery.” Applebee then began to hand out flyers, telling one passer-by: “People don’t notice until it goes off a cliff – which it will if something wonderful doesn’t happen very soon.” The leaflets posed the question: “Can #ourNHS survive the next five years?”

t’s not the first time that NHS campaigners have foretold the apocalypse, and newspapers have been predicting the organisation’s imminent demise almost since Aneurin Bevan, then Labour health minister, oversaw its creation. With politicians and the media lost in a maze of questions posed by Brexit, the weary familiarity of reports of staff shortages, growing waiting lists and increased rationing of care can seem perversely comforting by comparison.

This time is different. In the winter of 2016-17, the British Red Cross warned that the NHS was facing a “humanitarian crisis” after two patients died following long waits on trolleys. Though the use of a term usually reserved for famines or war zones had a ring of hyperbole, even the most sober voices have begun to sound the alarm. In October the Care Quality Commission, the health and social care regulator, warned that although standards had generally held up in the past year, the future looked “precarious”. Front-line staff are less diplomatic. “We feel that we are kind of working on a ship that is sinking and on fire at the same time,” one hospital doctor tells me during a busy evening shift. “There’s definitely a feeling of impending doom.”

Much of the public discourse on the NHS has traditionally revolved around the question of money – whether it is getting enough, and how to find more if it isn’t. Yet the dilemmas confronting the health service cannot be reduced to the one-dimensional question of resources alone. Many factors have shaped the contours of the current crisis, from the consequences of successive waves of market-based reforms stretching back to the 1990s, chronic staffing shortages, steadily declining bed numbers and the increasingly arms-length approach to the health service taken by the Conservative government. Looming over all these issues is the fact that the NHS and its 1.5 million staff now face a challenge it was never designed to meet: caring for a fast-growing, increasingly elderly cohort of patients living with multiple, chronic conditions. Patients like Steve Blum.

Seventy years ago, people tended to live “square-shaped lives” – staying in relatively good health before falling ill and passing away conveniently promptly. Half the population never reached the age of 65. The NHS was built on the assumption that one patient would see one doctor for one problem, and if they were really ill they would go to hospital where they would either get better or die. Childhood diseases such as polio or rickets were far more pressing problems than the later-life scourges of type 2 diabetes or dementia.

Now, every part of that picture is different, driven by a combination of medical advances and social changes. There are already more than 11 million people over 65 in the UK today, and a quarter of the population will fall into this age range by 2040. Survival rates for heart disease have increased dramatically in the past 15 years, and prognoses tend to be more optimistic for illnesses such as breast or childhood cancers. Life expectancy for men in Britain has risen to 79; for women it’s 83. But the problem is that longer lives do not necessarily mean healthier ones, and the number of patients suffering from chronic illness is rising fast. Dementia cases will top one million within the next three years according to one forecast, while millions more people will be living with preventable diseases fuelled by the self-destructive ways in which we eat, live and work. Obesity has almost doubled since the early 1990s and the UK now has the worst weight crisis in western Europe, according to the OECD.

Doctors fear bulging waistlines alone could break the NHS by fuelling a surge in type 2 diabetes, osteoarthritis and some cancers. “There’s a real risk that people will live for longer, but they will have spent longer dying,” says Sarah Jarvis, a GP and clinical director of patient.info, a website that offers information provided by doctors. “We are fighting against a rising tide of lifestyle factors that are threatening to overwhelm us.”

Unless the health system learns to focus on prevention as well as treatment, then its inexorably rising costs will strengthen the voices of those who see the NHS not as Britain’s proudest postwar achievement, but as a terminal patient beyond hope of a cure.

***

Though the NHS can make a good claim to be the world’s most iconic health-care system, its founders were by no means the first to conclude that governments should get involved in financing medicine. In the early 1880s, Otto von Bismarck, the German chancellor, pioneered a form of employer-funded social insurance that forms the basis of the system in various European countries that now provide near-universal coverage. Nevertheless, the sheer sweep and boldness of the NHS vision represented an entirely new way of thinking about the relationship between health care and the state. Ever since the first physicians began concocting herbal remedies and performing rudimentary surgery on our ancestors, the horror of falling sick and not being able to afford the right care has been passed down through generations like an unwanted heirloom, burrowing its way deep into the collective psyche. The inauguration of the NHS on 5 July 1948 lifted this ancient curse at a stroke. Health care would be brought under a single umbrella organisation, paid for from general taxation and offered free at the point of use – regardless of the contents of a patient’s wallet. Buoyed by postwar ideals of solidarity and egalitarianism, the organisation was more than just a giant patient-processing machine: it seemed to offer a more optimistic reading of the human future.

“It was an extraordinary act of leadership to have established the National Health Service,” says Don Berwick, emeritus president of the US-based Institute for Healthcare Improvement. “The whole world looks to the NHS as a learning system – a way to explore what can happen in government sponsorship of health care.”

Although the health service enjoyed a period of relative plenty in the early 2000s under New Labour, that largesse would not survive the 2008 financial crisis and the austerity agenda adopted by the Conservative-led coalition two years later. The NHS is now experiencing the leanest decade since it was founded, according to the King’s Fund think tank. While Theresa May is technically correct to say that her government is spending record amounts on the NHS, the more pertinent question is whether it is spending enough.

History suggests not: the King’s Fund has forecast that spending on the NHS will increase by an average of 0.7 per cent a year in real terms in the five years to 2020-21 – compared to a long-term average of about 4 per cent a year. The contrast between the virtually flat graph for spending and the steadily upward curves for hospital admissions, ill health among the elderly, the cost of new treatments and rising patient expectations suggests that something will have to give. Chancellor Philip Hammond succumbed to intense pressure to allocate additional funds in his last Budget, but the amount fell well short of the extra £4bn a year the NHS wanted.

With frozen welfare benefits and stagnant wage growth dragging hundreds of thousands more into poverty, and social care badly impacted by savage cuts to council budgets, the impact of years of austerity on Britain’s physical and mental health is increasingly being felt by GPs, paramedics, nurses and the managers battling to hold the line. “I have been a chief executive in London for 17 years and I don’t recall seeing the NHS under so much pressure,” says David Sloman, who runs a group of three hospitals including the Royal Free in Hampstead. “Staff are working incredibly hard in challenging circumstances and we need to think differently about how we deliver NHS services in the future.”

The NHS remains Britain’s biggest bastion of collectivism to have survived the neoliberal age. Yet many staff believe that the chronic underfunding is serving an ideologically driven agenda to place ever-larger segments of the health service under corporate control. Though the value of clinical services commissioned from private providers represents less than 8 per cent of the NHS budget, the firms’ roles have grown markedly in the past decade and this trend is accelerating. The value of NHS contracts won by private providers rose to £3.1bn in 2016-17, up from £2.4bn the previous year, according to the NHS Support Federation campaign group. Richard Branson’s Virgin Care led the charge, winning a record £1bn of NHS business last year. Even if such companies only control a small proportion of overall spending, the fear among NHS staff is that outsourcing the most profitable procedures – such as cataract surgery, hip replacements or diagnostics – is corroding the system slowly from within. Cherry-picking such activities is like removing blocks from a Jenga tower: take too many and the whole structure starts to wobble. “This is when we have to say enough is enough,” says Ben White, a doctor who has campaigned on behalf of the NHS. “Before we know it we’re sleepwalking into a completely different health service.”

***

When George Farrelly pursued his vision of “street medicine” in the early 1990s, Britain’s GPs had their share of struggles, but their workloads tended to be more manageable and on-the-job burnout was a relative rarity. Now, many feel more like storm-battered emergency workers fighting to prevent a dyke from bursting its banks.  Although GPs play a vital role in saving the NHS money by keeping patients out of expensive hospital beds, the organisation has gradually reduced the proportion of resources devoted to primary care – and surgeries are feeling the impact.

A record 92 practices closed in 2016 – a five-fold increase on 2013 – according to figures obtained by Pulse magazine. Although 34 of these closures were due to practices merging to pool resources, the BMA said a lack of funding was responsible for the bulk of the losses, which forced 265,000 patients to switch surgeries – more than in any previous year.

GPs were similarly aghast at the humiliating spectacle of one practice being forced to auction its equipment online to settle debts. “It was unheard of before; now we’re hearing stories every few weeks of practices having to close because they can’t afford to run any more,” says Mark Hamilton of campaign group GP Survival. “The goodwill that kept the NHS afloat for so many years is basically evaporating.”

With surgeries across the country struggling to fill vacancies, Farrelly was shocked to learn that up to half of a six-strong group of medical students visiting the Tredegar Practice on a placement were studying for qualifications needed to work overseas. “I’ve never heard people speak about this option,” he says. “Then hey presto: here I am with a group of people – they’re in their first year of medical school – and they’re already planning their exit.”

So many UK-trained medics have been emigrating to Australia, Canada or New Zealand that the Health Secretary, Jeremy Hunt, floated the idea of imposing fines to force them to stay. With unpaid overtime, roster gaps and stagnant wages taking their toll on hospital staff, there have been a slew of reports of nurses being forced to use food banks, or quitting to work in supermarkets. Brexit may make matters worse. NHS England employs 55,000 EU citizens, but applications from nurses wishing to move to the UK from Continental Europe fell by 96 per cent after the referendum. Even high-flying British specialists wonder what the future holds. “I believe in the NHS, it’s where my heart is,” says one cardiac surgeon in his mid-thirties. “But if they push me too hard, I will leave.”

The closest Farrelly came to quitting was midway through his career – when he seriously considered leaving Tower Hamlets to become a monk. Years later, there remains something of a spiritual seeker’s single-mindedness in his devotion to tightening procedures at his practice.

An evangelist for the “lean” school of hyper-efficient management pioneered in Toyota car factories in the 1980s, Farrelly encourages his staff to hold a weekly meeting where they brainstorm time-saving ideas with the help of a formidable-looking flow chart peppered with Post-it notes. Though he reserves particular scorn for politicians – whose top-down tinkering he blames for many of the NHS’s problems – Farrelly is equally adamant that the institution could do a lot more to reduce waste. “There’s a line between when you are coping and when you are not coping, and that’s not a very big space,” Farrelly says. “A lot of the system is at that tipping point.”

***

If Simon Stevens, the chief executive of NHS England, is daunted by the multi-pronged assault hammering at the walls of his kingdom, he doesn’t let it show. From his headquarters at Skipton House, a nondescript glass-fronted office block in Elephant and Castle, south London, Stevens is leading the most ambitious overhaul of the way clinical services are delivered since the NHS was founded. There is no question that the service needs to evolve. Yet there is still great scepticism over whether Stevens can reconcile two seemingly contradictory goals: providing better care, while simultaneously saving more money, more quickly, than ever before.

An imposing, cerebral figure with a reputation for knowing more about the NHS than just about anybody else alive, Stevens joined the organisation as a graduate trainee, going on to serve as an influential health policy adviser to Tony Blair. Having played a key role in the Blair government’s successful campaign to tackle waiting times and boost treatment outcomes, Stevens went on to spend a decade in senior positions at UnitedHealth Group, one of the largest health-care corporations in the US, before being headhunted to run NHS England in October 2013. His mission: to deliver an improbable-sounding £22bn of annual savings by 2020 (the day-to-day running costs of the NHS this year are about £110 billion).

Stevens set out his plan in a 39-page document called the Five Year Forward View. Despite its anodyne title, the dossier heralds far-reaching change. One of the main goals is to break down barriers between the many different organisations involved in care to provide better support to patients with complex needs, and with the hope of keeping more of them out of hospital.

That might sound like a straightforward idea, but in practice Stevens’s reforms herald a profound shift in the way the health service is run. After decades in which both Labour and Conservative governments sought to hold down costs by promoting internal competition in the NHS, Stevens has begun pushing the organisation in the opposite direction, believing closer co-operation is paramount.

With this guiding principle in place, Stevens set officials across England’s ecosystem of semi-autonomous hospitals, GP practices and local councils to work, sketching out proposals for how they could operate together more effectively. Dividing England into 44 areas with an average population of 1.2 million, the resulting proposals added a new entrant to the lexicon of NHS jargon: STPs (sustainability and transformation plans). In “vanguard” sites such as Blackpool and the Fylde Coast, South Yorkshire, Dorset and Berkshire, once-fragmented providers are starting to co-operate more.

“The heart of the idea is that there’s a lot that’s good. What needs to change is that there needs to be a better join-up between the components of care,” Stevens told me at Skipton House last summer. “Part of what we’ve been trying to do is to create those safe spaces, or those permissive environments, for those evolutionary developments to take hold.”

After years of watching management consultants approach NHS cost-cutting as a kind of extreme sport – axing frills as lowly as free tea bags for nurses – it was perhaps inevitable that some have nicknamed the STP exercise “slash, trash and plunder”. While many health providers have welcomed the idea of closer integration, others fear that plans to merge different hospitals and A&E departments will leave patients worse off and create new avenues for the private sector to snap up even bigger contracts.

Much of the controversy centres on plans to create so-called “accountable care organisations” (ACOs) – a model widely used in private health-care systems in the US and Europe – where a single organisation takes responsibility for providing a full spectrum of services to a given population. Although the margins for much of what the NHS does are too low to offer easy profits, campaigners cannot shake the suspicion that ACOs will serve as convenient bridgeheads for corporations seeking new in-roads into England’s health market. The concerns were widespread enough to prompt Bruce Keogh, NHS England’s medical director, to write in the Guardian earlier this month that the model was not a “Trojan horse” for greater privatisation.

Stevens, who has repeatedly braved the ire of ministers to make a public case for more NHS funds, has similarly little truck with concerns about the growing role of private health providers. “When you look back at points in the past at moments where we stared in the mirror and said, are we going to ‘re-up’ with the NHS, or are we going to do something different, we’ve decided as a country – on balance – that we’re going to persist,” he tells me. “There’s no great sense that there’s an alternative that people would prefer. The question is, how do we future-proof the NHS for this next phase?”

Stevens’s thinking already appears to be delivering closer co-operation in some of the “vanguard” areas, but the biggest question remains unanswered: can such a fundamental rethink succeed without more money? Colin Leys, an honorary professor at Goldsmiths, University of London and co-founder of the Centre for Health and the Public Interest, has analysed plans to transform care in north-east London, which includes Tower Hamlets. His conclusion was unambiguous: without significantly more investment, the plans would imply a decline in quality, staffing levels and access for patients. “That doesn’t mean they’re not good ideas in themselves,” Leys tells me. “The question in my mind is, if they are good ideas, where’s the evidence? And secondly, will these good ideas work in conditions of underfunding?”

***

One of the great paradoxes of the NHS is that for all the routine use of the term “crisis,” it is still possible to walk into one of London’s top hospitals and marvel. On a recent Friday at Guy’s Hospital near London Bridge, a consultant called Ben Challacombe donned his surgeon’s cap – decorated with pictures of a cartoon Merlin. Challacombe’s specialism rests on wizardry of the electronic kind: a praying mantis-like machine with four robotic arms that enables his team to perform operations with the kind of hair’s-breadth precision that surpasses the steadiest of human hands.

Bathed in the glare of theatre lights, the device – known as “da Vinci” – twitched into life, its limbs gyrating obediently under the control of an operator intent on tunnelling ever deeper towards a thumb-tip sized tumour on a patient’s kidney. “We’ve got no time pressure,” Challacombe told his team, as pop music played softly to help them maintain focus. “Just do it beautifully.”

Medicine is on the cusp of a tectonic shift that could deliver a very different future to the bleakest projections for the NHS. From advances in big data and artificial intelligence to the development of treatments tailored to an individual’s unique genetic make-up, breakthroughs in “med-tech” will soon make it easier to spot, prevent or quickly cure once unconquerable diseases – provided a way can be found to pay for it all. “I think in two to three hundred years’ time we might think of this as another Renaissance, in the way connectivity and technology advancements went off the curve,” says Nazneen Rahman, head of genomics at the Institute of Cancer Research. “We’re moving from the traditional way in which health systems were about making ill people better, to being about keeping well people well.”

If there is one clear lesson to be drawn from the NHS’s plight, it is that this Renaissance will go one of two ways. Blockbuster new treatments could enable more people to live longer lives in ruder health than ever before. Or the sheer weight of demand and the ever-multiplying cost of care could conspire to deliver a more dystopian future; in which the privileged enjoy extraordinary lifespans thanks to bespoke, privately funded medicine, while the have-nots are condemned to live shorter, more disease-ridden lives than their parents.

As Steve Blum learned when he was finally forced to quit smoking, a life-threatening diagnosis can be a great spur to change. It can just as easily lead to apathy and denial. Blueprints exist to evolve a system that genuinely serves to help people from all backgrounds to stay healthy – rather than accepting the growing burden of chronic, preventable illness as somehow inevitable or normal. But that won’t happen unless Britain – as the custodian of a singular experiment in health care – makes an unequivocal choice to rescue the NHS from its glide towards eternal winter.

It took a case of pneumonia to nudge George Farrelly into the realisation that a lifetime of serving others would ultimately yield richer rewards than the pursuit of success for its own sake.

For all the trials he has faced during more than a quarter of a century of “street medicine”, it is not yet a decision he has come to regret. “I had thoughts today that I can’t go on like this. But then later I’ll think, ‘We have a method to try to make this work,’” Farrelly said one afternoon at the Tredegar Practice. “If we have a meltdown of the whole system, we will just somehow or other put something together.” Then, he went back to his desk. 

This article first appeared in the 26 January 2018 issue of the New Statesman, How women took power