Ben put the boxes of medications on my desk. “Do I need to carry on with any of them?” he asked. The labels were in an unfamiliar language but there were enough similarities to the English names that I could work out what each was: two different antibiotics, two types of painkillers, and a decongestant that can be purchased over the counter here.
“Did they say what was wrong?”
Ben had developed a persistent headache during his holiday. The local clinic had performed blood tests and a CT scan, given him 24 hours of intravenous treatment, then discharged him with a small pharmacy’s worth of tablets.
“Something about my sinuses being infected.”
In the country Ben had visited, the more procedures and treatments doctors do, the more money they earn. A British GP would have diagnosed him without any investigations, advised him on self-care, gently nudged him to quit smoking, and at most might have prescribed some penicillin. The total cost to the NHS would have been about £40. Ben’s travel insurers were left with a bill approaching £1,000.
The medics abroad could doubtless have justified themselves. There’s so much uncertainty and variability inherent in medicine that clinicians can practise in wildly different ways, yet each will swear they’re acting in the patient’s best interests. It’s one of the reasons Nice (the National Institute for Health and Care Excellence) sets out guidance for so many clinical scenarios – to recommend what ought to be considered and to indicate what is unnecessary and wasteful.
I thought of Ben on 6 January, when NHS England published “Reforming Elective Care for Patients”, its plan to deal with the current unconscionable waiting lists. In pride of place was the fictional case of “Sarah” who had contacted her GP practice with sinus pain and a hearing problem. This was supposed to illustrate the envisioned new NHS, where “community diagnostic centres” in shopping precincts ensure scans and tests are available on demand Sarah’s case was dealt with by: a nurse, an ENT registrar, an ENT consultant and an audiologist, who subjected her to both a CT and an MRI scan and various other expensive investigations. The costs would have exceeded even those run up by Ben’s profligate overseas clinicians.
The case provoked widespread derision, doctors pointing out that if Sarah had seen a GP, then her problems would have been sorted at a fraction of the cost. NHS England swiftly removed all trace of Sarah and her sinuses from the online version of their plan.
“Reforming Elective Care for Patients” will have been through countless cycles of scrutiny and revision within NHS England and been signed off at the highest level. That such a monumentally misguided case study could have been presented in pride of place demonstrates the groupthink that pervades the organisation. There is simply no conception of how pivotal GPs are to the cost-effective performance of the health service – let alone to holistic patient care.
Health Secretary Wes Streeting has rightly ascribed the current NHS crisis to “14 years of mismanagement”, one of the most egregious aspects of which has been the negligent erosion of the GP workforce. The number of hospital doctors has increased by 48 per cent since 2010; GP numbers are down 12 per cent. Streeting understands the value of the expert medical generalist better than probably any of his predecessors – hence the policy to “bring back the family doctor” and to shift care out of hospital and into the community. But he needs a competent top team to deliver, and NHS England will only reform once confronted by how lamentably wrong-headed it has been. Streeting should commission an independent inquiry to establish how the health service’s leaders could have spent 14 years blithely presiding over the destruction of a cornerstone of the NHS, complacently believing that the GP is a largely unnecessary role.
[See also: Thought experiment 6: Twin Earth]
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This article appears in the 29 Jan 2025 issue of the New Statesman, Class War