It is 2017, the realities of Brexit loom large, political certainties are in tatters and Britain’s health service is in crisis. The Leave campaign has long distanced itself from its post-factual battle-cry of an extra £350m a week for the NHS.
After a bruising fight with government, junior doctor morale, recruitment and staff retention are at an all-time low. Paediatrics has a 20 per cent average senior trainee vacancy rate, while other specialities, including general medicine and psychiatry, report concerning recruitment falls of 7-18 per cent, and a surge in interest in working abroad.
The UK ratio of doctors per capita is already among the lowest of western nations. The analysis is straightforward: more doctors are needed, or NHS demand must be reduced.
NHS Trusts in England, already crippled by a staggering £2.45bn deficit, either have doctors work excessive hours to keep the system going, or appoint locums through for-profit agencies charging hefty fees.
Demand could be reduced by shifting tasks away from doctors and providing more out of hospital care, but the nursing vacancy rate is 10 per cent (17 per cent in London), cuts to public health have led to falling numbers of health visitors, and a shortfall of around 10,000 general practitioners is predicted by 2020.
Children form a quarter of a general practice workload but less than half of GP trainees have a paediatric placement during their three-year training.
The Royal College of General Practitioners has repeatedly called for training to be increased to four years to accommodate essential areas such as child health as children represent more than a quarter of emergency department attendances, but we have been told this is unaffordable.
Britain relies more heavily on foreign doctors than any other major European nation with more than a third of NHS doctors and over a fifth of nurses born abroad, yet overseas doctors permitted to enter the country have been severely restricted, and nursing bursaries have been cut.
And after successfully alienating a generation of junior doctors, the Health Secretary called for foreign doctor numbers to be slashed post-Brexit, heaping needless additional distress and insecurity upon the 55,000 NHS staff who are EU citizens.
The founding principles of the NHS – healthcare for all, free at the point of need, financed from central taxation – have served the UK well for over 60 years, but additionally, a uniquely stable medical workforce was created.
Salaries were reliable, centrally negotiated, with nationally consistent pay and conditions across all specialties, and came with regular increments and a generous pension package.
This provided security for doctors, freedom to follow a career path without the distractions of temptation to pursue financial gain, and a strong incentive to remain in the NHS.
A reliable, high quality workforce was created that was not wealthy, but well-off, committed to delivering care wholly driven by the patient’s best interests.
The imposition of a new contract predicated upon the unjustified but repeatedly made claim that patients were dying as a result of poor weekend care, destroyed this stability, and provoked the junior doctor strikes of 2016.
It’s worth noting that this was the first strike in 40 years. The contract abolishes pay equity across specialties, introduces differences in pay and conditions between the four nations, and in England, between NHS employers; and is likely to widen the gender pay gap, though over 50 per cent of new medical recruits are women.
The Health Secretary has announced plans to increase medical school places by 1,500 a year, accompanied by the claim, implausible because it takes more than 10 years to train a doctor: “By the end of the next parliament the NHS will be self-sufficient in doctors.”
This slim offering was soon soured by the mean-spirited threat of a fine if new recruits don’t work for the NHS for at least four years, failing to recognise or acknowledge that a defining strength of the NHS is that UK doctors have been proud to work as public servants for their entire careers, and that in a global era that the NHS benefits from a flexible workforce, with UK doctors equipped to work abroad, and overseas doctors made welcome.
The harshest financial squeeze in the history of the NHS has been imposed with exhortations to identify £22bn in efficiency savings, to do more with less.
Simultaneously the costs of marketisation and service fragmentation are consuming an increasing proportion of a budget that has effectively been frozen since 2010.
The resilience of a dedicated workforce is being pushed to the brink of breaking point. The end result has been a progressive contraction in NHS services. Mismanagement on such a scale defies belief. These actions only make sense if the purpose of constraining NHS services is ultimately to reduce demand by nudging those able to do so to seek care in the private sector.
Such a fix would be shallow and short-term in its thinking; a far more suitable alternative would be for the UK to commit to sustained cross-party support for the NHS as a visionary innovation that extends the concept of healthcare beyond universal coverage to responsibility for equitable access, clinical effectiveness, and cost-efficiency as a great moral duty of state.
Strengthening and modernising the NHS would benefit us all, no less the resilience and economic wellbeing of the nation.
The placards carried in the streets by young doctors proclaimed “Save our NHS”; now the UK public must decide if they concur.