It’s utterly terrifying isn’t it? When you look at the alternative to a functioning health and social care system it would seem to be a no-brainier, but not to policy makers; oh no. And this attack on low-paid migrant workers like they were somehow a drain on the system - have our ministers not eyes to see who’s employed in care homes and hospitals? What the hell do they think will happen without them? When my dad was in a specialist care home most of his carers were migrants. When my partner was being treated for cancer, ALL the nursing and personal care staff were migrants. The same will of course be true for every family accessing the NHS & social care in the country, including those who think migrants are the problem and will vote Reform whatever Shabana Mahmood or Keir Starmer or Wes Streeting says. I’m going on for a small op at my crumbling local hospital (Whipps Cross) next week. I hope not to be a drain on the system. Wish me luck.
Maggie Thatcher sold off the UK's social housing stock to force renters into the clutches of the private, Tory, landlords. She also sold off the water, gas and electricity utilities to the private sector who are making obscene profits instead of investing in the infrastructure. We have the worst state pension of any western society. However, the NHS has "national treasure" status and is untouchable so the Tories created a system of underfunded erosion to create instability and failing performance. The final death blow was Brexit which removed a huge number of qualified and willing key staff. And why? As Boris Johnson and Nigel Farage keep saying, they want a private health service allegedly part-funded by some sort of state insurance policy. And we all know how that will go. Welcome to feudal Britain, still proudly in the Middle Ages.
55 years ago, I married an incredible hard working staff nurse who had been very thoroughly trained to work hard and efficiently without the current division of tasks. That is to say, she did the cleaning of bedpans, cleaned the ward and patients hygienically and nursed them to a high standard. It is fair to say that she loved the hard work watched closely under the stern supervision of the hospital matron. At our wedding reception, the matron came to me and actually complained that I was taking one of her best nurses away to live in another town too far away. Since then, I have inevitably been in several hospitals with children and grandchildren and been horrified at the effects of division of labour that appears to have reduced the standards of care and hygiene. Yes, I have had to complain several times to get action. Trainee nurses no longer live in a nurses home and wages have not matched rising costs of living with inflation for them. Hospitals are bigger but the performance judgements are no substitute for providing a high standard of skills. It is not just austerity but also layers of non medical administration added that do not reflect in greater throughput of patients. I understand the frustration but, it seems to me, that many years ago governments decided privatisation was the way forward with the result that there is totally inadequate capacity for the elderly who need different care. I do understand your frustration and really hope the governments of the future do not kid themselves that private contracts are the answer with private health insurance. Good luck to you and I trust you do not give up pushing.
Thank you for sharing your embodied knowledge of the situation in the UK’s NHS. Dare I write what we all know to be the motive of successive political party’s continuing casual cruelty, lies, obfuscation and financial destruction of this present national public service? Global corporate greed. The crisis the majority who are never going to be personally protected within the golden ringfence provided by either great wealth or high political connections is existential. As has just been proven with the release of the Covid enquiry evidence. Our present ruling class neoliberal uniparty will continue to carelessly kill us in a personal pursuit of expanding their wealth portfolios. The urgent social question is that knowing there can be no humane let alone sane governance of the NHS by a political cabal driven by a murderous fanaticism borne of taught Thatcherite ideology. When do those in the NHS simply take back grassroots control of the service in a people’s revolution. Saving what common goods that we can before corporate tyrants take absolute control of the UK’s people’s health as in the US.
My experience working in the NHS since the late ‘70s is skewed towards mental health provision. If I were a cynical man, I should suspect a long term approach by Lady T onwards of undermining socialised health care. Monetisation of the straightforward aspects of all tiers of care has transformed the institution in foreseeable ways. It saddens me.
Heartbreaking. Faint echoes of what happened when Gove's poxy academies were forced on schools not wanting to convert by way of Ofsted changing the rules and playing his game.
Next step: "We have no option but to bring in the private sector to run things efficiently". Farage will be salivating like a rabid dog. And regarding immigrant workers, the aim seems to be to go back to c18 when we relied on immigrants in the Americas - we shipped them on big boats and didn't even bother paying them.
One commentary by the KIngs Fund in 2023 has really stuck with me. The UK it says is remarkable (not in a good way) for having a very low nurse and doctor ration per 1000 people. It had 3 doctors and 8.5 nurses per 1000. Compare this to 5.5 and 7.3 for Portugal, 4.3 and 10.9 for Sweden, 4.5 and 12.1 for Germany. Some countries make up for a low number of nurses by having more doctors e.g. Spain 6.1 nurses but 4.6 doctors per 1000. The UK is almost unique in having a low score on both counts. This seems such a fundamental issue that it should be adressed. If we believe in market economics for the NHS (and boy has it had this rammed down its throat by successive governments) the solution is clear. Pay more for nurses and doctors. To pay more we need to tax more. To tax more we need to change the debate and tell taxpayers what they are paying for i.e. nurses and doctors not Chief Executives and Finance Directors.
It's a vicious culture that believes you motivate people (only not them) by blame and humiliation. And that still after the Tories is in thrall to private medicine.
As a recently retired domiciliary carer the problem of delayed discharges from hospitals is going to get worse as many of my fellow workers were immigrants, How many people are willing to do a job that pays just above the minimum wage that some idiot in a previous government renamed the living wage.
On a typical day your first call would be 7 or 6 A.M. depending on the round.
You are paid per call and many companies do not pay for the travel time between calls.
Last call is usually between 7 and 9 P.M. but the latest I ever finished was 10.30 P.M.
This is classed as unskilled but to do it you need -
Gained a certificate in adult social care - I have 4 and can take up to 6 weeks in a classroom.
You need certificates for manual handling, food hygiene, medication, sexual harassment, first aid, fire safety, dementia. These are just the ones I can remember, there are quite a few more. These are done online.
An enhanced D.B.S. for working with vulnerable adults. I "own" mine because I paid for it but if the company you are working for paid for it and you move to another you have to re-apply.
It is low paid., very long hours job and they wonder why there is a shortage of people who want to do it?
Don’t hate me for what I’m about to say as a person who regularly uses the NHS for wet macular degeneration (no cure, just a holding pattern) and who was hospitalised for 10 days in 2023 for COVID/pneumonia following a fall in which I also fractured 3 ribs and had a suspected punctured spleen - fun times eh?
The standard of care at my beleaguered trust hospital and macular centre can’t be faulted. But.
1: The emergency department is always super busy, often with people presenting issues that ‘could/should’ be dealt with at GP surgeries. It seems that post-COVID, we have trained a part of the current generation to go to hospital even if it isn’t urgent. It’s not helped by families turning up in support.
2: The extent to which manual processes for routine tests and readings (think pulse/blood pressure) are taken by super sophisticated machines that require staff to manually scribble reading notes on whatever paper, towel, back of hand etc they have available and then transcribe said notes into a computer is…terrifying in the modern age.
These two ‘items’ for your friendly NHS P&L account are non trivial and yet whenever I hear folk moaning about resources, I almost never hear about process remediation or improvement. Why? What is so special - or is it sacred (?) - about the NHS that process effectiveness (financial efficiency falls out of that) cannot be meaningfully discussed without someone throwing their hands in the air yelling for more money? If that is an oversimplification or misrepresentation then I apologise. But it is what I see as a user. It is what I don’t see in the pushback from NHS professionals. In short, I don’t see enough by way of constructive, meaningful suggestions for radical, step change improvement.
I have no doubt at all that the services are stretched. That’s what happens with the UK’s demographic profile. No amount of funding or smart management overcomes that problem. But there comes a point when someone, somewhere has to ask - what can we do more effectively. Where is that conversation? I really, really want to know. Because that is where the answers and riposte come to those who would see us with an American style system. Sticking plaster BS like ‘charge for emergency care’ ain’t it.
I don’t hate you for saying it at all, Den, but there is somewhat more to the situation than that.
You’ve hit on one point - that more people are presenting to local EDs because of a lack of access to Primary Care - and that deserves a whole post on its own. But thinking about what you’re describing (seeing nurses writing down readings from advanced machines) is a tiny part of the broader “efficiency” fault-line in the NHS.
Fixing that one thing you note might make the process a bit quicker, yes - but understanding why it happens matters a lot more.
Are nurses writing down the readings because the machine hasn't been integrated into the EPR?
If so, why not?
Is the functionality missing? Has the integration work not been comissioned? Is there no IT resource available in the trust to do the work, or is it on the back burner until they have that resource? Is the tech supplier charging £150k for the interface that the trust just cannot afford? Is the device running on an obsolete standard? Has the Wi-Fi gone down in the ward? Have all the nurses had the training? Is the workflow itself outdated?
Each one of those things is a possible contributor to what you see - and each one of them still needs money, people or time to fix, and normally needs all three.
To the crux of your question - no, having been involved in multiple large scale transformation projects, you can't efficiency your way out of the crisis we find ourselves in when the issues are things like an absence of staffed hospital beds, a workforce shortfall of about 100k people, social care that's barely keeping pace and a rapidly ageing poopulation that means every year more people are living longer with higher levels of clinical need.
I would love to say its as simple as shaking the system until the loose change falls out, but unfortunately the issues are structural, demographic, political and, yes, financial.
Am I saying we should abandon the goal of getting better processes and technology in? Definitely not, and there are hundreds of us working in the system at the moment to modernise everything from discharge patwhays to how patients interact with clinical care in a modern and safe way, but improving the bits on the margins doesn't negate the real urgent need of staff, safe bed numbers and social care capacity.
Efficiency absolutely has a role, and any NHS manager will tell you about the multiple QIP (Quality Improvement Plans) that they personally have running (I currently have about 11), but if you don't address the structural issues, the capacity issues, you're going to go nowhere fast.
I appreciate you responding, and you absolutely make a point, but I can promise you, we have tried these things.
Thx for the response. There is so much to unpack. The point about underlying reasons feels like the kind of cesspool I’ll assiduously avoid on most occasions.
But from the little I know, the basic problem comes down to this: the NHS is an assortment of fiefdoms (often dominated by senior doctors) who hide behind patient confidentiality when it suits them. Harsh? Perhaps but logically insane as a modus operandi for efficient service delivery.
By way of illustration: at one point in my never ending macular treatments I was sent to a privately run specialist for possible cataract surgery. The battery of tests run were almost identical to those that are routinely run at the macular centre. When I asked why the repetition I was told that information isn’t shared. In either direction. I was stunned and immediately fag packet calculated the obvious waste from one afternoon’s surgery in a unit treating around 25-30 people per session. And there are three of these units in my area. They’re all crazy ass busy. Go figure the range of potential cost flushed away in a single treatment area. Now multiply that as many times as there are possible opportunities for sharing. This has to be low hanging fruit that could be harvested by mandating data sharing. At least where it makes obvious sense.
But heh…the private operator gets to charge £££ for repeating what is already known. Where else does this occur? Is it consistent across regions or between hospital groups?
That sounds like a pantomime horse to me. Yet its roots go back to the founding of the NHS when the largely self employed doctors and consultants had to be incorporated into the fledgling system on order to stand up the system. That’s a structural issue right there, the solutions for which are???
I could move on to procurement - I have a close family member in that shitty job for an NHS trust - but it seems the moment you/I/anyone opens one can of worms, there’s always another waiting to be crawled over.
I come back to my basic and slightly nuanced question: what exactly are the top three (I find it easier to process in 3’s) structural issues that are foundational to developing/building/creating/magicking (choose your preference) a 21st century NHS we can continue to love AND afford?
Very good points again, Den - but I'm going to gently redirect things a bit, because there's again, a bit more to it, because it's not at all the case that clinicians are jealously guarding data or "hiding behind confidentiality".
Usually when data isn't shared, nine times out of ten it's because:
- the systems literally are unable to talk to each other (EPIC, CERNER, System One, RIO - and all the other locally used EPRs were just not designed to function this way).
- nobody has the funding for the interface - you'd be shocked at how many pathways break down because a trust couldn't afford the £200k API build that's needed.
- IG is so insanely risk averse that perfectly legal sharing of data get shut down out of fear, or just a complete lack of capacity by the one Information Governance Officer that's trying to cover the whole trust.
- the trust just doesn't have the digital workforce needed to build, test and then maintain the connection.
- The private provider themselves haven't paid to access HIE (health information exchange) that they need to access history, or, isn't allowed to because their compliance might not be up to date.
All of the above comes back to the same issue - the health service does not have the capital investment needed for a modern data infrastructure.
NHSE (or the DHSC) can mandate data-sharing between providers until they're blue in the face, but if the underlying foundation of work isn't there (and it isn't), you're just not going to get any functionality.
As to your question about the top three structural issues?
Staff, Community and Social care, and Capital Investment.
You need more staffed beds in hospitals, nurses to look after them, healthcare assistants to do the day to day basic care bits and pieces, more community therapists to help people rehabilitate, more GPs and you need a social care sector that actually works.
We need to seriously invest in the actual physical infrastructure of the NHS, because the estates are ageing, we're still using scanners from the Jurassic period, there are trusts that are using EPRs that were introduced in the 1990s and just get a nice new interface now and then and just generally a massive lack of modern infrastructure.
I honestly do believe that the NHS can be updated into the 21st century - but it cannot do so without the necessary investment. I have to repeat, I can try to efficiency a broken roof, outdated IT system or broken 20 year old scanners until I fall over, but without actual money that can go towards that, it just will not get better.
We could continue this for a long time as it seems solutions are infinitely debatable.
I’ll close out with one point. £200k per API is a rip off. This is an area I know well. But then it is symptomatic of what we (tech analysts, some say anal-ysts) call Frankensoft. I’m sure you can use a little imagination to ‘get’ that reference… :-)
It’s utterly terrifying isn’t it? When you look at the alternative to a functioning health and social care system it would seem to be a no-brainier, but not to policy makers; oh no. And this attack on low-paid migrant workers like they were somehow a drain on the system - have our ministers not eyes to see who’s employed in care homes and hospitals? What the hell do they think will happen without them? When my dad was in a specialist care home most of his carers were migrants. When my partner was being treated for cancer, ALL the nursing and personal care staff were migrants. The same will of course be true for every family accessing the NHS & social care in the country, including those who think migrants are the problem and will vote Reform whatever Shabana Mahmood or Keir Starmer or Wes Streeting says. I’m going on for a small op at my crumbling local hospital (Whipps Cross) next week. I hope not to be a drain on the system. Wish me luck.
oh heck.
I've shared this with my (Labour) MP, but he's stopped answering emails recently.
I suspect he's as horrified by what's happening as I am, but not allowed to say so.
Maggie Thatcher sold off the UK's social housing stock to force renters into the clutches of the private, Tory, landlords. She also sold off the water, gas and electricity utilities to the private sector who are making obscene profits instead of investing in the infrastructure. We have the worst state pension of any western society. However, the NHS has "national treasure" status and is untouchable so the Tories created a system of underfunded erosion to create instability and failing performance. The final death blow was Brexit which removed a huge number of qualified and willing key staff. And why? As Boris Johnson and Nigel Farage keep saying, they want a private health service allegedly part-funded by some sort of state insurance policy. And we all know how that will go. Welcome to feudal Britain, still proudly in the Middle Ages.
55 years ago, I married an incredible hard working staff nurse who had been very thoroughly trained to work hard and efficiently without the current division of tasks. That is to say, she did the cleaning of bedpans, cleaned the ward and patients hygienically and nursed them to a high standard. It is fair to say that she loved the hard work watched closely under the stern supervision of the hospital matron. At our wedding reception, the matron came to me and actually complained that I was taking one of her best nurses away to live in another town too far away. Since then, I have inevitably been in several hospitals with children and grandchildren and been horrified at the effects of division of labour that appears to have reduced the standards of care and hygiene. Yes, I have had to complain several times to get action. Trainee nurses no longer live in a nurses home and wages have not matched rising costs of living with inflation for them. Hospitals are bigger but the performance judgements are no substitute for providing a high standard of skills. It is not just austerity but also layers of non medical administration added that do not reflect in greater throughput of patients. I understand the frustration but, it seems to me, that many years ago governments decided privatisation was the way forward with the result that there is totally inadequate capacity for the elderly who need different care. I do understand your frustration and really hope the governments of the future do not kid themselves that private contracts are the answer with private health insurance. Good luck to you and I trust you do not give up pushing.
I have shared this with my Labour MP. Never contacted him before, so I look forward to his response with interest but not much hope.
There has to be a better way, surely!
Thank you for sharing your embodied knowledge of the situation in the UK’s NHS. Dare I write what we all know to be the motive of successive political party’s continuing casual cruelty, lies, obfuscation and financial destruction of this present national public service? Global corporate greed. The crisis the majority who are never going to be personally protected within the golden ringfence provided by either great wealth or high political connections is existential. As has just been proven with the release of the Covid enquiry evidence. Our present ruling class neoliberal uniparty will continue to carelessly kill us in a personal pursuit of expanding their wealth portfolios. The urgent social question is that knowing there can be no humane let alone sane governance of the NHS by a political cabal driven by a murderous fanaticism borne of taught Thatcherite ideology. When do those in the NHS simply take back grassroots control of the service in a people’s revolution. Saving what common goods that we can before corporate tyrants take absolute control of the UK’s people’s health as in the US.
My experience working in the NHS since the late ‘70s is skewed towards mental health provision. If I were a cynical man, I should suspect a long term approach by Lady T onwards of undermining socialised health care. Monetisation of the straightforward aspects of all tiers of care has transformed the institution in foreseeable ways. It saddens me.
Heartbreaking. Faint echoes of what happened when Gove's poxy academies were forced on schools not wanting to convert by way of Ofsted changing the rules and playing his game.
Next step: "We have no option but to bring in the private sector to run things efficiently". Farage will be salivating like a rabid dog. And regarding immigrant workers, the aim seems to be to go back to c18 when we relied on immigrants in the Americas - we shipped them on big boats and didn't even bother paying them.
One commentary by the KIngs Fund in 2023 has really stuck with me. The UK it says is remarkable (not in a good way) for having a very low nurse and doctor ration per 1000 people. It had 3 doctors and 8.5 nurses per 1000. Compare this to 5.5 and 7.3 for Portugal, 4.3 and 10.9 for Sweden, 4.5 and 12.1 for Germany. Some countries make up for a low number of nurses by having more doctors e.g. Spain 6.1 nurses but 4.6 doctors per 1000. The UK is almost unique in having a low score on both counts. This seems such a fundamental issue that it should be adressed. If we believe in market economics for the NHS (and boy has it had this rammed down its throat by successive governments) the solution is clear. Pay more for nurses and doctors. To pay more we need to tax more. To tax more we need to change the debate and tell taxpayers what they are paying for i.e. nurses and doctors not Chief Executives and Finance Directors.
It's a vicious culture that believes you motivate people (only not them) by blame and humiliation. And that still after the Tories is in thrall to private medicine.
As a recently retired domiciliary carer the problem of delayed discharges from hospitals is going to get worse as many of my fellow workers were immigrants, How many people are willing to do a job that pays just above the minimum wage that some idiot in a previous government renamed the living wage.
On a typical day your first call would be 7 or 6 A.M. depending on the round.
You are paid per call and many companies do not pay for the travel time between calls.
Last call is usually between 7 and 9 P.M. but the latest I ever finished was 10.30 P.M.
This is classed as unskilled but to do it you need -
Gained a certificate in adult social care - I have 4 and can take up to 6 weeks in a classroom.
You need certificates for manual handling, food hygiene, medication, sexual harassment, first aid, fire safety, dementia. These are just the ones I can remember, there are quite a few more. These are done online.
An enhanced D.B.S. for working with vulnerable adults. I "own" mine because I paid for it but if the company you are working for paid for it and you move to another you have to re-apply.
It is low paid., very long hours job and they wonder why there is a shortage of people who want to do it?
Hi dear Bear 🐻. I don't know if you know of her, but this lady is fighting for the NHS as a doctor. Perhaps you can get together? Dr Julia Patterson
EveryDoctor Chief Exec
Don’t hate me for what I’m about to say as a person who regularly uses the NHS for wet macular degeneration (no cure, just a holding pattern) and who was hospitalised for 10 days in 2023 for COVID/pneumonia following a fall in which I also fractured 3 ribs and had a suspected punctured spleen - fun times eh?
The standard of care at my beleaguered trust hospital and macular centre can’t be faulted. But.
1: The emergency department is always super busy, often with people presenting issues that ‘could/should’ be dealt with at GP surgeries. It seems that post-COVID, we have trained a part of the current generation to go to hospital even if it isn’t urgent. It’s not helped by families turning up in support.
2: The extent to which manual processes for routine tests and readings (think pulse/blood pressure) are taken by super sophisticated machines that require staff to manually scribble reading notes on whatever paper, towel, back of hand etc they have available and then transcribe said notes into a computer is…terrifying in the modern age.
These two ‘items’ for your friendly NHS P&L account are non trivial and yet whenever I hear folk moaning about resources, I almost never hear about process remediation or improvement. Why? What is so special - or is it sacred (?) - about the NHS that process effectiveness (financial efficiency falls out of that) cannot be meaningfully discussed without someone throwing their hands in the air yelling for more money? If that is an oversimplification or misrepresentation then I apologise. But it is what I see as a user. It is what I don’t see in the pushback from NHS professionals. In short, I don’t see enough by way of constructive, meaningful suggestions for radical, step change improvement.
I have no doubt at all that the services are stretched. That’s what happens with the UK’s demographic profile. No amount of funding or smart management overcomes that problem. But there comes a point when someone, somewhere has to ask - what can we do more effectively. Where is that conversation? I really, really want to know. Because that is where the answers and riposte come to those who would see us with an American style system. Sticking plaster BS like ‘charge for emergency care’ ain’t it.
Or am I completely off kilter with this one?
I don’t hate you for saying it at all, Den, but there is somewhat more to the situation than that.
You’ve hit on one point - that more people are presenting to local EDs because of a lack of access to Primary Care - and that deserves a whole post on its own. But thinking about what you’re describing (seeing nurses writing down readings from advanced machines) is a tiny part of the broader “efficiency” fault-line in the NHS.
Fixing that one thing you note might make the process a bit quicker, yes - but understanding why it happens matters a lot more.
Are nurses writing down the readings because the machine hasn't been integrated into the EPR?
If so, why not?
Is the functionality missing? Has the integration work not been comissioned? Is there no IT resource available in the trust to do the work, or is it on the back burner until they have that resource? Is the tech supplier charging £150k for the interface that the trust just cannot afford? Is the device running on an obsolete standard? Has the Wi-Fi gone down in the ward? Have all the nurses had the training? Is the workflow itself outdated?
Each one of those things is a possible contributor to what you see - and each one of them still needs money, people or time to fix, and normally needs all three.
To the crux of your question - no, having been involved in multiple large scale transformation projects, you can't efficiency your way out of the crisis we find ourselves in when the issues are things like an absence of staffed hospital beds, a workforce shortfall of about 100k people, social care that's barely keeping pace and a rapidly ageing poopulation that means every year more people are living longer with higher levels of clinical need.
I would love to say its as simple as shaking the system until the loose change falls out, but unfortunately the issues are structural, demographic, political and, yes, financial.
Am I saying we should abandon the goal of getting better processes and technology in? Definitely not, and there are hundreds of us working in the system at the moment to modernise everything from discharge patwhays to how patients interact with clinical care in a modern and safe way, but improving the bits on the margins doesn't negate the real urgent need of staff, safe bed numbers and social care capacity.
Efficiency absolutely has a role, and any NHS manager will tell you about the multiple QIP (Quality Improvement Plans) that they personally have running (I currently have about 11), but if you don't address the structural issues, the capacity issues, you're going to go nowhere fast.
I appreciate you responding, and you absolutely make a point, but I can promise you, we have tried these things.
(Please excuse typos, I am on a full bus)
Thx for the response. There is so much to unpack. The point about underlying reasons feels like the kind of cesspool I’ll assiduously avoid on most occasions.
But from the little I know, the basic problem comes down to this: the NHS is an assortment of fiefdoms (often dominated by senior doctors) who hide behind patient confidentiality when it suits them. Harsh? Perhaps but logically insane as a modus operandi for efficient service delivery.
By way of illustration: at one point in my never ending macular treatments I was sent to a privately run specialist for possible cataract surgery. The battery of tests run were almost identical to those that are routinely run at the macular centre. When I asked why the repetition I was told that information isn’t shared. In either direction. I was stunned and immediately fag packet calculated the obvious waste from one afternoon’s surgery in a unit treating around 25-30 people per session. And there are three of these units in my area. They’re all crazy ass busy. Go figure the range of potential cost flushed away in a single treatment area. Now multiply that as many times as there are possible opportunities for sharing. This has to be low hanging fruit that could be harvested by mandating data sharing. At least where it makes obvious sense.
But heh…the private operator gets to charge £££ for repeating what is already known. Where else does this occur? Is it consistent across regions or between hospital groups?
That sounds like a pantomime horse to me. Yet its roots go back to the founding of the NHS when the largely self employed doctors and consultants had to be incorporated into the fledgling system on order to stand up the system. That’s a structural issue right there, the solutions for which are???
I could move on to procurement - I have a close family member in that shitty job for an NHS trust - but it seems the moment you/I/anyone opens one can of worms, there’s always another waiting to be crawled over.
I come back to my basic and slightly nuanced question: what exactly are the top three (I find it easier to process in 3’s) structural issues that are foundational to developing/building/creating/magicking (choose your preference) a 21st century NHS we can continue to love AND afford?
Or are we stuck in a doom loop?
Very good points again, Den - but I'm going to gently redirect things a bit, because there's again, a bit more to it, because it's not at all the case that clinicians are jealously guarding data or "hiding behind confidentiality".
Usually when data isn't shared, nine times out of ten it's because:
- the systems literally are unable to talk to each other (EPIC, CERNER, System One, RIO - and all the other locally used EPRs were just not designed to function this way).
- nobody has the funding for the interface - you'd be shocked at how many pathways break down because a trust couldn't afford the £200k API build that's needed.
- IG is so insanely risk averse that perfectly legal sharing of data get shut down out of fear, or just a complete lack of capacity by the one Information Governance Officer that's trying to cover the whole trust.
- the trust just doesn't have the digital workforce needed to build, test and then maintain the connection.
- The private provider themselves haven't paid to access HIE (health information exchange) that they need to access history, or, isn't allowed to because their compliance might not be up to date.
All of the above comes back to the same issue - the health service does not have the capital investment needed for a modern data infrastructure.
NHSE (or the DHSC) can mandate data-sharing between providers until they're blue in the face, but if the underlying foundation of work isn't there (and it isn't), you're just not going to get any functionality.
As to your question about the top three structural issues?
Staff, Community and Social care, and Capital Investment.
You need more staffed beds in hospitals, nurses to look after them, healthcare assistants to do the day to day basic care bits and pieces, more community therapists to help people rehabilitate, more GPs and you need a social care sector that actually works.
We need to seriously invest in the actual physical infrastructure of the NHS, because the estates are ageing, we're still using scanners from the Jurassic period, there are trusts that are using EPRs that were introduced in the 1990s and just get a nice new interface now and then and just generally a massive lack of modern infrastructure.
I honestly do believe that the NHS can be updated into the 21st century - but it cannot do so without the necessary investment. I have to repeat, I can try to efficiency a broken roof, outdated IT system or broken 20 year old scanners until I fall over, but without actual money that can go towards that, it just will not get better.
We could continue this for a long time as it seems solutions are infinitely debatable.
I’ll close out with one point. £200k per API is a rip off. This is an area I know well. But then it is symptomatic of what we (tech analysts, some say anal-ysts) call Frankensoft. I’m sure you can use a little imagination to ‘get’ that reference… :-)