The National Health Service:
My Part in Its Downfall
The United Kingdom has two world-famous institutions traditionally close to its heart, like a pair of old and beloved relatives. The first is the British Broadcasting Corporation (BBC), often referred to as “Auntie.” The second is the National Health Service (NHS), often referred to as “on the brink,” “under increasing pressure,” and “close to collapse.” I have never worked for the BBC — I don’t think they’d have me –, so my opinion concerning “the Beeb” would be simply that, an opinion.
But my opinion concerning the NHS is informed by experience. At various times between 1981 and 1997, and dove-tailing with my academic pursuits, I worked as a nurse, a health information officer, the manager of the Central Sterile Supplies Department (CSSD) at the United Kingdom’s second-largest hospital, and a medical librarian at the south London hospital where my father was born in 1926. Over the years, the NHS has been very good to me. What a pity it has not been as good to itself.
The NHS was born in 1948 and Labour politician Aneurin Bevan was the midwife. The simplicity of its central principle was its strength: a tax-funded, universal health service free at the point of use and so based on clinical need rather than ability to pay. Sadly, this worthwhile and achievable aim has fallen victim during my lifetime to technocracy, the managerial fallacy, and the simple brilliance the British public sector displays for wasting what it calls “government money.” To a limited extent, I watched it happen.
But just as working in the belly of the beast gave me an insight into what was wrong with the NHS, those jobs also showed me what is right with it. I have always believed that everyone who can should work at least briefly in two sectors: hospitality and healthcare. You will see both sides of humanity: people who are enjoying life and people who are not. These are equally instructive perspectives.
My first NHS job was in the unusually hot English summer of 1981. I was 20 and waiting to see if I had attained the required A-level examination grades to enter university. If I had not, I intended to train as a psychiatric nurse, but I did get the grades, and went on to study philosophy. I’m sure there is some moral to that story, but it eludes me.
I was employed that gorgeous summer as an auxiliary nurse (unqualified help on the wards, basically) at The Royal Earlswood Hospital for the Mentally Handicapped in leafy Surrey. This beautiful building had been a Victorian prison before it was a mental hospital, and I believe it is now apartments. Make of that evolutionary progress what you will.
Looking after the mentally handicapped is not an experience like any other. And these were mentally handicapped people, not mentally ill people (although the mentally handicapped can become mentally ill). The difference is important. One boy on one of the wards I worked on hallucinated constantly, his eyes rolling around in his head like pinballs. It wasn’t some psychological glitch, the head nurse told me. The boy had drank lead-based paint as a child, about a liter of it, mistaking its bright color for a milkshake.
Nursing was also an investment. I was able to work as an agency nurse in geriatric wards at Brighton Hospital the following year, my first at university, to supplement my student grant. I recall that my hourly agency rate was higher than that of the professional nurses I was working with on the same wards. This did not seem to be an incentive for a nurse to stay professional, and it wasn’t. Many left and returned to the same wards they had quit, but now working for agencies like mine for obvious reasons. More money. There were many of these administrative paradoxes that indicated a sector with problems, but it took my next NHS post to reveal the real culprits in the slow but inexorable decline of this magnificent but doomed organization: management.
After a chance meeting with a NHS sub-contractor in 1990, I worked for a year at St. George’s Hospital in south London, at that time the country’s second-largest hospital after Manchester Royal Infirmary and a famous teaching hospital. My job was to facilitate and monitor the control, standard, and delivery of sterile supplies throughout the hospital.
This meant items and products as different as the Redi-Vac bottle (mostly used to remove blood and mucus from a patient’s body by means of a vacuum-sealed container) and super-sterile silver surgical equipment which required autoclaves to sterilize them. And it also meant everything in between, all the small stuff: from tongue depressors to bulk-order rubber gloves, from operating-theater gowns to disposable toenail brushes for podiatrists. I saw to everything which needs to be sterile before being used in a hospital — which means everything used in a hospital.
I would visit every ward and unit every day, by strange serendipity beginning my rounds at the neo-natal unit (where I once saw a premature baby that weighed two pounds and lived) and ending at the geriatric unit. All human life really was here. My job, as I saw it to begin with, was to absorb information from those at the sharp end of the health system — the “front line” of the NHS, as the newspapers always call it — and use that to improve the provision of sterile supplies as the job progressed. But, as we shall see, if I was visiting the front line as some kind of dispatch rider, there were snipers in the woods.
On my first day in the job, my understanding from my employer was that I had a free brief to improve an ailing system. So, I thought it would be a good idea to visit the head nurse (or equivalent) on every ward and unit, introduce myself and my role, and see what their biggest gripe was in terms of CSSD provision. I set off on my trek around the vast building, and took the temperature, as it were, of the hospital, asking all those in charge medically what they would change in terms of CSSD, and why. It was pretty much a unanimous verdict: It was the basic dressing pack (BDP).
It is self-explanatory. The BDP is an easy-open package which at that time contained a roll of bandage, safety pins, low-tack tape, a small tube of antiseptic cream, a sterile field (basically a super-disinfectant, large baby wipe), a little plastic gallipot, and plastic tweezers (sometimes called “forceps” in the United States, I think). All of these nestled neatly into a pulp tray, which are absorbent and keep down the mess if someone has just cut their arm open and you are cleaning it up. And this is really what a BDP is for. You aren’t going to be field-dressing any gunshot wounds with a BDP, but you can keep a gash under control and pick out any grit or whatever before swabbing. Or you can just clean an existent wound on a daily, ward-based basis. I would seriously recommend everyone have at least one BDP in their home.
The BDP at that time in that particular hospital also included two swabs of cotton wool, and most head nurses told me that was the problem. If you swab a wound with cotton-wool it often “lints,” meaning that tiny strands of cotton can be left inside a wound. These might be missed before suturing (the strands are near-microscopic) and can escape further swabbing. At best, the suture has to be reopened and cleaned. At worst, if this lint remains in the wound when sutured it can begin to rot, and there is a risk of septicemia, although the skin will flare up long before the rot literally sets in.
The answer to this, the head nurses all said, was something called (from memory) Medi-Gauze, a crisscross fabric swab which does not lint. I see now, on checking, that it (or something similar) is standard in today’s BDPs, but it wasn’t in the UK then. What the head nurses really wanted was a BDP containing Medi-Gauze. Absorbing of information, followed by resultant action, here we come!
In 1990, the Internet was not really available to people like me, but using a telephone directory and a pay phone I sourced a reasonably local medical supplies company who not only stocked a BDP containing Medi-Gauze, but sold it cheaper than the one containing cotton wool currently used by the hospital. I changed the order immediately, having been given to understand that I had that executive power. But I thought I had been employed because my perceived competence would enable me to make decisions my boss trusted me enough to make before he hired me. How wrong I was.
A couple of days after the first order arrived I got the beep on my pager, with an internal number to ring (no mobile phones then, either). It was from the hospital’s “User Group Co-ordinator,” a species of manager, and he asked if I might visit him in his office. This I did.
His office was huge, beautifully oak-lined, and looked out onto baronial lawns. He was the only one there, behind his presidential desk. I thought of the nurses I had spoken to in their “offices”: drafty cubbyholes with a kettle and a filing cabinet with photos of their kids taped to the front and a view of the car park. At our meeting, this managerial kingpin politely told me that I should not have changed the order for the BDP without consulting the user group. I pointed out that I had, de facto, consulted the user group, having visited every user in the hospital. No, he said. He meant the User Group. Okay, I said, can I do that now? No. The next meeting is next month.
You get the idea. The order change was allowed to stand because I was new and I think this guy realized the head nurses might run him and not me out of town if he changed it back. But the year that followed, although enjoyable, was a weary procession of these stupid little tussles intended to remind me that I was not management and these people were.
Virtue-signaling alert, but this was a job in which the results were exactly quantifiable, and I took its efficiency from 48% when I started to 97% when I left a year later, although a constant low-level arm-wrestle with technocratic clone-people made that more rather than less difficult to achieve.
Is this to say that there are no good managers in the NHS? That would be very unfair to my next boss, who I will call June. She had that singular skill of taking a small team of people and encouraging them to do individually what she had already worked out they were best at to the benefit of the team as a whole.
The health information team, huddled in one cold office in an abandoned hospital, comprised six or seven researchers and telephone staff providing information by telephone and mail, and we would swap roles. One day I would man the phones in the morning (I can say that because I was the only man on the team) and research in the afternoon; the next day it would be the other way around.
As soon as you sat down in the morning and the phones went live — it was a toll-free number — you had no idea what your next caller would be asking. It could be an elderly lady wanting to find her nearest dentist in Worthing, a pediatrician looking for a hypo-allergenic stethoscope, a minor government underling updating a government press release on chlamydia, or a schizophrenic from a psychiatric hospital who just wanted to chat. Actually, there were regulars on that front. I used to regularly talk to an inmate of one psychiatric hospital who wanted to talk — and knew an alarming amount about — Tamla Motown.
June was a brilliant manager, easily the best I have ever worked under, anywhere. I followed her on to what would be my last NHS job, as medical librarian throughout another freakishly hot summer in 1997. She was a good manager because she was hands-on, not sitting in a remote office looking at charts and projections. Management is engagement and not autocracy. NHS bosses should tattoo that on their arms.
No NHS story would be complete without the tale of how it once saved the life of the teller. In June of 1977 I was in a car-smash so bad it put me in a coma for two days and nights, and left me with half a spleen and half a bladder. A surgeon also remarked to my father while I was in intensive care that the accident had smashed my pelvis “like a dropped dinner plate.” I still don’t walk right even now. But I can walk, and the reason is that the same NHS surgeon made a decision based on his expertise.
The first suggested procedure was to replace some of my pelvis with polyurethane plastic, which would have meant I would forever walk hanging between two sticks and likely be in a wheelchair by the age of 30. But the surgeon in charge decided that as I was 16 my body would knit itself, and it did. They left it, and the broken dinner plate mended itself. I have had 45 years of still being able to walk because of the snap professional decision of a man I never met. An NHS man. I often think about that, and it is one of the many things that make me angry about what has happened to this great institution.
As you see, my last gainful employment with the NHS was a quarter of a century ago, and so these are notes on the life experience I gained from the organization then rather than any current factual study or snapshot. I remember so many moments, so many tiny school lessons, such as a conversation with a very pleasant Indian pharmacist at a health information group sandwiches-and-coffee morning. During our conversation, I had used the term “side effects” concerning prescription drugs. The pharmacist smiled at me in a kindly, owl-like way over his half-moon spectacles. There are, he said, no side effects to any drug. There are just effects. One of them is the one you want.
I once gave a talk to a group of doctors about the health information service. They were skeptical about untrained people like myself giving out medical information over the telephone. I felt like Luther in the dock in Rome, but I managed at least to ease their concerns.
Afterwards, there was a small drinks party where, in a quaint English way, we drank sherry. I spoke to a surprisingly tall, middle-aged, female Muslim General Practitioner, or GP. I asked her what type of people were the greatest waste of time in her profession. She said, unhesitatingly, Muslim women patients. They are malingerers and time-wasters, she said. Their husbands won’t talk to them except to insult or threaten them, and they can’t talk to each other because they can’t leave the house. So they come to surgery to talk to me. “Oh doctor, my arm hurts so . . .”
I am still interested in the NHS, but I find myself avoiding most news items as they are just depressing. A random sample at the time of writing: The new NHS diversity “tsar” (tsarina?) is on an annual salary of £230,000 (over $300,000), which is 50% more than Prime Minister Boris Johnson earns. This amount could have paid for nine fully qualified nurses.
The modern obsession with diversity also serves to add stress to an already demanding job, giving medical staff an extra reason to be frightened in case they misgender someone and lose their job. And if you think I am being glib, think again. Not long ago a GP had his 26-year career ended for refusing to call a six-foot bearded man who had decided he was a woman “madam.”
With the possible exception of the railways, I am not a supporter of central planning — aka in Britain “nationalization” — but the NHS really should be for the people, as it is paid for by the people to protect the people. It is the perfect hybrid of economics and community. It should not be the playground for a managerial class who generally, in my experience, have no real interest in the health of the vulnerable and sick except insofar as those things relate to the protection and promotion of their own careers.
Nor do I believe that laissez faire economics works for a universal healthcare provider. I am not an economist (I am not even sure if economists are), but successive governments have gradually remodeled the NHS along private sector lines in order to improve efficiency, which always means an attendant cadre of technocrats and managers rather than nurses and matrons. I think I detect an obvious flaw in the business model.
Private sector principles are fine when you are dealing with end-use consumers who are buying a car or a pair of hiking boots. They are making a choice they need not make. Up to them. Buy the boots, don’t buy the boots. Water will find its own level in the relevant economic market whatever. But people don’t choose to break their leg or get glaucoma. The end-user of the NHS is not really a consumer in the familiar sense, so how can you treat — and even construct — the economic infrastructure around them as though having epilepsy or prostate cancer is a lifestyle choice akin to which jeans you wear?
Also, for all the talk of free markets that was buzzing around 25 years ago when I last worked for the NHS, allocated funding is essentially always a state-controlled transaction, like it or not — as centrally planned as it gets, and the public sector capping system was always a disgrace. I remember being down in the delivery bays of a hospital at the end of the UK financial year one March. If the NHS Trust didn’t spend its allotted amount that year, that figure would be accordingly clipped back the next year, and so a lot of crap would turn up in the last week or two of the year: unnecessary chairs, horrible waiting-room art, unneeded rolls of carpet. The NHS requires around 20% of the British national public sector budget, and if you saw what some of that money was spent on, it would make you weep.
As for pressure on NHS resources, the British media are currently using the old magician’s distraction trick of waving one hand theatrically while the other one is holding the coin. The NHS is creaking under the strain of COVID, runs the narrative. Nonsense. Nurses had plenty of time to make Tik-Tok videos at the pandemic’s supposed height.
The media is still happy to blame the nominal Tories, as though Labour would somehow streamline the NHS and restore it to its former glory. Again, nonsense on stilts. The NHS is less and less able to give a service not just because of the misprioritization of funding, but also because the country is being if not flooded then at least irrigated with the sewage water of untrammeled immigration. Hundreds of undocumented people arrive every day on England’s Kent coast. The authorities can’t even track all of them once they get off the dinghies and ghost away into the local towns, so how are they going to test them for COVID? Or tuberculosis? Or syphilis or HIV or cholera? These invaders will end up using the NHS without having paid a single rupee for the privilege. And, boy, in my experience will they use it. The people they come into contact with will also have to use the NHS in greater numbers. Illegal immigration is one long super-spreader event.
It is sad to watch, even from afar, the gradual decline into senility of a once-proud dowager, and this mostly down to overmanagement. Where the opening line of the Hippocratic Oath is, famously, first do no harm, the first line of management’s mantra — the Hypocritic Oath, perhaps? — seems to be, first do no good, unless it is to your own wretched career.
My own memories of the NHS are fond and grateful. I have been fortunate enough to hold posts which taught me something useful and lasting in life, which you cannot say about all jobs. I believe I brought something to them. Also, I am still able to walk because of NHS expertise shown by a professional surgeon when I was 16. He wasn’t a diversity outreach coordinator or the user-group guy. He was doing a different type of job. He practiced medicine, whereas the modern NHS practices management.
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Two thoughts come to mind, one generic, one specific.
My old Irish grandma’s homegrown version of Murphy’s law, “All human things, given time, go badly.”
And as regards health care systems, the three desiderata are quality, access and affordability. Turns out you can only have two out of three.
Glad you got care before both laws had kicked in.
Your idea of 2 out of 3 deserves an essay in its own right. Tattoo the following on your arm. Irish grannies are always right. They are the unacknowledged legislators of the world.
Wow, talk about synchronicity! Only this week I learned the Solzhenitsyn quote about poets being the unacknowledged legislators of society. Very enjoyable and enlightening column, as usual.
I thought it was Shelley, but I am known for what the English call cock-ups.
I read that Solzhenitsyn said it to Shelley, so you were not too off the mark.
From the Spike Milligan allusion, I expected anarchic comedy… Well, the lead-paint boy was pretty good anyway.
The lead-paint boy. Form a band, Margot. Call it that.
Should anyone in the USA be beguiled by Dr Gullick’s portrait of the NHS can I put in a plug for our system down under?
There is a no-frills but reasonably safe and accessible public hospital system which is open to all citizens and permanent residents (and surprisingly many other recent arrivals ). It is riven with many of the problems of bureaucracy and inertia that seem to bedevil essentially socialist institutions but most of the doctors, nurses and other allied health workers are real professionals, in the sense of putting the patients’ welfare above their own. This system will give excellent care in extremis, such as when your pelvis is shattered or you have very complex medical problems. For less urgent problems you will get a variable level of care, ranging from excellent to occasionally unacceptably slow. There is a large private hospital sector which, for those with some means (private insurance for a family costs about 7% of median household income), will provide many of the services which the public system offers but with better access, better food, and more direct access to the consultant medical practitioners, rather than the registrars ( residents in the US ).
Out-patient care is entirely in private hands, and is co-ordinated largely by general practitioners who refer to specialists as they see fit. Most medical services are partially subsidised by the ‘National Health’ or ‘Medicare’ as it’s called here, but a specialist’s services are only subsidized if the patient has been referred by another doctor or sometimes a physiotherapist. Doctors charge according to inclination and market forces. In my experience fee-level is not a reliable indicator of a physician’s performance. Poorer patients, and many not so poor, can almost always get treatment which is entirely subsidized. Patients have unlimited access to any doctor they like. The modest payments provided by Medicare and the absence of any other third-party payer means that there is a somewhat competitive market for outpatient services, moderating fees but also providing nearly-instant access to specialist services and medical imaging.
This system, whilst imperfect, gives the well-enough-heeled great freedom of choice whilst providing a reasonable safety net for the poor. How it will cope if we import hordes of sub-Saharans, as we are currently being programmed to expect in print and video advertising, time will tell.
“If I had not, I intended to train as a psychiatric nurse, but I did get the grades, and went on to study philosophy. I’m sure there is some moral to that story, but it eludes me.”
The moral is that you think and write clearly. So does Greg Johnson, who has a PhD in philosophy. So does Stephen Paul Foster who I think has a PhD in philosophy and so do I with my MA in philosophy. I quit after the MA because of the lack of tenure track jobs but I sometimes regret it.
Philosophy. It gets us all in the end, my friend…
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