When the Covid-19 pandemic first hit and the UK went into lockdown, hospitals were overwhelmed with patients sick with the virus, and death rates were, and continue to be, high. Yet the response was admirable when faced with not only the burden of care for something so unforeseen, but the emotional toll on staff of spikes in death and disability.
In tandem with this, primary care successfully transitioned to predominantly virtual consultations,1 and has gradually been returning to normal service, whilst being largely responsible for carrying out most of the very successful Covid-19 vaccination campaign. Both primary and secondary care deservedly drew plaudits for what they did well during the earlier phases of the pandemic.
However, the huge backlog for elective secondary care treatment, currently over 6 million2 and predicted to rise to 12 million by 20253, has badly undermined public confidence in the NHS overall, and has damaged the relationship between primary and secondary care, without occupying the media headlines or debate on solutions it deserves. The NHS currently functions as predominantly an emergency service, and the elective element of secondary care seems permanently broken.
In this Viewpoint, I will argue that these problems have their origins in inadequate planning well before the pandemic, encompassing both well known problems such as poor staffing levels relative to comparable developed countries,4 but also less appreciated issues such as endemic dysfunctional management structures, and reluctance by the political class to countenance meaningful changes to funding structures.
Is the NHS overwhelmed?
In a recent editorial in the BMJ ‘Is the NHS overwhelmed’5 the author Hugh Alderwick deliberately avoids answering the question on the basis that ‘overwhelmed’ lacks a hard definition, unlike, for example, recession. But just two examples of the evidence he presents, staff absences up by around 40%,6 and with more than two million waiting longer than 18 weeks for elective care by October 20217, hint at the real answer.
Research by The Health Foundation indicated that 58,000 hip replacements that would normally have been done during 2020 were postponed.8 The same year saw a 24% reduction in the rate of diagnosis of both type 1 and type 2 diabetes,8 yet another example of unmet need.
Sadly, these backlogs, and a rapidly evolving blame culture, have significantly damaged the relationship between primary and secondary care. The infamous letter from Nicky Kanani and Ed Waller,9 urging GPs to see more patients face-to-face, would not have offended GPs like me, who had reopened for business as usual once it was possible, had secondary care been equally censured for poor patient throughput. The number of rejected referrals from primary to secondary care rose from 238,859 in February 2020 to 401,115 in November 2021.10
If the cold statistics are of concern, the coalface reality is even more distressing. Patients whose referrals are rejected repeatedly attend or message their primary care teams, in distress with significant symptoms, asking us to expedite their care.
What is more startling is that emergency care, obstetrics and cancer care have carried on without too much disruption, reinforcing the emerging evidence that the NHS is becoming a purely emergency service. Yet even separating emergency and routine care clouds the reality of how intertwined they are, in the same way that primary and secondary care are.
Today’s delayed transurethral resection of the prostate (TURP) will be tomorrow’s acute retention, and today’s depressed adolescent who cannot access mental health services in a timely manner will be tomorrow’s unfulfilled, underachieving young adult. My personal experience is that some specialties are struggling much more than others. In my area, mental health, particularly the child and adolescent service, has virtually collapsed, whilst the musculoskeletal service seems largely sustained by GPs with a special interest, and junior physiotherapists, but with little meaningful clinical activity such as joint replacements or nerve root injections taking place. The net effect will be a rapid worsening of public health and economic productivity, at a time the latter is independently also struggling.
Need visible leadership from the top
One of the common themes in particularly under-performing units I note is paucity of consultant input. I understand many consultants have been deployed elsewhere, including treating Covid and non-Covid emergencies. I also acknowledge that many are working past midnight to clear backlogs. Yet without visible leadership from the top, it is unlikely that the experience of patients waiting for elective care will improve.
Notwithstanding the fact that the UK has been hit brutally hard by Covid-19, given that this is an endemic, mutating virus, I believe we must learn to live with it and can no longer exercise nth degree caution to the detriment of all other healthcare.
Leadership sometimes needs a gambler’s throw, and I believe that one of the problems in both primary and secondary care is that rather than working together, the disconnect between clinicians and managers is worsening. In turn, I believe that much of the blame for this is that rather than having GPs, consultants and other clinicians involved in management to a reasonable degree without it heavily impacting on their core clinical commitment, we have seen the rise of the full-time doctor manager and nurse manager, many of whom, almost overnight, seem to forget the realities of that coalface their former colleagues still inhabit.
In his article ‘A lament for the Three Wise Men (or Women),11 the surgeon Peter McDonald describes a harrowing case of how an unsympathetic medical director reacted to a groundless patient complaint by suspending a consultant, stripping him off his merit award, with the latter soon dying of cancer, having wrongly attributed his own pain and weight loss down to the stress of suspension.
CCG Boards are similarly dominated by GPs who have left the clinical frontline, whilst the middle tiers of the hierarchy are dominated by nurse managers who have similarly left the coalface for easier, less accountable yet more lucrative roles within this multi-layered bureaucracy.
In the presence of a massive recruitment and retention problem with nursing, such a perverse incentive must rank as one of the ineptest parts of healthcare planning. Beyond being culpable for sucking away much-needed clinicians, the bureaucracy of CCGs is counterproductive, with overlapping roles failing to resolve complaints or implement useful change, as almost anything can be passed off as someone else’s problem.
Government interference in the NHS
Whilst it is always pleasing to receive praise, and the clapping in the early phase of the pandemic was a boost to morale, it is also possible that the tendency of eulogise the NHS may impede public participation in debate about its shortcomings, and how it may be improved.12
A CQC survey of patient experience in 144 trusts, reported in 2019 just before the pandemic but encompassing data from 2018, showed that whilst overall satisfaction was reasonable, it had been declining.13 The public may reasonably ask why – irrespective of one’s personal views on the matter – pubs, restaurants, sports stadiums and even nightclubs can operate as usual, but healthcare seems paralysed. No less a problem is the tendency of governments to needlessly interfere in areas likely to either be of no help, or positively destructive.
Jeremy Hunt is a highly intelligent and erudite man, yet as Health Secretary, in the face of poor staffing levels, he pursued the project of the 7-day working week, alienating junior doctors to the point of striking.14 The current incumbent Sajid Javid, an equally engaging man, needlessly wishes to make general practice a salaried service run by NHS trusts,15 oblivious to the similar fury he is likely to provoke, especially now that the GP cadre has plenty of evidence of failures of NHS trusts.
This seems a political sleight of hand to deflect attention from meaningful debates, perhaps resigned to the intractable nature of the crisis with elective care. Those debates should really encompass discussion on future funding and whether, by way of an example, means-tested health insurance that could cover a much higher proportion of the population than current exorbitant, elitist private health insurance does, might be a pragmatic way forward.
This cannot be divorced from the wider issue of national political leadership, which has, I believe, been depressingly poor for the last decade-and-a-half. But this pantomime, and its villains, are no laughing matter. Domestically, it detracts from attending to obvious national problems such as falling living standards, inflation, worsening inequalities and, of course, the NHS.
Internationally, a well-run UK has always been a force for moderation and decency. Yet the recent invasion of Ukraine will surely be the final nail in the coffin of the peace, prosperity and improving health most of the world has enjoyed since 1945.
Edin Lakasing, GP, trainer and tutor, Chorleywood Health Centre, 15 Lower Road, Chorleywood, Hertfordshire WD3 5EA
Competing interests: none.
- Joy M, McGagh D, Jones N, et al. Reorganisation of primary care for older adults during COVID-19: a cross-sectional database study in the UK. Br J Gen Pract 2020; Jul 30; 70(697): e540-e547.
- NHS England. Statistical work areas. https://www.england.nhs.uk/statistics/statistical-work-areas. (accessed 24 Feb 2022).
- National Audit Office. NHS backlogs and waiting times in England. 1 December 2021. https://www.nao.org.uk/press-release/nhs-backlogs-and-waiting-times-in-england/ (accessed 24 Feb 2022).
- Health at a glance: Europe 2020. https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2020_82129230-en (accessed 24 Feb 2022).
- Alderwick H. Is the NHS overwhelmed? BMJ 2022; 376:
- NHS England. Urgent and emergency care daily situation reports 2021-22. Staff absences 29 November 2021 to 2 January 2022. https://www.england.nhs.uk/statistics/statistical-work-areas/uec-sitrep/urgent-and-emergency-care-daily-situation-reports-2021-22/ (accessed 24 Feb 2022).
- Nuffield Trust. NHS performance summary: October-November 2021. https://www.nuffieldtrust.org.uk/news-item/nhs-performance-summary-october-november-2021 (accessed 24 Feb 2022).
- Krelle H, Barclay C, Tallack C. Waiting for care: nnderstanding the pandemic’s effects on people’s health and quality of life. The health Foundation 2021, 26 Aug. https://www.health.org.uk/publications/long-reads/waiting-for-care (accessed 24 Feb 2022).
- Kanani N, Waller E. Updated Standard Operating Procedures (SOP) to support restoration of General Practice Services. NHS England. 13 May 2021. https://www.england.nhs.uk/publication/updated-standard-operating-procedure-sop-to-support-restoration-of-general-practice-services/ (accessed 24 Feb 2022).
- Jameel F. The primary care backlog is a ticking time bomb. BMJ 2022; 376:
- McDonald P. A lament for the Three Wise Men (or Women). The Bulletin of the Royal College of Surgeons of England 2019; 101(4): 138-139.
- Jeffreys H. Let’s be honest, the NHS is awful. UnHerd 2020, 1 Sept. https://unherd.com/2020/09/lets-be-honest-the-nhs-is-awful/ (accessed 24 Feb 2022).
- Care Quality Commission. 2018 Adult Inpatient Survey. Statistical release. CQC 2019. https://www.cqc.org.uk/sites/default/files/20190620_ip18_statisticalrelease.pdf (accessed 24 Feb 2022).
- Lakasing E. In support of our striking junior colleagues. Pulse, 17 May 2016. https://www.pulsetoday.co.uk/views/contract/in-support-of-our-striking-junior-colleagues/ (accessed 24 Feb 2022).
- Salisbury H. Sajid Javid’s plan for a salaried GP service. BMJ 2022; 376: