Tales of the red tape that stifles innovation and enthusiasm
‘People imagine the worst part of my job is blood, gore and rectal exams. It’s the boxticking that I loathe’
Ten years ago, NHS supermanagers with six-figure salaries, expense accounts and hefty pensions were a rare breed in the country’s hospital boardrooms and local commissioning groups.
Not any more. While nurses have seen their pay fall in real terms over the past decade, the ranks of these richly rewarded health bosses have swelled dramatically. In September 2010, there were 985 hospital directors and healthcare managers in England earning more than £110,000, according to NHS Digital, the health information centre that tracks the numbers of “very senior managers” for salary reviews. But by September 2020 there were 2,788, meaning the number has almost tripled in a decade.
The top tier of NHS bosses who get pay and pension benefits worth up to £450,000 a year is about to get even bigger. Earlier this month it was revealed that the NHS is hiring 42 new executives on salaries of up to £270,000 for new integrated caresystem boards for health and social care. Tory MPS said they were “appalled” by the decision.
Critics say the NHS – which faces a record waiting list in England of 5.6million patients – is already well stocked with highly paid managers. Much more important than hiring even more, they say, is to cut the stifling levels of bureaucracy that hamper doctors, nurses and other front-line staff who treat patients.
Doctors have made repeated complaints about bureaucracy: they criticised the constant demands to report data that may be unnecessary or duplicated elsewhere; the glacial pace of decision-making by regulators and hospital committees; and an outdated referrals system that leads to patients who do not require specialist services being bounced around the system ahead of others with greater need.
“The solution of managers to new problems is always to hire more managers,” says Joseph Meirion Thomas, a former cancer consultant at the Royal Marsden Hospital in London, who has investigated healthcare reforms over the past four decades.
He says: “They often have very little clinical knowledge and can be more worried about hitting targets than treating the patients in most need.”
He adds that a friend of his left the NHS after he found that patients on the operating list, which had been drawn up on clinical need, were being replaced with those on the waiting list to meet the hospital’s targets.
Bungled change
Since 1980, there have been more than 20 reorganisations of the NHS, one of the world’s biggest employers, with 1.2million staff and a £130billion budget (excluding Covid funding) in England.
The coalition government reforms under the Health and Social Care Act 2012 created a fragmented system – and were later admitted by senior Tories to be one of their worst mistakes. The number of managers, which had been falling, began to rise again. By 2015, Lord Rose, former head of M & S, said in a review of the NHS that it was “drowning in bureaucracy”.
One of the biggest demands on front-line staff is the constant requirement to record every aspect of care on excessively detailed forms, from how many times a seriously ill patient might be turned over during the night to their daily nutritional intake, which costs up to £2billion a year. The array of regulators – from the Care Quality Commission to the General Medical Council – also mean added reviews, appraisals and form filling.
Mervyn Singer, a critical care consultant at University College Hospital and professor of intensive care medicine at University College London, says: “The idea was that using computers would save time, but technology has created a new monster that takes the doctor and nurses away from the patient.
“An intensive-care nurse may spend more than 20 minutes an hour just filling in patient data. In the old days, you had paper notes, but you had far less form filling.” A Health Education England report in 2019 warned that up to 70 per cent of a junior doctor’s working time can be spent on administrative tasks.
Treating a patient admitted to A & E may require logging in to six separate systems to access clinical records and order diagnostic tests.
The bureaucracy also stalls new treatments. Prof Singer says the introduction of new procedures or devices can be held up for years because of regulatory hurdles and the need for approval by various hospital committees. It was a “breath of fresh air”, he adds, that this red tape was swept away during the pandemic. A new breathing device for Covid-19 patients, which he and his colleagues worked on in partnership with the Mercedes Formula 1 team, took just 100 hours from the initial concept meeting to approval for use on patients in March last year.
Prof Singer estimates that prepandemic it would have taken two years for the devices to be approved. Lord Frost, the Brexit minister, told peers last week there would be reform of “outdated EU legislation” around medical devices and clinical trials.
Prof Karol Sikora, a leading oncologist and medical director of Rutherford Cancer Centres, which provides cancer treatment and diagnostic imaging services to the NHS, said: “There are a lot of talented people who can really innovate, but NHS bureaucracy dampens innovation and dampens enthusiasm.”
Dr Owain Hughes is a former NHS ear, nose and throat surgeon who founded Cinapsis, a digital tool to streamline the referral system. During his 18 years in the NHS, he found GPS often operated “in silos”, referring patients to specialist services sometimes without need, creating longer waits for patients who required treatment.
He says: “The system is dangerously inefficient. Communications between GPS and consultants are often hugely time-consuming and expensive … it comes at an astronomical cost to the taxpayer”.
Practices face multiple targets under the Quality and Outcomes Framework, a pay-for-performance scheme under which GPS must provide information or meet more than 70 indicators, from maintaining a register of patients with heart disease to participating in “network peer review” meetings. “Whenever I talk to non-medical people about my job, they always imagine the worst part is blood, gore, suppurating wounds, dead bodies and rectal examinations,” Dr David Turner, a Hertfordshire GP, wrote earlier this year. “The reality is very different – it’s the red tape, bureaucracy and boxticking that I loathe.”
Where now?
Extra money promised by the Government will help the NHS, but requires spending well to really make a difference, experts say. Documents obtained last November revealed that about two-thirds of the private hospital capacity block-purchased by NHS England at an estimated £400million a month was left unused in the summer of 2020.
With the NHS straining at its seams, ministers will be keen to avoid claims they are squandering cash. One project already been given the green light is “accelerator sites” to help fast-track treatments with pop-up clinics.
Prof Stephen Smith, former Dean of Medicine at Imperial College, has called for a national review on how to fund the NHS in the 21st century, suggesting a Royal Commission or judge-led inquiry.
Prof Sir Chris Ham, former chief executive of the health think tank The King’s Fund and co-chairman of the NHS Assembly, which advises on NHS delivery, said: “People who are running services locally spend too much time feeding the beast of the NHS with information and it takes away time from things that are much more important.”
He said lessons should also be learnt from the pandemic, where decisions were made without waiting for instructions from central management.
Will those lessons be learnt? Prof Singer is not optimistic. “Since the pandemic has abated, we’ve reverted to type,” he said. “The committees are back, along with prevarication and the form filling.”
Prof Sikora thinks the Government should retrain its eye on a complete NHS overhaul. He says: “Throwing money at it without reform is not going to achieve anything.”