The NHS is broken: does it need a radical rethink?

With almost 50,000 people a year dying for want of effective treatment, Laura Donnelly, Rosa Silverman and Alex Clark look at ways to reinvent the health service – starting with The Telegraph’s new tracking app

I‘I don’t think I’d phone 999 if something happened to my children. I’d drive them to hospital myself’ Emma Bailey, whose brother died after an ambulance was delayed

t was just before 5am on Feb 20 when Jonathan awoke and told his partner he couldn’t breathe. As the 47-year-old gasped for breath, his partner dialled 999. She was told there would be a two-hour wait for an ambulance.

She again stressed the seriousness of the situation and the call handler asked her if she knew where the nearest defibrillator was. “Of course I don’t!”, came the reply.

“So they told her to Google it while her partner was dying in front of her,” recounts Jonathan’s sister, Emma Bailey, 46, who works for the police. They then asked that she take him to the hospital herself. Somehow she managed to get Jonathan downstairs and into the car, and drove him from their Derbyshire home to the Ripley Hospital.

As she drove, Jonathan lost consciousness. On pulling into the hospital, she found its urgent treatment centre closed, his weight slumped onto her shoulder. In desperation, she banged on the windows, and phoned 999 again, at which point she was advised on how to perform cardiopulmonary resuscitation. An unrelated ambulance then pulled up but by the time the paramedics reached Jonathan, he had died.

“They gave him no chance at all,” says Emma, of the ambulance service’s failure to reach her brother at home. “I don’t think I’d even phone 999 if something happened to my children now, I’d drive them to hospital myself.”

Emma is not alone in losing faith in the ability of the NHS to respond to the most pressing of emergencies. Earlier this month, the fertility expert and Labour peer Lord Winston accused a 999 call handler of wasting time as his wife lay dying in his arms.

And theirs are not isolated cases. Far from it. Across the country, the average time it takes for an ambulance to arrive for Category 1 emergencies such as heart attacks is nine minutes and six seconds, against a target of seven minutes. The average in the East Midlands where Jonathan died, is nine minutes and 46 seconds. And this for conditions where every extra minute without treatment greatly increases the chances of death or life-changing damage.

Not that the situation is much better at hospitals themselves. The latest figures for June show more than 22,000 people a month spending at least 12 hours on trolleys in Accident & Emergency. A year ago, the figure was 1,289. Before the pandemic, it was 462 for the same month.

For operations, too, waiting lists continue to grow. A record 6.6 million people now languish on the official NHS waiting list for England, including those facing waits of more than two years. Surgeons say they are doing their best but are struggling to tread water. Waiting times are one thing, medical outcomes another – and it is on this measure that the crisis in the NHS is perhaps most frightening.

As The Daily Telegraph reports today, almost 50,000 people a year are now dying in the UK for want of effective medical intervention. The NHS is bottom of the international league for five-year survival for colon cancer, second-worst for lung and stomach cancer, and towards the bottom of the charts for breast cancer. The research, by Civitas, tracked 19 wealthy countries across 16 key healthcare measures, and found that only the US fared worse, despite record UK spending on health.

Not surprisingly, perhaps, thousands of those who can afford it are now abandoning the NHS and booking themselves in for private treatment, here and overseas. The BBC reported yesterday that there were 69,000 self-funded treatments in the UK in the final three months of 2021 – a 39 per cent rise on the same period before the pandemic. The total numbers paying for care topped 250,000 last year.

Announcing record boosts to NHS funding, ministers have repeatedly pledged action to bust “Covid backlogs”, which they blame for the NHS’S problems. Stephen Barclay, the fifth Conservative Health Secretary since 2010, evoked the legend of the NHS when taking up the post two weeks ago.

“Our NHS and social care staff have shown us time and again – throughout the pandemic and beyond – what it means to work with compassion and dedication to transform lives. This Government is investing more than ever before in our NHS and care services to beat the Covid backlogs, recruit 50,000 more nurses, reform social care and ensure patients across the country can access the care they need.”

But seasoned observers note that the deterioration in NHS performance long predates the pandemic. Indeed, it is now a full seven years since NHS targets to start treatment within two months for referrals classed as urgent have been met. And this despite record spending.

So how did the NHS – for so long the pride of Britain – end up in such a perilous state? Just how precarious is it? And might it finally be time for a fundamental rethink of how Britain’s health system is run and funded?

When David Cameron’s coalition came into power in 2010, the NHS was ticking along nicely – at least by some headline measures. Public satisfaction with the service was peaking at 70 per cent, while key waiting targets, including those for cancer and A&E, were being met.

It followed a period of sustained investment, backed by a plethora of centralised targets which had been introduced some years earlier under then prime minister Tony Blair. An “internal market” had ushered in a degree of productivity gain and much needed innovation.

However, unlike many health systems in Europe, the NHS was being run “lean”. Spare capacity – in the form of beds per head of population – was seen as wasteful. Efficiency was the watchword among health economists and a “just in time” system seen as the ideal. In total, around 20,000 acute and general hospital beds were lost during Labour’s time in office, despite promises by Blair to expand bed numbers.

After the financial crash of 2008 and during the decade of austerity that would follow, bed numbers and staffing rations were hacked back further by the coalition government – some would say cut back to the bone.

By 2019, Britain was already languishing at the bottom of international cancer league tables, with the lowest survival for five of seven common cancers, in rankings by the World Health Organisation. For some cancers, survival rates were worse than those of other countries a full two decades earlier.

“There appear to be three main factors contributing to lower cancer survival in England – getting a diagnosis at a later stage, sub-optimal treatment, and inferior care for older patients,” John Butler, clinical lead to the International Cancer Benchmarking study, told a parliamentary select committee last September. “In broad terms, England’s cancer survival is 10 to 15 years behind leading nations”.

And all the while the English population was getting older, fatter and more sedentary – that is to say, ever more dependent on an increasingly precarious health system.

When the pandemic hit Britain in the spring of 2020, it collided with a health service that was already struggling to keep its head above water. Not only were beds thin on the ground and ventilated wards of the type common in Singapore unheard of, but many of the basics such as ventilators, surgical masks and even plastic aprons were in short supply. Moreover, it quickly transpired that the Department of Health and its public health arm, then Public Health England, had never planned to stop or even slow a fast-moving pandemic.

The Prime Minister was given terrifying projections about how the NHS could collapse unless extreme counter-measures were taken. It was too late to close our borders as countries like Taiwan, South Korea and New Zealand had done and continue life (and business) with a degree of normality. Boris Johnson found he had no option other than to order a nationwide lockdown. Britain was ordered to stay at home, and told that by doing so they were doing their bit to “Protect the NHS”.

“From this evening I must give the British people a very simple instruction –you must stay at home,” Johnson told the nation on the evening of 23 March 2020. “If you don’t follow the rules, the police will have the powers to enforce them … Each and every one of us is now obliged to join together. To halt the spread of this disease. To protect our NHS.”

Today the Telegraph launches its NHS Data Tracker – the first data dashboard to comprehensively track the performance of the NHS in England for consumers. It reveals in startling detail the terrible toll the pandemic has had on an already fragile health service.

It shows that the NHS in England is failing to meet every single one of its key duties of care to patients, with not a single official target being met. Too many patients are waiting too long for treatment; not enough A&E patents are being seen on time; ambulances are not responding fast enough; diagnostic tests as well as treatments are being delayed; and GPS are seeing just 55 per cent of patients face-to-face. Worst of all, things are headed in the wrong direction, with four out of six of our key metrics getting worse, not better.

The best and worst areas of the country – a veritable postcode lottery – are also revealed. The worst acute trust in England for overall performance is University Hospitals Birmingham NHS Foundation Trust. It has the worst waiting list for planned treatment in the country (184,956 people waiting for treatment, with 30,000 patients waiting more than a year).

The worst region in England for overall performance is the East of England, where trusts are furthest from their key targets. On average, trusts in the region have the most backlogged waiting lists (40 per cent waiting more than 18 weeks), the most swamped A&E departments (only 66.5 per cent seen within four hours) and the longest waits for diagnostic tests.

Two trusts in the region are performing particularly badly: The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, which has the worst waiting times in the country for getting a diagnostic test, and North West Anglia NHS Foundation Trust, which has the third poorest performing A&E department in the country.

East of England is not the worst region for cancer waits, however. That title goes to the Midlands, where on average only 90.8 per cent of cancer patients start treatment within a month, versus a target of 96 per cent. Put another way, only one in 10 trusts in the region are meeting the cancer treatment target in the Midlands, versus an average of four in 10 across the rest of the country.

The dashboard also reveals the areas of the country experiencing the highest hospital mortality rates. It reveals that eight trusts in England are now seeing higher-than-expected deaths. In total these problematic trusts saw 2,590 deaths in excess of what would be expected based on the rest of the country in the year ending February 2022. One trust – Norfolk and Norwich – has had higher-thanexpected deaths for two years.

The worry for medics is that this is happening in the summer, a time of year when the NHS normally gets a chance to draw breath and catch up. “This is the height of summer and yet we are seeing a state of affairs that we’d be dismayed by even in the depths of winter,” says Dr Katherine Henderson, president of the Royal College of Emergency Medicine.

“We understand very much how difficult it is for patients who are waiting for surgery,” added Tim Mitchell, vice-president of the Royal College of Surgeons, on Radio 4’s Today programme yesterday. “We’re very concerned to hear that people are using up their savings, or getting into debt, in order to fund their surgery privately. This really makes the priority to get the NHS back to providing timely surgery as soon as possible.”

So where next for the NHS? Business as usual, radical reform within the existing free-at-the-point-of-delivery envelope, or time to start afresh?

Sir David Prior, a former health minister, who was chairman of NHS England until March, says fundamental and sweeping changes are required. “We have to completely change the system from a late-stage sickness system to one that is about [preventative] health,” says Sir David.

“It was the original intention back in 1948; it was called the health service, not the sickness service, for good reason. Fiddling around with structure and organisational change, trying to squeeze out additional productivity – none of this is going to get us ahead of the curve.

“We have to completely relook at the way we spend resources, which means a progressive shift from secondary care to primary prevention and investment in public health.”

Persuading Britain to overhaul unhealthy lifestyles is perhaps the biggest challenge facing any

‘We’re concerned to hear people are using up their savings or getting into debt to fund private surgery’ Tim Mitchell, vice-president Royal College of Surgeons

Government, and ministers are wary of being accused of “nanny state” tactics.

And so the tide of chronic diseases keeps swelling.

Alan Milburn, who as Labour Health Secretary under Blair was the architect of foundation trusts, also wants a “fundamental shift” in the way services are delivered, with far more use of technology and data analytics to prevent the NHS being overwhelmed by a “tide” of chronic diseases.

“The NHS is in a worse state than I’ve ever seen in my adult life”, says Milburn, now a senior advisor to PWC, describing the challenges facing the NHS as “enormous and unprecedented”.

He adds: “One more heave – simply doing more of what we’ve been doing – will not do the trick. Waiting lists had already been rising for a decade, so one more push will not make the NHS sustainable.”

Earlier this month, then Health Secretary Sajid Javid catapulted the Government into chaos, with his sudden resignation, minutes before that of Rishi Sunak. In his last speech in post, he positioned himself as a “warrior for patients” who was prepared to tell “the unvarnished truth” about the failings of the NHS. Sources close to him say he was keen to see a “radical shake-up” of the service. In particular, there was interest in deploying the type of reforms seen in schools, introducing Academies or Reform Trusts, with the best organisations given extra rewards and freedoms, in return for improving the standards of laggards.

His replacement, Barclay, a former chief secretary to the Treasury, is said to have a keen eye for detail – and an impatience with public sector bloat and bureaucracy.

The Health Service Journal, the trade magazine for NHS managers, described his appointment as Health Secretary as the “worst nightmare” its readers could imagine.

On Barclay’s first day in post, the head of NHS England ordered a cull of 40 per cent of central jobs – stripping out 8,000 roles, as three organisations merged. Health chiefs say the move will save £1billion over five years.

Meanwhile, the NHS front line is terribly short-staffed, with pay one of the biggest headaches facing the new Health Secretary. The British Medical Association is threatening strikes, amid a campaign for a 30 per cent pay hike for doctors. They say the pay of GPS, with average earnings of £100,0000, and consultants, on £120,000, has failed to keep up with inflation, with union leaders last week urging medics to “channel our inner Mick Lynch”.

It is a workforce that is demoralised and increasingly burned out. There are now more than 100,000 vacancies across the NHS, and a global shortage of medical workers.

Tim Knox, author of the report on comparative outcomes by Civitas, says the argument that Britain’s poor health outcomes are caused by lack of investment is “now at the point of death”. The study shows UK spending costing around £10,000 per household, with the third highest share of GDP in Europe by 2020.

“It is time we look elsewhere,” says Knox, suggesting that countries such as the Netherlands – which insist on compulsory health insurance – offer particular promise. “It means people can shop around and get the best deal, you can top it up and those who cannot afford to do that are covered by a very good safety net.”

Robert Ede, head of health at think-tank Policy Exchange, says that if Britain was starting from scratch, the NHS isn’t the system he would opt for. He also highlights the Netherlands, as well as Germany and Switzerland, as examples of countries which often have better outcomes than the UK, and successfully use blended systems.

But Ede suggests that the massive disruption of abolishing a state-run system and replacing it is time and money that Britain cannot afford.

“The big question is whether the pain of transitioning to this type of model over a decade or more would ultimately be worth it. In some ways it is reminiscent of the debates around Brexit: is the juice worth the squeeze?”

Ede suggests the NHS could do far more to maximise its advantages, such as using its “bulk-buying powers” to bring down the cost of purchasing equipment such as MRI and CT scanners. Other ideas under consideration include tax breaks for those who choose private healthcare, lifting pressures on the health service. But some question if this would make much material difference, suggesting that much of this would subsidise those already prepared to pay.

Jeremy Hunt, Britain’s longestserving health secretary, says the NHS is facing the “toughest” days it has seen in its 74-year history. But he believes reform of the funding system is the wrong answer.

“I think we’d end up going down a politically toxic rabbit hole. And five years later nothing would have changed. It’s a massive distraction that eclipses everything else and you end up not doing the reforms that would actually tackle the problems.”