The NHS at 70

This week marked 70 years since the founding of the National Health Service, which provides healthcare largely free at point of use for the majority of people across the UK.¹ It is in all our interests to have a functioning public health service which is free at the point of use. Even if you are a multi-millionaire and grumble about subsidising other people, you benefit enormously from initiatives such as the large-scale NHS vaccination programme, which protects not only those vaccinated but also anyone coming into contact with them.²

I have used public and private health services and my experience is that there is no difference in the standard of care. However, there is a huge variance in the availability of care, with waiting lists for private consultations being measured in days rather than weeks. It’s difficult to make a fair comparison on this basis though, as I don’t know how much I pay for my treatment on the NHS. I know how much tax I pay, and roughly how much of that goes towards the NHS, but it’s not possible to calculate how much I’m paying for my GP appointment. As a rough guide though, the NHS warns me in every letter that a missed appointment costs them £160, which is not dissimilar to the cost of a private appointment (the amount varies depending on whether you see a GP or consultant, how long the appointment lasts etc.)

There are, however, some major areas of reform needed, which I think are worth visiting on the anniversary of the NHS.

Information Technology

As I’ve said many times elsewhere, the state of IT in the NHS is appalling. Here are just a few examples I’ve experienced:

• Full care records are held by your GP practice, which means if you want to change GPs it can take a couple of weeks to transfer everything over.
• Hospitals in different NHS trusts can’t talk electronically to each other, so if you visit a hospital in a different trust to your GP, they might not be able to see your care records, including blood tests and x-rays.
• Systems fail regularly – one instance meant that a nurse couldn’t find out which blood tests I was booked in for, so he had to take every possible sample just in case.
• Every time a healthcare professional finds out that I work in IT, their first comment is ‘oh, perhaps you could come in and fix our systems, they’re awful’.

Or how about the current process for requesting a repeat prescription at my local pharmacy:

1. I tick the relevant boxes on my green prescription slip.
2. I walk up to the pharmacy and hand them my slip.
3. The pharmacy drives to my GP practice to drop off the slip.
4. The GP practice transfers the repeat request onto their system.
5. The GP approves the request.
6. Two days later, the pharmacy drives to my GP practice and picks up the slip.
7. The pharmacy prepares my prescription.
8. I go to the pharmacy a couple of days later and hope that my prescription is ready.

This process has multiple places where data needs to be physically moved on paper and re-keyed, which allows for errors to creep in. Furthermore, it introduces a polling process, whereby I have to keep checking to see if my prescription is ready, resulting in wasted trips to the pharmacy.

If technology was used properly, the process could be compressed into the following steps:

1. I order my repeat online and select which pharmacy I want to collect it from. Since this is done online rather than paper, it’s possible for the request to get onto my GP’s system automatically.
2. My GP clicks a button to approve the request.
3. My pharmacy receives the repeat details electronically and prepares my prescription. If they don’t have it in stock, it can be ordered automatically and should arrive the next day.
4. My pharmacy texts me directly to tell me the prescription has arrived. Alternatively, to keep my personal data in one place for privacy and updating purposes, they could send an electronic message to my GP practice and have them send the notification.

I think this could halve the time taken to process a repeat in many cases, as well as reducing paper, data re-keying (and the associated errors) and trips to the pharmacy. A similar system could be used for one-off prescriptions, where the prescriber can send the information directly to a pharmacy so that it is ready by the time you get there.

A similar issue exists for blood tests. These are tracked by barcodes from the point where the blood is taken to the uploading of records to my GP, yet I still have to call up a few days later to get the results. Why can’t I get a text message telling me the results, or at least a notification that the results are available? This would have to be opt-in to protect the privacy of people where others have access to their phones (e.g. abusive partners), but it would save me and my GP practice a huge amount of time.

The frustrating thing about all the above issues is that the technology exists to fix them, and has done for some time. There doesn’t seem to be any ‘guiding mind’ for NHS IT who has both the budget and powers to force through changes. An organisation with turnover of over £100bn ought to be able to spend a bit of money sorting this out.

Decentralisation of Service Provision

At present, the majority of service provision on the NHS is centralised. I can get some services at my GP, but all of these require appointments and for other items I have to visit a hospital, which is expensive (for me and the NHS), time-consuming and stressful. Ideally, services should be pushed out to the furthest possible point of the healthcare network.

For example, in the UK we have a huge network of pharmacies, most of which are open longer hours than GP surgeries and they will often have spare capacity during the day. For example, I can go to my pharmacy with a minor ailment and treat it as a walk-in service with a waiting time of less than 15 minutes – in most cases I can see a pharmacist immediately. Many people also live closer to a pharmacy than their GP practice.

It would be hugely beneficial if we could push more services out into pharmacies, which are already run by professionals who have gone through rigorous academic and professional training. One possibility would be for blood tests, particularly those which can be taken via pricking a digit instead of drawing blood from a vein, to be made available at pharmacists, cutting down the current 1-2 week waiting list which exists at our practice (I can get a postal kit from a private provider ordered and turned round in less time than that).

Another example are electrocardiography examinations, or ECGs. If I have this at my local GP practice, they have to send the results to a third party provider for processing, which can take a couple of days (immediate results are possible, but the provider charges more). The process for transferring the data is to hold a telephone over the ECG device whilst the readings are played back (no, this is not an exaggeration or joke). However, the technology exists to record, print and analyse ECG readings immediately. Private GPs do this, so why can’t the NHS?

Many decentralisation services require that IT is sorted out beforehand, but once that is done we could cut the waiting times for patients, which is a huge benefit to them both in terms of quicker diagnoses – and therefore more positive outcomes – and reduced stress. Decentralisation also reduces the risk of a major incident (fire, flooding etc.) taking out all healthcare services for an entire area, meaning the system is more robust.

There are of course some services where it makes sense to centralise, usually because they are either highly specialised or use substantial capital equipment such as MRI machines, and it wouldn’t be cost-effective or practical to have them in GP surgeries or pharmacies. The vast majority of front-line diagnostic tests though are relatively cheap, simple to administer, and can give a quick indication of whether a patient needs to have their case escalated quickly.

Drug Research

The NHS has one of the most valuable medical data sources in the world, with histories of millions of people with all sorts of problems. There’s also a huge amount of medical expertise across the network, at every level of specialism. However, this world-class pool of resources isn’t being effectively tapped to bring the maximum benefit to patients.

I think it is time that the NHS started to invest significant resources into drug research, using the data available to identify areas where existing drugs are ineffective and patients who might be suitable for clinical trials. I think this already happens to an extent where anonymised data is shared with researchers and pharmaceutical companies, but I would like this process to be moved in-house.

If the NHS were to research new drugs, there would be three ways of managing any discoveries.

1. Patent the drugs and license them for sale in other countries. This would raise revenue for the NHS to spend on further research or invest in care services. There would be no licence fee for drugs produced and sold in the UK.
2. Enter into a license-swap agreement, whereby pharmaceutical companies get the right to produce drugs developed by the NHS in exchange for cutting their prices on other drugs. This would save the NHS money on prescriptions.
3. Make the drugs patent-free worldwide and allow market competition to push down the price.

My preferred option is number 3, as I am generally opposed to patents and I think any research funded by general taxation should be made freely available to stimulate further research and push forward the frontiers of scientific knowledge.

I wouldn’t expect the NHS to take drugs beyond clinical trials – the actual manufacture can be outsourced to the many companies who already produce generic versions of drugs, the wholesale cost of which can be as little as a few pence per dose.

The resourcing for this would have to initially come from a higher NHS budget, probably several billion pounds a year. However, if the NHS can develop a small number of effective drugs, the resourcing could eventually begin to pay for itself through licence fees or reduced prices.

Conclusions

Notwithstanding waiting times, bureaucracy and dreadful systems, the NHS is a world-class healthcare system from which everyone in the UK benefits at some point in their lives. It’s not perfect, and there are some major projects which could make substantial improvements to the cost and efficiency of care delivery, but I wouldn’t want to live in a country without an equivalent system.

1. Some NHS services, such as prescriptions and dentistry, are subject to fees, albeit heavily subsidised. Immigrants are also not always able to access routine NHS services immediately. Accident and Emergency services are free at point of use to all patients, regardless of residence.
2. Herd immunity is the indirect protection given to people without immunity to an infectious disease once a sufficiently large percentage of the population has immunity. The ultimate effect in some cases is to eradicate a disease.