What’s wrong with the NHS? – Part 4

8th December 2023

Nothing can simply be ‘good enough’. Before beginning this blog, I thought I would introduce you to the first two laws of regulation ‘regulation-omics’:

I know that many of the things that are obliterating productivity in the NHS are happening in all health care services, everywhere. A couple of blogs back I mentioned a US study which looked at all the guidelines primary care practitioners (PCPs) are now required to follow. If they were to do all the work required, it would take them twenty-seven hours a day.

So, clearly, they don’t.

Which raises a few interesting questions that I shall just let hang there at present. For example, what are these PCPs doing? Making stuff up? Hoping no-one notices? As for those creating these endless guidelines. Does it bother them that the vast majority are being quietly ignored?

Or do they simply announce. ‘Hear ye, hear ye, hear ye. The mighty guidelines hast been written; our work is done. Now, make it so.’ Snapping of fingers, courtiers shuffle off, heads bowed, hidden and exasperated eyebrows raised.

Very recently a conference for GPs in England debated a motion. One that was easily passed. It was reported in Pulse magazine – a weekly magazine for GPs – as: ‘NICE ‘out of touch with reality of General Practice, say GP leaders.’ The motion was:

‘That conference applauds the aspiration for clinical excellence across the NHS but believes:

(i) that NICE guidance is often out of touch with the reality of working in general practice

(ii) in the current climate practitioners should be judged against ‘good enough’ rather than unrealistic ‘gold standards’

(iii) that the GMC and NHS Performance teams should not be judging practitioner performance against NICE guidelines

(iv) that GPC England should lobby for professional and clinical standards to be aligned to current workforce and workload capacity.’ ¹

As Voltaire once said. ‘The excellent is the enemy of the good.’

Good enough is no longer… good enough. In the NHS it is now demanded of everyone that all workers should constantly strive for excellence. Woe betide anyone who dares let their standards fall below perfect excellent-ness.

This is where all those one hundred and twenty-six organizations [one hundred and twenty-five, plus NICE] who are involved in regulating the NHS – cause so much pain. Whatever they look at, it requires constant improvement. You must now do this better, and this, and this, and most certainly this. No bed sore shall ever be missed. No patient shall ever fall over. Falls audits shall be completed relentlessly.

All patients shall be asked each and every hour if their every need is being met. At all times all staff shall be attentive, and smiling and helpful and, and, and….and? All guidelines will be met, at all times. All sinews shalt be strained in a constant drive for improvement. To quote Joseph Stalin at the First Conference of Stakhanovites in 1935:

‘These are new people, people of a special type … the Stakhanov movement is a movement of working men and women which sets itself the aim of surpassing the present technical standards, surpassing the existing designed capacities, surpassing the existing production plans and estimates. Surpassing them – because these standards have already become antiquated for our day, for our new people.’

There is nothing wrong in asking people to provide a good, and safe, standard of care. But there comes a breaking point in striving for ‘the excellent’. A point that has long since disappeared in the rear-view mirror.

I have not analysed the time it would take GPs in the UK to meet NICE guidelines, but I strongly suspect it would be far more than twenty-seven hours a day. Here, for example, plucked at random, is a reference to the latest NICE guidelines on the management of hypertension (high blood pressure) in adults. This, the short version document, runs to fifty-two pages.²

Have I read the entire document. No. Has anyone. Possibly. But this, the primary guideline on hypertension for adults, is but one of many. There are associated guidelines on hypertension in pregnancy. In addition, there are links to formal risk assessment in cardiovascular disease. With bonus hyperlinks to NICE’s guidelines on hypertension in chronic kidney disease and type I diabetes and type II diabetes and on and on.

In short, this fifty-two-page document is but the tip of a massive iceberg when it comes to high blood pressure, monitoring, measuring, and treating. Which, in turn, is one very small part of the totality of medical practice. No-one can read all this stuff. No-one can keep up. You sure as hell can’t remember it all. It is, truly, impossible.

So, what do GPs actually do when presented with such demands? Well, at present, many of them are considering RLE. Retire, leave, emigrate. “RLE” is now popular trope in GP discussion fora. This is because the sheer stress and overall unpleasantness of the job has become overwhelming.

There was a time when being a GP was an enjoyable job. No more. Those days are gone my friend. Twenty years ago, a partnership in General Practice attracted hundreds of applications. Today, many adverts result in no applications at all.

If you set people an endless barrage of targets and guidelines that can never be reached, it drains people of any, and all, enthusiasm. Every day at work becomes a day of failure. Rolling that great rock up a slope, only to see it roll straight back down again.

Yet, those who drive this catastrophic system just can’t stop themselves from cascading more and more guidelines, and targets, upon a workforce that long since gave up trying to meet them all.

Not only does this crush morale; it also obliterates productivity. So very many pointless tasks. So much time doing work that has only the most tenuous link to patient care, and benefit. I have focussed on GPs in this blog, but everything I have written is much the same, everywhere. Primary care, secondary care.

I think nurses have it worse than doctors. Indeed, from chatting to them, I know they do. Whilst doctors have still managed to cling onto some small scraps of clinical freedom. By which I mean the ability to manage and treat the patient in the way they think best. Nurses have no such freedoms. Their guidelines, and targets, are cast from hard, unbending iron. You do it, or else. And do not dare deviate.

Why can’t these organisations just, stop? Even better go into reverse. Can they not even attempt to define what is ‘good enough.’ No, we the mighty, have told you what constitutes perfect care for raised blood pressure. So, this is what you must do. Even if it takes about ten hours per patient, per year – for one condition.

How long does a GP get with each patient? On average, ten minutes, six times a year. That is, to deal with everything.

There are a number of interconnected reasons why regulations and targets and guidelines cannot, currently, be reversed, and I intend to look at a couple of the most important in the next blog.

1:https://www.pulsetoday.co.uk/news/workload/nice-out-of-touch-with-reality-of-general-practice-say-gp-leaders/

2: https://www.nice.org.uk/guidance/ng136/resources/hypertension-in-adults-diagnosis-and-management-pdf-66141722710213