NHS at 70: Five medical experts diagnose NHS problems - and prescribe cures

Henry Marsh - Neurosurgeon

What are the biggest changes you observed in your 40 years as a consultant?

The single biggest change has been the European working time directive and its shortened working week. It’s not all bad – it has meant less tiring hours and enabled more women to go into the surgical specialties – but it has also hugely diluted surgical training and fragmented continuity of care so that, their consultant aside, patients are now looked after by committees of junior doctors. Care has become dispersed.

There is also the loss of authority of senior doctors. When I became a consultant there was one pyramid, one hierarchy, and senior doctors sat at the top of it. Now there are all kinds of pyramids – doctors, nurses and management among others – and nobody is in overall charge. The result is chaos. Patients are better informed, which is a good thing, but that, too, has a flip side: greater patient autonomy has resulted in one per cent of the NHS budget – more than £1 billion a year – now going on legal expenses.

What are the most significant issues facing the NHS?

The simple fact is that an ageing population and advances in medical technology mean more expense for the NHS. For instance, if you make operations simpler and safer you end up operating on more people. There are no easy answers, and many of the suggested solutions, be it rationing healthcare, or eliminating some procedures, aren’t really solutions at all.

The reality is that we already have a degree of rationing in the form of waiting lists, which act to some extent as a filter. And while it’s reasonable to question whether procedures like cosmetic surgery should be funded, I don’t think it would make a big difference to the NHS budget if they weren’t. Similarly, while I am an advocate of assisted dying, I don’t think it would make any difference to costs were it to be introduced. Ultimately, most of us cling to life for as long as possible.

So where does the nub of the problem lie?

One of the factors making medicine more expensive is cancer. It’s essentially a disease of old age, and one that has become more treatable with developments such as immunotherapy. But the critical thing is that a lot of cancers don’t need treating – earlier this month immensely important research was reported that showed that a large number of women with breast cancer do not require chemotherapy. A similar study has been done on prostate cancer sufferers, which showed that 25 per cent of those diagnosed did not go on to progress beyond the early stages of the disease. At the moment we can’t ascertain who will and won’t progress – but my hope is that advances in molecular genetic studies will help us get better at selecting who needs treatment. That’s where we should be putting our money – and it might actually save money.

Is there cause for optimism?

Absolutely. I passionately believe that the principle behind the NHS is still the best one. We may have to accept, though, that this is a model that needs to be tweaked, whether it’s by supplementing with insurance or paying for some aspects of our medical care. I’m in favour of a Royal Commission being set up to discuss how this could be done, so the public have some say in what should happen.

Henry Marsh's book Admissions: A Life in Brain Surgery is now available in paperback

Professor Magdi Yacoub - Cardiothoracic Surgeon

Do you still believe in the NHS?

Absolutely. I have worked for it all my life and I would do the same again. I travel to some of the world’s poorest countries with my charity the Chain of Hope, which works to establish sustainable centres for cardiology, and it’s a continual reminder that what we have is the best healthcare delivery system in the world. Every patient who comes is welcomed and given the best without discrimination, and that is a wonderful thing. But we have to be continually critical and not just congratulate ourselves on what has happened in the past.

What do you think are the main problems we face today?

The very large number of administrators in the NHS and the urge to keep changing things has bedevilled the system. Its effects trickle right through the system: at the coalface workers wake up wanting to do something good and then find there are new regulations and new rules.

What needs to happen?

Doctors have only two masters: patients and science. To my way of thinking we need to spend more on integrating science instead of on new administrators and managers. Allowing for innovation is very important. We also have to encourage the public to work in partnership with the NHS, to be part of the whole system, because they own it. The idea that there is somehow a competition between prevention and hi-tech medicine is a fallacy – it’s a continuum. The drop in the rates of heart disease, for example, is due both to better prevention and better medicine.

You favour changing organ donor laws so that people have to opt out, rather than opt in. Can the NHS afford increasing numbers of transplants?

Organ donation is a gift: when you have seen someone dying in the middle of the night and then you meet them again 30 years later after they have received a transplant – you cannot put a price tag on that. What people forget is that the process of learning about and perfecting transplantation benefits so many other branches of medicine too.

Professor Farah Bhatti - Consultant Cardiac Surgeon

What has changed in the service since you qualified in 1990?

The medical advances have been phenomenal. When I qualified, cardiac surgery was just an emerging field, and now people talk about open-heart surgery as if it were commonplace – which in some ways it is. We’ve got technological advances in all areas of medicine and surgery is no exception. There’s also been a shift towards greater team-working. Today it’s not a hierarchy of doctors and nurses, but a wealth of paramedical and support staff working together.

So what are the challenges?

It’s common knowledge that we are dealing with an increasingly elderly population, with quite complex medical needs, with limited resources: we need an uplift of four percent in spending just to stand still. Everyone within the NHS from doctors to domestics is working incredibly hard to cover shortages, working extra shifts and filling in rota gaps. They do it out of goodwill, but it has implications for the health of the staff and patient outcomes. We also need to think about the best use of the resources we do have – we have patients in hospital who are medically well enough to go home but there is no one to care for them. We desperately need more joined-up health and social care.

Should we be looking at rationing resources?

I don’t think the words healthcare and rationing should be in the same sentence. The focus needs to be resourcing the NHS properly and then using what we have sensibly and logically. That starts with evidence-based medicine – everything I do as a cardiac surgeon I do with that and the patient in mind: ie, is surgery the right choice in terms of survival and quality of life?

Would you be in favour of compulsory insurance in addition to our tax-funded system?

I think if you go down the insurance route, the result will be that there are people in need of medical attention who would not seek it. I think where the money conversation should be happening is around how all our taxes are spent, and the proportion going into healthcare. Seventy years ago if you were unwell and you weren’t wealthy, you could die. The landscape has changed immeasurably since then but we can’t lose sight of all we have achieved and what we have created.

Dr Michael Mosley - Writer/broadcaster

What are the most pressing problems faced by the NHS?

The scale of staff shortages is unprecedented. The number of unfulfilled nursing posts is horrendous, and a huge number of qualified doctors are moving abroad. We’ve had crises before – when I qualified in the 80s it was also quite grim – but it’s as bad as it’s ever been.

Does it need more money?

It clearly does, but we are already spending, in real terms, four times more money than when I qualified. So the amount going into it has increased enormously – but so has demand. We’re living longer, getting fatter and people now have more chronic and complicated diseases.

What should we do?

If the primary problem is demand, then that needs to be tackled. The NHS as a system actually works very well – it’s lifestyles that are causing many of the problems. We are getting fatter, and rates of Type 2 diabetes have doubled, which leads to an increased risk of heart disease and kidney failure, and possibly dementia. The rise in obesity is also linked to an increased risk of cancer. All these problems are related. I think the Government needs to focus on getting people healthier earlier and for longer.

How do they do that?

The sugar tax is a good start, but we need to think more imaginatively, such as redesigning cities to encourage people to walk more.

Michael Mosley appears in Celebrities on the NHS frontline, Thursday 28th June at 9pm on BBC1 (BBC2 in Wales)

Professor Robert Winston - Fertility Expert

What angers you most about the current state of the NHS?

It has become a political football, with different parties clamouring to style themselves as the service’s saviour. This has led to a constant restructuring of the service, which is unhelpful. We should be collectively deciding the percentage of GDP we’re prepared to spend on it, which should be agreed by all the main parties.

What would be the first thing you would do to help secure the future of the NHS?

I would abolish the internal market, which has created a vast unwieldy bureaucracy, squandering taxes. I had personal experience recently when the research charity I represent wanted to recruit a junior research assistant, a role easily accomplished by the equivalent of a PhD student. I asked the business manager of the relevant NHS department what they would expect me to pay – they said over £60,000 a year. The charity wasn’t prepared to spend such a sum. Consequently a project benefiting NHS patients and making reproductive treatment much cheaper has been halted.

What needs to happen next?

Once we have agreed what we are prepared to spend, we need to have an honest, realistic public debate. Do we increase taxation, do we have a specific NHS tax, should we look at an insurance-based system? We must safeguard NHS care for the less well-off while asking more of people who can afford it. Most importantly, the NHS needs to do more to support academic medicine.

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