Richard Smith: Five things about the NHS that are not sustainable

Richard Smith“There are five things about the NHS that are not sustainable,” said Phil Morley, chief executive of Hull and East Yorkshire Trust, in the middle of a conference last week on sustainability and health. He spoke like Cicero, only with more humour and a strong Northern accent. The conference was about environmental sustainability, but Morley painted on a broader canvas. Although they might simultaneously be horrified, his troops must surely be inspired by his rhetoric.

 The first thing that is not sustainable is the amount of resources the NHS consumes. How many pages of A4 paper do you think my trust uses a year, he asked the audience. People thought tens of thousands, but it’s 16 million. What is the cost of a unit of blood? The answer is £450, and yet too often blood that is not transfused is left to warm up and wasted. Morley would like everything to be labelled with its cost.

Money is the second thing that is not sustainable. Imagine, he told the audience, putting a pound into a slot every second. It would take just over 11 days to pay a million pounds, but to pay off the nation’s debt would take 33 500 years. Hull has to save £25m a year on a budget of around £500m. Seventy per cent of the cost is staff, and so there will have to be fewer staff—and 90% of the staff are doctors and nurses. Yet the service can’t be delivered with 2000 fewer staff, and productivity has gone down. There will have to be less estate, and each member of staff has to save £3000. How can it be done?

One way is changing patient expectations, and they are the third thing that is “totally unsustainable.” The hospital in Hull has just done a third hip replacement on a woman of 90. A mother in her 20s brought her 7 year old into casualty crying because his hamster had died. A family of five came to casualty because they all had head lice.

Morley works half a day a month somewhere in the NHS, and one day he worked as a secretary in orthopaedics. He rang a man to tell him that his shoulder replacement would be next Thursday. It’s a complicated business to get everything coordinated for such an operation, but the man said “Oh I can’t do Thursday. Can you make it Friday?” You wouldn’t,” said Morley, “say to an airline ‘I can’t make 9, can you get the plane to leave at 9.30?’ We have to tell people what we can do, what we can’t do, and what they have to do for themselves.” That’s hard for professionals, he added; they want to help.

 Really beginning to get into his stride, Morley said that fourth thing that is not unsustainable is “the way we treat our patients.” What’s the biggest killer in the Britain, he asked the audience. People knew it was cardiovascular disease. What’s the second? “It’s not cancer, it’s being in hospital. The NHS kills more people than cancer does.”

 Then he told the story of a 75 year old woman who’d come to see him. She was tiny and very neat. She said how she’d come to hospital one night with her husband who had had a heart attack. She and her husband had been married for 50 years and hadn’t spent a night apart. She wanted to stay with her husband, but the nurse told her to go home. “Be sure to ring me,” the woman said, “if anything happens.” The nurse promised, and the woman went home and waited nervously by the phone all night. Unable to wait any longer she went back to the hospital in the morning. The nurses were busy, but the woman saw that her husband’s bed was empty. “He died last night and was asking for you at the end,” said the patient in the next bed.

The woman asked to speak to the nurse who had told her to go home and hadn’t rung, but the nurse had refused and been supported by her union. The woman simply wanted her to say sorry.

Morley countered this story with one of exemplary behaviour, but his fifth thing that was unsustainable was “the way we treat our staff.” NHS staff are the most valuable thing we have, he said, because staff who are well looked after look after patients well. But working in casualty he sees staff being cursed and hit and patients saying “Gimme, gimme, gimme.” Morley asks other leaders in the NHS “How were you inspired today?” Leaders need to be inspired by what they do. “If NHS leaders are not inspired by the NHS then they should go and work in Sainsbury’s.”

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

  • I was not there for the lecture, and I certainly was not there for the moving stories that the speaker told, but for at least three of them, I disagree with his conclusions:

    1. NHS staff are, every day, doing things inefficiently, and there is plenty of room for improvement. For me as a junior doctor, the realisation came to me when I was – once again – delivering the theatre list from the theatre to secretary downstairs. In the theatre I had to write it onto a piece of paper, then I had to walk downstairs to to the secretary's office, then to rewrite from my piece of paper into the diary of the surgeon's secretary. My pager was going off throughout.

    All over the NHS, doctors, nurses and other professional are doing things that anyone in any other industry would be horrified by (as a waste of human effort) but instead the Royal Colleges think the problem is the European Working Time Directive rather than their resistance to adopting simple technology.

    2. “You wouldn’t say to an airline ‘I can’t make 9, can you get the plane to leave at 9.30?'”, no, but neither did the patient ask the surgeon to operate on Friday instead of Thursday.

    What he asked was what any reasonable person would do when told by the airline, i.e. “do you have another flight at 9:30 that I could take instead”, which is just as reasonable as “do you have a slot on Friday that I could take instead”. This is not hard to provide, and even if it was, no one should take offence at a perfectly reasonable request.

    3. “The woman asked to speak to the nurse who had told her to go home and hadn’t rung, but the nurse had refused and been supported by her union” This story is so sad and so wrong it is going to bother me all night. It is not that the poor man died, or that his poor wife was not told – sadly, mistakes will always happen.

    But why did the nurse not see the lady, why did she not say sorry, and how dare the Union side with the nurse? It is not hard to say sorry, and to include this story with the conclusion “the way we treat our staff” as opposed to “the way we treat our patients and their relatives” is really disappointing.

  • sam george

    Any Institution which does not generate cash is not sustainable.
    Any nation which relies mostly on redistributing Tax payers money will end up borrowing.
    Reduce tax, Stimulate growth, Support Industry and Remodel NHS.

  • R C

    The largest cost of the NHS is staff time. It seems this is being horrendously mismanaged. Sort this out – with better management and use of technology – and most of the productivity battle will be won.

  • susanne stevens

    Many people have complicated lives, a weeks notice gives very little time to rearrange things bearing in mind the time necessary for recovery afterwards. Would the request to reschedule the operation received a different reception had the person had been an airline pilot, or another clinician… Most of the people in my world just don't have unreasonably high expectations of the NHS. On the contrary many are hugely disappointed with the state of it. Despite the rhetoric of 'patient empowerment' this is something heard vaguely on the media usually as part of the nonsense of political interviews, very few have any real idea of 'rights,' and no real power. The thought of even asking to see their records is off the radar let alone demanding major operations. Many people from all walks of life just do not understand the system, going to casualty for help or advice is a reasonable action if parents are unaware of where to go elsewhere. If these are the only examples the clinician came up with surely things are not so bad. The public needs better education about how the NHS works rather than critiscism for not knowing, it has been quite useful to have apopulation gratefully accepting whatever is given, and still too often treated like sheep or worse as the latest report on so called care for senior citizens has shown once again.

  • Brendan

    simple solution     more nurses less managers    less paperwork  and you dont need a degree to care !