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.