Rachel Clarke on staffing
Staff vacancies in NHS England are around 112,000 (8%) – and are predicted to keep rising
(Source: NHS England vacancy rates, March 2023)
Dr Rachel Clarke is a palliative care doctor and writer. Her books include Breathtaking, about working on NHS Covid wards in the first wave of the pandemic
A palliative care doctor is nothing if not a realist. When death is your day job, you can’t flinch away. Mortal arithmetic has a haunting simplicity. Grief hurts as much as it ought to – as much as the person you are losing is adored.
From its inception, as every opinion poll shows, the NHS has been Britain’s best-loved institution. The jewel in our crown; a national religion; the comforting story that for all our shortcomings, we will not allow those in need of medical care to be cast aside.
But public love and affection are immaterial. As surely as I’ve ever known anything, I know this: the NHS is dying. Its lifeblood is draining away. I want to say otherwise, I long to, but the signs are too stark to ignore. There’s the patient marooned on a trolley for hours in their own body fluids. The junior doctor who begins to weep on a ward. The A&E consultant, a reliable pillar of calm under pressure, who suddenly snaps and yells at her team. The stalwart of the hospital – the sort of senior clinician everyone looks up to – who finally, reluctantly, throws in the towel.
This is a major haemorrhage not of corpuscles but staff. The NHS is currently blighted by record levels of staff vacancies – more than 112,000 in England in March, a slight improvement on the previous count but 6% higher than at the same time last year. A recent report predicted vacancies could be as high as 571,000 staff by 2036 on current trends. It is shameful, nothing short of a national scandal, that for 12 years successive Conservative governments have at best disregarded – or worse, wilfully exacerbated – NHS understaffing. These days, every ward, every department in my hospital is struggling with the impact of frontline staff who once loved their jobs being driven out of the NHS by a corrosive combination of lousy pay and intolerable conditions of work. There is no respite. Morale is much lower now than it was during Covid. A pall of collective hopelessness hangs in the air.
But even now – unless, of course, the ruling party actually wants to bleed the NHS dry – they could reverse this workforce crisis. They could recognise strikes for what they are – a cry of “enough” from a workforce that’s been pushed too far – and address the incontrovertible fact that NHS pay has plummeted in real terms. They could publish the workforce plan they’ve been promising ad nauseam, complete with hard figures for the additional staff needed and a pledge to train and deliver them. They could stop pretending to the public that the NHS is not in crisis, because nothing is more soul-destroying for staff than having what we know is true – because we are living it – denied.
There’s more. I would be lying if I didn’t admit that sometimes, irrespective of the government in charge, the NHS can be a spectacularly awful employer. The amount of bullying and abuse of staff from on high has to be seen to be believed. There is institutional racism, sexism, homophobia, transphobia and toxic hierarchies of every kind. Yet there should be zero tolerance of all of the above, exemplified by the leadership of NHS England.
I am miraculously fortunate to work in a team led by an inspirational head of department who has integrity, determination and a sincere commitment to the wellbeing of her colleagues as well as the patients under her care. She leads by example – with both compassion and steel. We all feel safe, supported and valued by her. But how telling that this feels rare. It should not be the exception but the norm. So, in addition to long-term, meaningful government plans for addressing understaffing, I want to see a radical overhaul of NHS employment culture. There would be immediate benefits for patients if the NHS strove to retain its vital, yet terminally beleaguered staff.
Jack Thorne on social care
Between 2011 and 2018 government spending per adult on social care in England fell by 6.5%
(Health Foundation report: What should be done to fix the crisis in social care?, 2019)
Jack Thorne is a screenwriter and playwright. He was Bafta-nominated for Help, his 2021 Channel 4 drama set in a care home during Covid
My mum was a care worker. She worked in a day centre and then in residential care. If we forgot our key, we’d go find her in the day centre, and her clients (that was what she called them) would frequently come around to our house for coffee mornings. When she was working in residential care, she volunteered for the Christmas shift and we’d go over to the home and hang out there for a bit. She made her work part of our lives. When she retired in 2001 she was earning £4.60 an hour.
The idea that social care has ever been properly valued by our country is a nonsense, but it is certainly the case that it has never been as undervalued as it is now. Devolution has shown how brutally a Conservative government in particular has treated social care, dropping funding to £324 per person in England by 2017/18, compared with £446 in Scotland and £424 in Wales (according to the Health Foundation’s 2019 report).
But nothing revealed the consequence of this more brutally than the Covid crisis, when care homes were restricted on tests, on PPE and on medical support. The stories we heard making Help for Channel 4 were brutal. One particular thing that echoes with me was a woman who ran a care home, still clearly traumatised, with tears in her eyes, saying to us that she “had let her gentlemen down”. When the government’s Covid inquiry finally comes back, the findings on care homes are going to be startling. They will reveal immense bravery on the part of the staff who stayed and looked after their vulnerable residents, and an absolute dereliction of duty on the part of our government.
It is shocking that the crisis hasn’t led already to a change in how we treat social care. In particular it feels reckless that we still don’t pay our care workers a living wage. A 2022 BMA report revealed that by 2030 we could see 500,000 vacancies in social care. Why? Because the social care workforce receives the lowest wages of almost any sector in the UK, with almost a quarter employed on zero-hours contracts, rising to a staggering 41% in London.
But more than that we need to start valuing the people who need care. At a time when our population is ageing, that figure means more people get less support. The pension triple lock gets discussed endlessly, but care for that same generation is ignored. Whether that’s time with a carer in their homes, or support and dignity if they have to move into care homes, elderly and vulnerable people are being left unseen.
It is essential we change this It is essential that care becomes part of the NHS from an efficiency point of view (too many hospital beds are taken up with people who could be in homes) and because it will mean the perverse distinction between health and care dissolves away. A National Health and Care Service would combine two parts of the same ship, and make care float again.
My mum loved her job, and she was really good at it. She made us part of it because her clients liked having kids around and because she knew we liked being around. There are people like my mum in jobs all over the country, and with proper value placed upon them they can make our country better. The love is there, the need is there, the money needs to be there.
Henry Marsh on privatisation
In 2022 private hospitals in the UK treated 820,000 patients – a new record
(Private Healthcare Information Network: market update May 2023)
Henry Marsh is a neurosurgeon and author. His books include the bestselling memoir Do No Harm: Stories of Life, Death and Brain Surgery
The private health industry in the UK is flourishing because the NHS is withering. In 2022 private hospitals in the UK treated 820,000 patients – a new record. Between 2010 and 2021 the self-pay private health business doubled in value. Since most doctors in the private sector also work in the NHS, this growth is damaging to the NHS, as well as to training. Doctors’ loyalty to the NHS is being eroded by years of austerity and the frustration and progressive loss of autonomy that has come with it. If this trend continues, we will see a two-tier healthcare system in the UK, as we already have with education, and as was the case before the NHS was established.
It would be hypocritical for me to damn private medicine – like most surgeons, I treated private patients, in addition to my NHS work, for many years. All doctors have to find a balance between medicine as a vocation and medicine as a means of earning a living. There are a few saints and a few crooks, and most of us are somewhere in between. A society where the quality of your healthcare depends on your wealth is deplorable but it also needs to be understood that there are some important differences between private medicine and state-funded medicine.
In private medicine the wellbeing of the patient is no longer an end in itself, but has become instead the means to the end of making money for both doctors and hospitals. In market economic theory this is a good thing, as consumers choose where to spend their money, and so resources are efficiently allocated. There are two problems with this. First, patients are rarely informed consumers. The relationship between doctors and patients is largely about patients trusting doctors (sometimes to their cost), rather than about patients making informed choices. It is a simple statement of fact, not of paternalism, that as patients we usually do not know what is best for us.
Second, most medical decisions are not clearcut. There are many shades of grey, as medical decision-making is all about probabilities (although as patients we want certainty). Profit-making all too easily distorts clinical decision-making, albeit unconsciously – typically to underestimate the risks of treatment and overestimate the risks of no treatment. Private medicine, therefore, tends to be extravagant and more expensive than state healthcare, where doctors have no personal pecuniary interest in their decisions.
The private medical sector is heavily subsidised by the state and taxpayers. All the basic training of clinical staff is undertaken in the public sector, and if patients in private hospital run into difficulties, they can be transferred to a public hospital. Furthermore, the private sector can cherrypick and only treat patients who are at low risk of complications or expensive diseases, leaving the public sector to deal with emergencies, the elderly and complex cancer cases. The public sector has to deal with emergencies which, in principle, require surplus capacity, as emergencies do not always come at a predictable rate. The private sector mainly deals with elective work, which can be organised in an “efficient” way with little waste.
Healthcare systems all over the world are in crisis – a crisis caused by increasingly expensive advances in medical technology and more and more elderly people who can benefit from them. “Privatising the NHS” can mean many things. In recent years it has often meant diverting low-risk operations – such as hip replacements – to the private sector, and starving the NHS of funds relative to its ever growing needs, so that wealthier people choose to go privately, and poorer people suffer and queue.
There is a role for private medicine alongside the NHS, but it is important to understand that it is ideological nonsense to argue that the NHS is inherently “unfit for purpose” compared with the private sector. The Scandinavian countries, for instance, have tax-funded systems that work reasonably well. It is really the other way around – at least it is if you believe that the primary purpose of a healthcare system is to ensure equality of access to good healthcare for all members of society.
Julia Samuel on mental health
Referrals to NHS mental health services increased by 44% between 2016-17 and 2021-22, from 4.4 million to 6.4 million
(National Audit Office: Progress in improving mental health services in England, February 2023)
Julia Samuel is a psychotherapist and paediatric counsellor. Her most recent book, Every Family Has a Story: How We Inherit Love and Loss, is published by Penguin
No one is entirely clear why demand for NHS mental health services is increasing so rapidly, though there are lots of factors that people talk about, and none of them are rocket science. For one, there is more self-awareness about mental health and less stigma around seeking support. It tends to be younger people who are seeking it – more than four times as many children and young people are in contact with mental health services compared with seven years ago – and considerably more women than men.
In terms of causes, there is generally a lot of psychological disturbance because of the sense of political chaos and living in uncertainty – we’ve always lived in uncertainty but it’s much more in-your-face now. I’ve been a therapist for more than 30 years, and the biggest change I’ve seen is a real increase in anxiety, the sense of “the ground I stand on is moving, I want to find something to hold on to, to feel secure, but I don’t know what I can trust”.
Social media is another factor. The single biggest thing that supports people’s mental health is connection to others and having good quality relationships that are reliable, whereas a lot of relationships on social media are very shallow and based on comparison rather than connection, leading to self-criticism and dysfunction. And of course there’s the climate crisis, which particularly for young people is like the Jaws music that gets louder and louder.
The pandemic has played an enormous part, particularly in the mental distress of children and young people. The vulnerabilities that people had before the pandemic became many times worse. For instance, Camhs eating disorder services saw almost a doubling in the number of referrals during the pandemic. Some of my patients were going through situations that were already incredibly difficult before Covid and then became almost intolerable. I was able to help them through it, but imagine having to go through that on your own without professional help.
I worked in the NHS for 25 years, and I have such a sense of gratitude for its existence. But mental and physical services have never been equal. Mental health services have always been the poor relation, never properly invested in. I am a vice president of the British Association of Counselling and Psychotherapy, and we’ve been advocating for equity and investment for decades. Most of us think that the system is not fit for purpose, that it’s broken. You can be a suicidal young person in a particular postcode and be told it’s 12 to 15 months before you can see a psychiatrist. That child could be dead by the time an appointment becomes available.
But the problem is cultural as well as governmental. We individuals have to take responsibility too, rather than putting mental health entirely in the hands of organisations to fix it for us. The behaviours we choose have a big influence on our outcomes.
The basics of mental health are straightforward. The four pillars are connection with others, exercise, regular sleep and what you eat. If you’re in a heightened state of fight, flight or freeze, having tools to regulate your system is incredibly valuable too. But actually putting these principles into practice is the hard thing. As a therapist, I’ve observed that people find it very hard to deal with things that are difficult, they want to stay in denial – “if I don’t look at it, hopefully it will just be OK”. But we can’t fix what we don’t face.
The problem is systemic. It’s the fault of governments over time. And as a society we’ve all ignored the importance of mental health. It’s taken a massive crisis in the pandemic for us to really see it for what it is.
Karan Rajan on population health
At 68.9 years, Britain has the worst healthy life expectancy in western Europe
(Global Burden of Disease report, 2020)
Dr Karan Rajan is an NHS surgeon whose health videos on YouTube and TikTok have attracted millions of followers. His guide to healthy living, This Book May Save Your Life, will be published by Century in December
I have worked in many hospitals over the years, and it’s clear there are health inequalities on a geographical basis. In affluent areas such as Surrey, for example, the patient population I’d see tended to be healthier at an older age. In more impoverished areas, with less access to healthcare or lower health literacy, I’d see conditions that I shouldn’t be seeing in a younger population. So there’s a geographical distribution and skew when it comes to health. But generally in the UK we don’t, on a national level, take care of our health in the same way that certain Mediterranean populations do. As well as having the worst healthy life expectancy (and life expectancy), obesity rates in the UK are the highest in Europe (one in four people are obese).
No matter how healthy you are, and whether you eat kale salads and exercise for two hours every day, you still might get struck with cancer or any number of diseases, perhaps owing to genetic causes. Equally, you can be a lifelong smoker and never get lung cancer, although these would be the exceptions rather than the norm. But I think it would be foolish to say there isn’t a role for regulating the modifiable risk factors that we have in our lifestyle, through exercise, sleep, diet, stress levels and social contacts. All of these things play a significant role in determining acute and chronic health outcomes.
In countries such as Spain and France, there is a culture of napping in the afternoon, which has been shown to be beneficial in improving learning abilities. Social and family connectedness is another important factor: when parents get older and are supported by children and grandchildren, as they often are in other cultures, that plays a huge role in offsetting the risk of dementia and other neurodegenerative conditions.
Then there’s diet. In the clinic, I’m seeing a huge number of patients who are suffering with constipation, haemorrhoids and other consequences of a chronically low-fibre diet. That is probably one of the easiest fixes. I’m not necessarily saying anyone needs to be vegetarian or vegan, but having a diet where the main star of a meal is plants, not meat, is a great way to boost fibre. If you’re making chips with your potatoes, leave the skin on – that’s where all the fibre is.
In terms of reducing the burden on the NHS, it’s not right or fair for me to say that patients are a burden in any way. We are here to help people. But healthcare professionals can play a more active role in preventing health issues, instead of just providing a reactive treatment when something has gone wrong. And that’s where social media comes in – I can reach millions of people on a daily basis and provide preventive advice, which is the holy grail of medicine. I’m not saying you can prevent bowel cancer, or in all cases prevent haemorrhoids, but you can provide advice to reduce the risk of these things and maybe bypass the worst-case scenario. Patients want the skills to take greater ownership of their health, and, really, they don’t want to see me, a doctor – I’m the bogeyman. And, with the best intentions in the world, I don’t want to see them either.
These messages can come from the government, but I often feel that social media messaging from institutions can feel very cardboard and scripted. If organisations partnered with the healthcare professionals on the frontlines who are dealing with patients day in, day out, the information could be dispersed in a more native way. That would be much more useful than the sometimes very didactic advice that you see on NHS websites.
Leah Hazard on women’s health
Of 156 countries, the UK has the 12th worst female gender health gap
(Manual: gender health gap report)
Leah Hazard is a midwife and author. Her latest book, Womb: The Inside Story of Where We All Began, is published by Virago
Where I live in the west of Scotland, we’re used to our reputation as the sick man of Europe. There’s a grim acceptance of the fact that poverty, environmental stressors and lifestyle choices have helped us top the charts of illness and early death. But when I moved here from the US 24 years ago, I never would have imagined that the UK as a whole would soon be polishing its crown as one of the “sick women” of the world.
According to a study by the health platform Manual, examining data from 156 countries, the UK now has the 12th worst female gender health gap in the world, with women’s health ranking 38 places below men’s. For one of the wealthiest, most powerful countries in the world, this disparity is inexcusable: a stain on the UK’s reputation, and the legacy of years of Tory austerity and thinly veiled misogyny.
Who falls, flailing and unwell, into this “gap”? Women of every age and stage. The teenager with debilitating periods who faces a seven- to 10-year wait for an endometriosis diagnosis. The young woman who can’t get a bed for her eating disorder treatment unless and until she is almost sick enough to die. The new mother who is traumatised by the short-staffed conveyor belt of her local labour ward. The perimenopausal woman who risks devastating side effects because of rolling shortages of the HRT she needs to function. The list goes on, and it also includes the countless women whose physical and mental health is crushed by overwork, lack of affordable childcare, the hostile environment or any or all of the above. Quite simply, modern Britain sets women up to fail, and to suffer.
As a midwife, I see this suffering every time I turn up to work, and I’m not just talking about the pain of childbirth. I’m talking about women who are all too often rushed through a system without true choice or autonomy at a time when they should be celebrated and cherished.
I’m talking, too, about the NHS staff who are truly broken by the moral injury of propping up this broken machine. Many of my colleagues leapt at early retirement or less challenging roles once the worst of the pandemic had passed, which tallies with the recent workforce report from the Nursing and Midwifery Council. Of all the nurses and midwives who had left the register between April 2022 and March 2023, 52% did so earlier than planned. I’m hardly immune to these pressures; having navigated burnout and the immense toll it takes, I still start each shift wondering if it will be my last. There’s no way I can do this job until I’m of pensionable age; like so many on the frontline, I can only think about getting through each day. Weeks, months and years are unimaginable.
It’s little wonder that so many staff, having scraped through the pandemic, are leaving for other countries or other careers, and that so many women are seeking private healthcare if they can, or getting sicker if they can’t. This mess is all part of the Tory plan to break the NHS into little pieces and share it among their friends. We don’t need a fragmented, commercialised health service, though. We need one that recognises that women deserve to survive and even thrive as much as men, and we need the human and material resources to make that a reality. This goal will require not only a massive cash injection into the historically underfunded areas of obstetrics and gynaecology, but also a government that places a more holistic value on women’s wellbeing across every sector of society. We are waiting to be levelled up. To truly live, and be well.
Molly Case on funding
Government spending on healthcare was £30.5bn lower a year than the EU14 average from 2010-2019
(Health Foundation report: How does UK health spending compare across Europe over the past decade?/OECD 2022)
Molly Case is a spoken word artist, author and palliative and end-of-life care nurse. Her book, How to Treat People: A Nurse at Work, is published by Penguin.
Funding is problematic in every sector of the NHS. A recent Health Foundation analysis of OECD figures found that between 2010 and 2019, the government spent £30.5bn less a year on healthcare than the EU14 average. When it comes to capital investment – infrastructure and equipment – the UK during the same period spent £33bn less than the EU14 average. Cumulatively, the problem will get worse as our population ages and we get better at treating more complex conditions for longer.
In the field I work in, palliative and end of life care, funding is crucial. When looking after somebody with the fluctuations of a life-limiting condition, we only get one chance to get it right – a single opportunity to support them while living with this condition, and to provide a good death and a peaceful memory to the loved ones living on.
Sam was 28 when he died. I remember entering the flat he shared with his girlfriend and being struck by a “young person’s home”. The items that he and Laura had picked out together – the coffee-table travel books, the photos on the wall. Sam was dying from pancreatic cancer that had metastasised around his body. He was getting less well and he wanted to die at home. It was a small flat at the top of a building and the lift was broken. He just wanted to spend his last days going outside, watching people from the local community play basketball, feeling the sun on his skin.
Many of the issues our patients face are also related to poor funding beyond the NHS – lack of access to heating or food, housing repairs that never get attended to, meaning they may have to come to our hospice rather than die at home. Watching your friends play basketball outside your house should not be a difficult wish to grant someone who is dying, but it becomes so when services are not funded for purpose. Sam was able to die at home, holding his girlfriend’s hand, but the weeks before were riddled with worry about being trapped in the flat if things became unmanageable. This anxiety manifested in pain that we had to treat with medication. In the end, he died peacefully beside his open window with the sound of a basketball clearing the rim.
This year, hospices are facing more than £100m in extra costs because of rising bills and trying to pay their workers a fair wage. Hospice UK has called on the government for an urgent increase in funding for a critical service – a World Health Organization-deemed human right.
The cost of a specialist palliative care nurse delivering care in somebody’s house is estimated to be about £103 per contact. Our hospice cared for almost 5,000 people last year. If each of those people received one visit a week from a specialist nurse over a six-month period it would have cost the service £13m. That is before factoring in all the other professionals from the hospice involved in care: dieticians, complementary therapists, physios, social workers.
Last year it cost £25.4m to run our hospice – £9m (35%) came from the government, the rest from cake sales, skydives, sponsored marathons, fashion shows, charity shops and the generosity of the community. This figure is significantly less than two years ago, when the government funded about 55% of our spending, as Covid relief money had been factored in. Does the government not realise that fundraising is more difficult than ever, as people have less money to give during a cost of living crisis?
The £100m deficit impacts the way people live and die. Funding is needed for out-of-hours palliative care because, like birth, dying does not happen nine to five. The money is needed for cross-service collaboration, ensuring our IT is fit for purpose and we can all safely and efficiently connect across the same digital landscape. We need to ensure we are recruiting and retaining a skilled workforce in what is an emotionally and physically intense speciality. We need money for hospice home care, inpatient care, outpatient care, bereavement and after-death support, complementary therapies and palliative rehabilitation, to help people meet their goals and give meaning and quality to however long they have left.
Put simply, the palliative and end of life care speciality urgently needs more government funding. It is a human right to be allowed to die well, to die with dignity and choice, to die with adequate symptom control, to feel valued and cared for until the very end. It couldn’t be said better than the words of the pioneer of the modern hospice movement, Dame Cicely Saunders: “You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.”
