Society

The NHS's pot of gold

Christine Martin

When in late 1946 the Health Bill became law, the BMA vehemently opposed it. They feared its members would lose their 'independence'. They determined to 'stir up as much emotion as they can in the profession'.
     By the time of its inception in 1948, Aneurin Bevan had reached a reluctant accommodation with the Royal College of Physicians.   Consultants would be able to work within the National Health Service – while at the same time treating patients, who could afford it, within their private practices. Bevan described how a settlement was reached with hospital consultants in bald, bold terms – 'by stuffing their mouths with gold'.
     When the National Health Service was born in July 1948, over 90% of doctors had signed up to the service. Funded by taxation, it provided free medical care to all at the point of use – probably the single greatest achievement of any government. From the outset, the Health Service gobbled up more cash than anticipated. Succeeding decades have witnessed the erosion of a number of core services – eye care, dental care and, with the exception of certain cases, freely dispensed medicines.
    
The new coalition government has pledged to 'ring-fence' the NHS budget. Last year this amounted to £120 billion. 'Trimming' is anticipated – one casualty being the discredited multi-billion-pound computer system. By far the most contentious area for cuts is where they are most needed – staffing costs. The much criticised burgeoning of hospital managers accounts for only part of the massive inflation of expenditure on salaries in recent years.
     Of the total NHS annual budget, almost two thirds is spent on salaries and pensions. A senior hospital consultant earns around £120,000 per annum. Many consultants opt to work part-time for the NHS – the remaining time being devoted to their private practice. This can result in the doubling, even trebling of their income.
     Additionally a system of 'discretionary' payments is employed. These too can double a salary. 'Discretion' does not automatically extend to consultants who are personally committed to work solely for the National Health Service. Those with lucrative private practices are eligible to receive substantial financial rewards.
     Pensions are linked to salaries. It is not unusual for a hospital consultant to retire on a pension of £60,000 a year accompanied by a 'golden' handshake. Many consultants who work part-time for the NHS while expanding their income in the private sector, opt to return to work for the NHS two years prior to retiring, thus maximising their NHS pension. An index-linked, pensionable life can last 20 years, and more. The sums involved are astronomical and unsustainable.
     In recent years GPs have seen huge increase in salary, coupled with a decrease in working hours. Until 2004, GPs were contracted to care for their patients 24 hours a day, seven days a week – anachronistic and  unrealistic. The GP contract requires GPs to be responsible for the care of their patients between 8.30am and 6.30pm, Monday to Friday. The average GP's salary is now on a par with that of an hospital consultant. Working on a self-employed basis, general practitioners' salaries and conditions vary throughout the country. Some GPs earn less, while many considerably more. GPs too have the anticipation of a gold-plated pension along with a generous retiral settlement.   
     Hours which are no longer covered by a patient's own general practitioner are catered for by contractors overseen by NHS 24  – 'A doctor in every home, 24 hours a day'. When the last government set up the GP contract, there was an oversight. They forgot to factor in to how to manage the additional costs.
     It was not just costs which posed a problem, but how to 'man' the 'out of hours'. The self-same, overworked general practitioners who had recently won for themselves 'reasonable working hours', enthusiastically volunteered to provide continuous medical cover. This was very different. For working an overnight shift at a weekend, it was possible to earn upwards of £1,000 per night.
     As further large salary increases worked into their bank accounts, GPs found working nights and weekends less attractive. This is when health boards had to look further afield. Now we are faced with a situation where, routinely, general practitioners are flown in from various European countries to provide medical cover. Inherent dangers in this practice have recently been witnessed.
     For general practitioners from France, Germany and, particularly, Poland who, in many cases, possess limited English, not to say medical English, spending a weekend in the UK is very lucrative. General practitioners in Europe earn a third, in some cases a quarter, of the income of their British counterparts.

There are many other disciplines which contribute to making the National Health Service 'work'. Nurses, now university graduates, bring an altogether different attitude to the job. It might be a case of looking through rose-tinted lenses, but nurses appeared to be much more committed to their vocation, their profession and to patient care when they trained under the apprenticeship system. Where doctors and nurses were once complementary, they have become increasingly competitive.
     Nursing unions fought for years to overcome an attitude where nurses were frequently viewed as 'hand servants to doctors' and quite right too. Sadly this positive change in attitude has come at the cost of the relationship between nurse and patient. Increasingly this once special relationship involves the interfaces of bureacracy and technology. Hands-on nursing is fast becoming a thing of the past. It is to the detriment of both nurse and patient that personal contact is so limited.
     Nurses too have succumbed to the lure of more remunerative and 'prestigious' careers within hospital management. The antithesis of a nursing vocation, this invariably is a job where savings not patient care becomes paramount – savings which can only be made at the price of care of the patient.
     We have moved light years away from the delivery of the original concept of a National Health Service which, despite flaws, was the envy of the world for decades. Can the country afford to maintain this kind of  'service'? Or has the time come for a major, open minded, independent review of the largest employer in Europe, where not one single person can be held accountable?