Voters are to blame for crisis in NHS

FAME is a strange concept these days, rendered trashy and meaningless by the celebrity machine of reality TV and the reputation-devouring lure of social media, where the rich and powerful go to swap acclaim for notoriety and kill their legacy for a few clicks.

Some, though, still carry fame with dignity – like Dr Gavin Francis, the internationally acclaimed bestselling author. Despite his accolades, every week you’ll find him at his GP surgery in Edinburgh, treating patients from morning to night.

Francis is part of a long line of doctors who’ve balanced stethoscope with pen and took up the literary life while still a medic: from Scotland’s Sir Arthur Conan Doyle to Oliver Sacks, who wrote Awakenings.

Francis’s works include Adventures in Human Being which won the Saltire Award; Intensive Care: A GP, A Community and Covid-19; Shapeshifters: A Journey Through the Changing Human Body; and this year’s bestseller Recovery: The Lost Art of Convalescence. Although these books explore the human condition through the eyes of a doctor, Francis is equally admired for his adventure and travelling writing – works like True North: Travels in Artic Europe; Island Dreams; and Empire Antartica. A doctor for 23 years, he’s a fellow of both the Royal College of Physicians and the Royal College of GPs. His books have been translated into 18 languages.

He’ll surely hate the notion, but Francis is probably the most famous doctor in Scotland, if not Britain. In person, there’s no hint of fame, though. He’s thoughtful, considered, quietly spoken - the quintessential community doctor, not a literary celebrity. Though he does bear a slightly unsettling similarity to Ewan McGregor, both in looks and accent.

However, his renown gives him clout. His words matter – and today, Francis has some rather challenging points to make about the state of the NHS in Scotland and the rest of Britain.

Crisis

The NHS is in “crisis” and urgent life-threatening procedures could soon be in jeopardy, he warns. Francis fears for the future of the NHS. But he doesn’t simply blame politicians in Edinburgh and London. As you’d expect with a medic, he’s ruthless with facts – he gives bad news honestly so the patient can make the most informed choice about their future.

So here’s the bad news: we’re to blame for the state of the NHS, the great British, and Scottish, public. We elected the politicians who made this mess – and we keep electing them. Like the best medicine, it doesn’t taste good, but it’s necessary.

The illness that besets the NHS is “chronic under-funding”. Discussing mental health, as an example, he says the NHS must “concentrate on the severe end of the scale – people who need sectioned, are suicidal, dangerously psychotic. There’s not enough slack in the system, not enough resource to deal with everything.”

The NHS needs more money. That means taxation. “There doesn’t seem to be any political party on offer suggesting to people that we find more money from the national budget … Parties that say, ‘right, we’re going to have to charge you all more money and we’ll get better health services’ – they don’t get voted in.”

Although “frustrated”, Francis says: “I also have to accept that we live in a democracy, and this is the level [of services] voters want, because they’d vote to pay more if they wanted a better NHS, but they don’t seem to want to vote for a better NHS.

“I’d rather people pay a large proportion of the national budget towards healthcare but my view isn’t widely shared because we’re seeing general NHS funding drop off. We certainly haven’t keep pace with our European neighbours. So this is very deliberate underfunding by our political masters – north and south of the border.”

Anger

Overworked and overstressed GPs are quitting as “that’s what happens when you pressurise the system”. Waiting times mean “people can’t access what they know they need and they get angry and take it out on the person closest to them who’s often the GP or district nurse”. Phone consultations, which have become normalised, aren’t what’s best for patients.

Compared to the late 1990s, the change in the NHS is striking. “There was massive funding put in,” he says, which drastically reduced waiting lists. “There was a feeling of optimism, that society wanted to back [the NHS], that we’d adequately fund the NHS – but that’s just fallen away. I don’t get the sense at all that there’s a willingness among our political masters to adequately fund what we need.

“We’re constantly told as clinicians to work smarter, more efficiently – to do more with less. We’re all working as hard and efficiently as we can.” In Francis’s experience, waiting lists for dermatology, vascular surgery, ear nose and throat and a “whole load of specialities are absolutely enormous.” For routine specialist appointments for non-life-threatening conditions, “it’s not unusual to wait a couple of years. Ten years ago, that was unthinkable.”

Overwhelmed

The state of the NHS means GPs know some patients “need the expertise of specialists but are unable to access that because waiting lists are so long”. Some colleagues are “overwhelmed by demand”. An ageing population means demand “is going up but provision and resource isn’t”.

He refers to “mendacious” Brexiteer claims of £350m going from the EU to the NHS weekly, adding: “We’re reaching a real crunch point. I’m now worried that urgent things aren’t going to be seen in a timely manner.” Waits for ambulances are going up. “It’s getting harder to get an urgent ambulance; it’s getting harder to get a patient seen by specialists.”

Francis says he isn’t making party political points. “I just want to talk about facts. We’re not getting resourced adequately. That seems a democratic choice because politicians do focus groups. They work out what people want to vote for, and they presumably keep finding that people don’t want to pay more for their health care.

“I get people getting cross with me about waiting lists to see specialists and I say, ‘well, you can write to your MSP. We live in a democracy. You’ve got lots of options to make your voice known about how unhappy you are with this state of affairs. I’d urge you to take those up, and I’ll do the best I can for you in the system I work within’. So I can only presume this is either the NHS people want, or our democracy doesn’t work – because it can’t be both.”

Honesty

Francis adds: “It feels like we’re at a real low at the moment. It felt like this towards the end of the Major government – we were getting to a real low and things needed to reverse and there was a sense, certainly within the NHS in the late nineties and early noughties, that things were reversing and the NHS was being adequately prioritised. That sense is certainly gone.”

He doesn’t “have an opinion one way or another” if the Conservative or SNP government handles the NHS crisis better or worse, but adds: “If the people of Scotland had a radically different opinion of how much they value the NHS then I hope they’ll make that known to their political masters. But my experience at the frontline of the health service is that there isn’t enough resource to meet demand. And I don’t know how we get around that.”

Dr Gavin Francis says the public must be honest with what they want from the NHS and what it will actually take to deliver (Image: Colin Mearns)

Francis suggests we need an “honest” national conversation where the public is told “there’s just not enough resources to have the kind of NHS you believe you’re entitled to, and so we’re going to cut these things … cut certain kinds of elective surgeries”. The alternative is “finding a way of putting it to people that you’re going to have to pay a bit more somehow”.

Given that the public constantly talks of its “love” for the NHS, Francis says: “I’d like to see that love recognised and spoken about with more direct honesty. At the moment, the message seems to be that it’s all going fine, and if we just worked a bit more efficiently it’ll be hunky dory … That’s not true. We’re already working very hard, very efficiently.”

Austerity

Discussing the effects of Conservative austerity policies on health, he says: “Society makes its priorities and chooses where to spend its money.” Does austerity kill people? “Of course it affects health. Everybody knows that increasing poverty increases ill health. Everybody also knows that’s what the Tory Party are happy with. They’re happy with wider inequalities because they see that as the path to creating greater wealth in society … so that’s the choice society has made.” The “lever” to change that is “the ballot box”.

Francis refers to the well known professor of public health Michael Marmot who carried out a “famous study of Whitehall civil servants”. It overturned the assumption “that those at the top had very stressful lives and that justified their pay packet. [Marmot] showed that actually the lower you are in the hierarchy, the more stressful your life is, and the younger you die. The people at the top have the easiest time.”

Marmot, Francis notes, also had a famous encounter with a group of American doctors. America, Francis says, “has one of the most expensive healthcare systems in the world, they spend well over triple what we spend, yet they’ve the worst outcomes in the developed world. In terms of infant mortality, maternal mortality, big public health crises, we think we’ve got it bad here – they’ve got it terrible”.

Marmot addressed an American doctors’ conference and, says Francis, told them “you live in a democracy. This must be the level of infant mortality you want because if you believed it was really important to save the lives of children you’d have different health policies”. Francis adds: “The science is there, if you want better outcomes, you know what to do. It’s political. So this must be the level of the NHS – the level of health inequalities – that society wants, or it would change.”

Pandemic

Evidently, though, he acknowledges prioritising healthcare means other areas – defence, education, energy, industry – suffer. Government’s job, Francis says, is to “give us the least worst society”.

Francis was on the frontline during pandemic. It was devastating, he says, in terms of the trauma of lockdown and widespread deaths, yet it also, counter-intuitively, had some “silver linings”. He’s praises cities like Edinburgh where local politicians and charities worked to house the homeless during Covid, and how red tape was slashed to develop vaccines. Now, when politicians say social ills can’t be tackled, the public can reply “hang on” and point to what happened during pandemic. Remember when we were all told there was no “magic money tree” by the Conservative government, he notes. “Lo and behold, Covid came along and so did the magic money tree.”

The fact that homeless people are now back queuing at soup kitchens simply reveals that “people are showing they’ve got different priorities again. What I’m saying is the silver lining is that we now know it can be done. Nobody can say ‘we can’t solve problems’. Because actually, we did.”

Lockdown

The impact of lockdown on the young was catastrophic, Francis says. Their lives were suspended - at the most crucial point in their development – as society told them “you’ve got to stay home. If you don’t you’re a danger and putting everyone at risk, you’ll kill granny”. This happened, he notes, even though “the proportion of people under 20 who got ill was absolutely minuscule”.

He’s not saying there shouldn’t have been lockdowns. “If we didn’t have lockdowns, we’d have needed hospices beside hospital carparks … there’d have been a much higher death rate,” Francis explains. Rather what he’s saying is that we should now prioritise the young to repay what they did for society. “[The young] paid a very high price to ensure the safety of their elders … Those lockdowns had terrible consequences.” We need to “thank that generation for the sacrifices they made.”

During lockdown, his mental health caseload rose from a third of his appointments to two-thirds. Surprisingly, he saw few anti-vaccine conspiracists. “They make a lot of noise on social media but people almost always want the vaccine in real life. We’ve got pretty much the highest take up in the world.”

Pressure

Francis also warns against politicians ‘medicalising’ society’s woes and piling responsibility onto doctors, like recent moves around GPs “prescribing fruit and vegetables”.

“When the NHS is under such huge pressure, you have to draw the line about what health services can do.” On a home visit, one patient asked Francis to fix her boiler.

His average day is pretty relentless. With hospitals so overstretched, GPs must take on additional duties. He starts work at 8.30am with a mountain of admin. Patient appointments between 9am and noon must be just 10 minutes. “That’s often inadequate.” If appointments run over the knock-on effect can be dire. Then he’s got reams of paperwork like blood tests and hospital reports to get through, before it’s back to seeing patients until 6.30pm. He does home visits too for the frail and elderly. You also might hear him on the phone if you call NHS 24 where he mans lines. As his own working life shows, in terms of NHS staff efficiency, “the electorate are getting the most bang for their buck. In order to get more bang, they need to put in more buck”.

When it comes to “non-urgent medical presentations, the can is being kicked further and further down the line, as the NHS has to turn its resources to dealing with urgent presentations … It keeps cutting the non-urgent stuff in order to preserve its capacity to deal with the urgent stuff”.

Cutting non-urgent cases, he says, “causes all sorts of suffering and eventually leads to poor outcomes in lots of ways”. The NHS “still does manage urgent life-threatening illnesses very well … We do still have the capacity to deal with urgent life-threatening stuff but I’m worried that’s going to go. I’m worried urgent care is soon going to start to suffer if this crisis isn’t adequately addressed.”

Succumb

Francis feels the word ‘crisis’ is apt as it means “the point in an illness’s evolution at which everything hangs - either the patient recovers or succumbs”. Today, someone suffering cardiac arrest in Glasgow would get to hospital and be treated, “but I’m worried that we’re at the moment now that if things don’t improve I wouldn’t have that confidence that this time next year you’d get the ambulance … We’re at a point in the development of the NHS where I’m starting to feel that even urgent things are harder to get addressed”. Patients with non-urgent ailments that harm their quality of life, like severe eczema, sinus problems or mobility issues, are on waiting lists for years. “Myocardial infarction, stroke, road traffic accidents … if we don’t see adequate resources, those things will also start to suffer”.

Governments are “an emanation of us … it’s not a case of ‘us and them’. We keep telling them what we want them to do. We vote for them, we chose them. If we want to be a modern European country, we have to compare ourselves to modern European countries, which spend a lot more than us on health”.

Unthinkable

He doesn’t believe there’s too many managers in the NHS, however – a common refrain from politicians. The problem is money and resources. Patients are increasingly using their savings to go private due to waiting lists. “When I began studying medicine 30 years ago, that was unthinkable.”

Privatisation, he warns, is simply “bad medicine”. The central idea of the NHS was “a doctor speaking to a patient without thinking about the patient’s wallet. In order to make good decisions, you need to take money out of the consulting room. Privatised medicine leads to over-investigation and over-treatment.”

If this all sounds very dark – well, surprisingly, Francis disagrees. He’s eternally optimistic. Society has vastly improved from a century ago when “it was routinely acceptable to have Poor Houses. The trajectory is in the right direction. We’re less able to tolerate big inequalities”. We need to focus more on the positive, he says. The front page of every newspaper should, he adds, carry the headline: “Success! Humanity has done wonderful things transforming life expectancy”. Instead, the media focuses on elderly ‘bed blockers’. “We’re looking at it all the wrong way around,” he concludes.

Read more Big Reads from Neil Mackay:

• Leading global academic on independence says SNP can easily win indyref2 – if it embraces populism
• Meet the pagans ... inside the secretive world of Scotland's real-life witches
• Culloden, colonialism and PTSD … Scotland and the dark secrets of our bloody battlefields