What is it about your job that you feel would surprise the public?
That despite being a senior officer of the Royal College of Physicians, I still spend two or three days of every week working as a frontline NHS doctor. I have a ward with 28 patients on it, and I’m regularly on call for the acute medical unit until nine in the evening. I still do the job well into my 50s despite being in a senior professional leadership role.
What’s been the biggest change you’ve seen since you started working in health and social care?
We’ve had nearly a doubling in demand, both in primary and secondary care. We have more people living with multiple long-term and complex conditions, and more people with age-related conditions. And while all that demand has been going up, we’ve had a falling number of beds – we’ve lost about a quarter of our beds during my career. We’ve also now got far more regulation and general management applied to doctors. I think the public are rightly less deferential and more questioning, so what we do is under more scrutiny.
If you could make one change to the NHS and social care over the next 10 years, what would it be?
Social care needs a meaningful long-term funding and provision settlement, because it has been hammered in a way the NHS can only imagine over the past decade. There are far too many people who need social care who don’t receive it, and far too many carers who don’t receive the support they need. Within the NHS, without any question it’s workforce. We fail to plan the workforce properly – we’ve got to do more to make people feel valued, engaged and supported, because we’re losing people at every stage – from every junior doctor grade to the GPs and consultants retiring early. And ultimately, everybody else in the NHS is there to support the clinical workforce who support patients.
Change from the top
If you could give Matt Hancock one piece of advice, what would it be?
Listen to people with genuine expertise in health services. And don’t overpromise unrealistic gains at unachievable pace.
What do you wish people at the top of the NHS understood?
There’s a huge chasm between policy rhetoric and aspiration – on things like prevention, technology, wellbeing or integration – and actually making that happen on the ground. To make some of those policy buzzwords happen in real life, we need meaningful policy – on minimum alcohol pricing, proper investment in public health, addressing health inequalities. We've also got to stop the constant narrative that we have too many hospital beds. We can all agree we should focus on keeping people well and in their own homes, but the solution to that is not to cut even more capacity from hospitals that are already rammed full, or to believe that delivering case closer to home will necessarily be cheaper.
Policy in practice
What policy have you seen successfully implemented, and why did it work?
We’ve transformed the care of people with hip fractures and stroke care, which were both examples of clinically-led drives from the centre, focused on a particular group of patients. We set out good standards and incentivised people to do the right thing, and had a community of practice and peer support to drive change. And crucially, we were able to sustain it – because there have been too many short-term eye-catching initiatives. Change can take years not months, with the problem in a heavily politicised system being that change is driven by the ministerial cycle, to demonstrate that something has been done very quickly. It would be much better to under-promise and over-deliver over a five- or ten-year cycle around funding and priorities, and not keep imposing the priority of the month on the system every time there’s an election or a new minister.
What policy have you seen fail, or not be as successful as first intended?
I think the obvious answer is around technology. The National Programme for IT and Connecting for Health wasted billions of pounds. Then we had the 3 Million Lives project, where three million lives would be transformed by telehealth and telecare: it didn’t deliver very much. We’ve repeatedly tried to impose technology at pace onto the service like it’s a solution in need of a problem, instead of delivering bespoke solutions that the service said it needed.
What policy and/or change in behaviour are you currently trying to implement, and how’s it going?
At the RCP we are aware that the current and future medical workforce is going to be increasingly dealing with patients with multiple, long-term conditions. As the Nuffield Trust’s own recent report on small- and medium-sized hospitals showed, we need more doctors skilled in and committed to medical generalism to make sure our current and future population GPs are ‘expert generalists’ par excellence and, despite a welcome increase in recruitment to training posts, general practice and community nursing still face major workforce and workload pressures. But generalists who support a high volume of undifferentiated acute patients with many things wrong also exist in secondary care. These include emergency medicine, geriatric medicine, acute internal medicine, and those ‘ologists’ who are also trained in general internal medicine and contribute to acute takes and inpatient medical care.
And finally
The NHS is under pressure because...
It’s received an inadequate funding settlement for each of the past seven years, and we’ve reduced investment in social care at exactly a time when we needed more investment. But most of all, the NHS is under pressure because we have an inadequate workforce to meet population needs, and anything we try to do (such as more care closer to home) requires the workforce to deliver it. That is the biggest single challenge facing the NHS. With no clinical workforce there is no sustainable service – or services will have to be scaled down or restricted in their scope. That’s an existential crisis.
David is Clinical Vice President of the Royal College of Physicians. Keep your eyes peeled for the next in our new Q&A series on Friday 14 December.
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