The NHS has many strengths and has been a remarkably resilient organisation since it was founded in 1948. But if we want it to continue, we need to be aware of its weaknesses and what to guard against. So, what would someone who deliberately wanted to wreck the NHS do?
Encourage patients to overuse NHS services
The NHS is a community service which is dedicated to the health of the population. It has economies of scale because we all pay for it and are covered by it. This makes it difficult to break because private services cannot compete on cost so defeating it will require the help of the general public. If they can be persuaded to behave as selfish consumers and use as much as they can without considering the NHS a common good then they could overwhelm it with demand. Make things worse by banning services from asking patients to wait or call back later with routine problems.
Belittle and demoralise Doctors
Doctors are a problem because they are really quite bright and committed to their profession. Getting into medical school requires top exam grades while also getting involved in community projects and showing high levels of initiative. Their pay has always lagged far behind what they could earn in business or industry, but this has been offset by the respect they get for sacrificing years to gain knowledge and the burden of being responsible for patients. Persuading Doctors to abandon the NHS will require systematically belittling their skills and dedication using sustained attacks in the press as well as continued deterioration in their pay and conditions.
Overwork and burn out Nurses
Nurses are the backbone of the NHS and provide the majority of the procedures and care for patients. They work in highly trained teams and are well loved by their patients. Undermining nurses requires reduction in their pay and conditions, but it will also be necessary to disrupt their team working by repeated reorganisations. The stressfulness of their jobs can also be increased by withdrawing senior cover and by encouraging them to take on responsibilities usually borne by Doctors without giving them a similar depth of training.
Get rid of GPs
The universal network of GPs who know and are trusted by their patients has led to dramatic cost savings because problems are usually dealt with at first contact without the need for expensive specialist referral. A key strategy to break the NHS will be to encourage patients to see specialists directly. This will increase training costs because of the increased number of specialists required while also reducing their effectiveness because they will have to deal with all the mundane GP level problems. Costs will rise because specialists are more expensive than GPs and also many patients may choose to see the wrong specialist so wasting consultations with no health benefit.
Set clinicians against each other
The NHS thrives when clinicians act together to make it easier for each other to help look after patients. It is important therefore to make clinicians compete for resources and see each other as adversaries. Reducing funding for GPs will make them refer patients because they don’t have the resources to manage them in the community and thus increase workload and waiting times for hospital services. Overloading hospitals so they discharge patients before they are fully better will further stretch GP services and increase the chances of readmission. Transferring patients back and forth between services is a time-consuming process that does no actual patient care and is a good way to make the NHS less efficient.
Use reorganisations to disrupt and confuse
Over time, workers learn how to work together and develop relationships within and between teams and this makes the whole system more efficient. It is necessary, therefore, to disrupt these relationships and confuse workers with new pathways. Reorganisations offer an opportunity to break up effective teams while spending significantly without doing any health care. Ideally these reorganisations should be repeated every 3 to 5 years to prevent clinicians getting used to their new teams and not allow the outcomes of one reorganisation to being assessed before the next.
Prevent the spread of successful ideas
Over the past 30 years, successive governments have followed these principles to good effect and the NHS is in a far worse state than when they started. However, there are pockets where NHS care continues to thrive and develop despite these policies. It is important to ignore and suppress these ideas and to plough on with regular top-down reorganisations to reduce the risk that the NHS as a whole may benefit.