Let’s be frank about the NHS

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Part of The public and the NHS

In a guest blog for our NHS and the public project, Laura Fulcher explains how her poor experience as an NHS patient has prompted her to question whether our affection for the NHS as a national institution is blinding us to how it needs to change and improve.

What best represents the UK today?

Is it Britannia, with flowing mane, trident in hand, on a 50p coin? Or perhaps Lord Kitchener, his stubby finger pointing at you from World War 1 propaganda: ‘Your country needs you.’ No, such militaristic images don’t define us nowadays.

For a country devoid of a unifying religion, with nationalist pride used by some to justify racist thuggery, we must find our identity somewhere. And we find it in the NHS – that all-compassionate healer of the sick.

Yet NHS propaganda comes with the implicit threat of Kitchener’s finger. Without our zealous support, the health service could well be snatched away. ‘Save the NHS!’, the placards scream. For if we are deprived of our health service, who will cure the sick, who will deliver babies, who will save us in our hour of need?

And so we clutch the NHS to our bosom. We must protect it; ensure it doesn’t change; never a bad word must pass our lips.

I was born within the NHS for free – it’s the greatest treasure in the world!

No one could ever say anything bad about the NHS, because it’s made up of such caring, hardworking people.

With the NHS so entrenched in the nation’s psyche, it has become almost a treasonous act to call for improvements. We place the NHS on a pedestal as the envy of the western world. And as the system is now synonymous with hardworking clinicians, negative patient feedback is stifled further. We can’t possibly criticise overworked nurses, can we?

And so we don’t seek policy change or campaign for specific meaningful investment.

I too trusted the NHS once.

As a secondary school teacher, I was confident that the health service would be there for me in much the same way as I supported my students. But after the 15 months it took to fight for a cancer diagnosis at 29, that blind trust is long gone. Thousands of others are placed in a similar or worse situation every year, many of us waiting months or years to be diagnosed.

But there’s no use complaining about the delay. You’re told no mistake has been made; your treatment was timely; the only thing failing the NHS is ‘limited resources’ – something seemingly out of any one person’s hands.

As a secondary school teacher, I was confident that the health service would be there for me in much the same way as I supported my students. But after the 15 months it took to fight for a cancer diagnosis at 29, that blind trust is long gone.

‘Limited resources’ has become a catch-all of excuses; the ultimate shut-down of debate and improvement. This inertia now pervades the public, NHS workers and politicians too.

And to those whose eyes are open to the NHS’s issues, what options are there but disillusionment and disempowerment?

Certainly you can’t speak up. The formal complaints procedure is out of reach for anyone who values their mental health. Policy decisions are kept far away from patients. Not one person sits on the NHS England board in the sole capacity of a patient. Where is our People’s Champion? Who represents our views? Even NHS jargon, either purposefully esoteric or pointlessly truistic (‘person-centred care’ – I ask you!), seems set to complicate matters further.

With no opportunity to campaign for better, disillusionment breeds frustration. Harsh words are spoken. Commissioners begin to believe all patients just want to cause trouble; they batten down the hatches; they don’t want to engage. The public is perceived as too passionate, too uncontrollable.

Behind closed doors, financial decisions take priority over human life. Commissioners are told they can’t slide into further debt, so NICE guidance is overruled, services cut, waiting times lengthened… capacity never found. Propaganda states that private hospitals are the devil for putting profits first – but is this worse than an NHS at the mercy of an austerity-leaning government?

I paint a picture steeped in impossibility – everything seems just too difficult. With the menacing rhetoric, the ‘limited resources’, the jargon, the adversarial public relationships, the demonised government, the politicised system, the fact that policy decisions are all made so very far away… how can change ever be made?

The solution is brutal honesty.

The NHS in its current form is a system born of policy, targets and financial investment. Viewing it as such allows us to talk frankly about what we actually want from a health service without worrying about denigrating overworked staff or bruising our national pride.

The NHS in its current form is a system born of policy, targets and financial investment. Viewing it as such allows us to talk frankly about what we actually want from a health service without worrying about denigrating overworked staff or bruising our national pride.

Hard questions do not just need posing, they also need answering. And it is the public’s responsibility to do just that.

How long does Grandma really need wait for her hip replacement? A month, or two. Shouldn’t all cancer patients be diagnosed within two weeks? Yes! Do we really want our hardworking doctors and nurses run in to the ground? Definitely not. And fundamentally, don’t we all want a service that genuinely meets the needs of all?

The nation’s answers to these blunt questions must replace the current moveable targets that are so easily manipulated. Instead, they will form a transparent contract outlining what the public can expect from the NHS, with no place for blind trust in vague promises. Solid expectations would empower us all to champion ourselves.

But to reach this open and honest world, culture needs to change. The NHS should never feel faceless or corporate but should be ‘people powered’ and wholly entwined with the local community. Red pens should be wielded to cut the jargon that makes strategy so inaccessible. Communication channels should open – through social media, email, by providing open-office hours, and launching Westminster ‘fly-ins’ to engage the public in debate.

Complaints should be treated as opportunities to improve rather than pesky letters to be dismissed and ignored by departments that are so distanced from the front line. Leaders must stop seeing policy as a set of divine commandments inscribed in stone, but guidance to be challenged and upgraded.

And in all this, the public should be reimagined, not as the ‘great unwashed’ fixated on problems, but as energetic folk with the capacity to lead on improvements with innovation, passion, and resolve.


Dr Umesh Prabhu

Medical Director for 14 years,
Comment date
19 March 2018

Dear Laura, very well written article. I love your title! If only NHS is an honest organization! NHS has an amazing staff and their dedication is beyond belief but it is the culture of bullying, harassment, victimization, discrimination which is shocking.

NHS is an insular organization. Its leaders move from one place to another. Club culture, old boys network are rife. Yes, it needs more resource but only giving more resource without changing current leadership, the culture will not change anything.

Today in NHS, out of £127 Billion a year, nearly £20 to £30 Billion can be saved if we get leadership, good governance, excellent staff and patient engagement right and if we transform the service.

Racism, bullying, harassment and bad treatment of many BME staff and those who stand up for theirs and patients rights like Whistleblowers lives have been destroyed by many leaders and no one has been held to account!

We need safest and the best NHS and only honest, sincere, kind, caring leaders can make NHS safest and the best and an honest organization.

NHS does have many good leaders and it is their job to make sure bad leaders who bully staff are removed and there is accountability for each and everyone. NHS must promote a culture of learning and supportive culture than a culture of blaming, shaming and discipline and rewarding wrong leaders and wrong managers simply because they collude with a bad system. bad process and bad leaders.

Until and unless we have clear accountability and good governance in NHS, we will keep on wasting money and many patients, staff, and NHS will continue to suffer.

Pearl Baker

Carer/Independent Mental Health Advocate and Adviser,
Comment date
19 March 2018

A number of years ago I was admitted to Hospital for a serious Kidney condition, after several attempts to remove Kidney stones by Laser Treatments, one last difficult operation was planned to save this very 'small kidney'? I asked the question 'if this operation is not possible will you remove my kidney'? I would think so?

It was unfortunate the operation was not possible, however I still had my 'very small' Kidney? I joined others of a similar age waiting to recover before going home.

The short stay on this WARD gave me an insight into the delivery of food to those quite unable to reach the tray placed at the bottom of their beds. I decided to feed a very elderly lady who could not speak, or do anything else for herself, she nodded if she wanted more, and shook her head when she had enough.

I returned to my bed with 'dripping' blood from the cannula fitment to my hand. I was informed to return to my bed and place pressure to my hand. I requested for it to be removed, but that came later. My blood pressure was taken, but informed by another that I was not sitting in the correct position to get a correct reading.

I took the decision to write to the Chief Executive regarding the elderly lady I fed with my concerns, others within this small ward said had I not fed her she would have gone without.

At home and still with my 'very small kidney' I enquired when it would be removed? you will need another appointment? I decided to seek help from a Consultant Urologist in the Private sector. I requested my file should be forwarded on for a second opinion, this request was not met very well and I was informed you will need to be referred by your GP? incorrect if a Private Patient. My request that this operation be carried out within the next 14days by the very nice NHS/Private Consultant or I go Private, was accepted.

This is where my troubles began: I was admitted to the same ward I had concerns about, and payback time was on the 'Cards', after a very difficult operation that lasted several hours. I was not spoken to by anybody, other than to say have you 'washed' yourself, this is a few hours after the operation, with a bowl of water, and my toiletries on the floor out of my reach it was not possible, during the night I requested help as I was feeling pain from the catheter bag: I was informed it is because you are lying on the tube. The following day I was approached by an auxiliary member of staff asking if I been to have a wash in the bathroom, my reply was I am not sure I can get out of bed.

My experience in this Hospital remains with me today. The question is should I have put forward my concerns to the CEO? or just remain silent? I have a friend who is a Consultant and did discuss my options, where I made my decision to take my concerns to the CEO. (only about the feeding of those unable to feed themselves)

I was discharged from Hospital just one day after Surgery, arriving home in Pain and very 'yellow'. I contacted the District Nurse to visit me, she was amazed I was discharged so quickly, blood taken identified an infection, and raised 'liver' function. It appeared I was allergic to Paracetamol.

The Surgeon did an excellent 'job' but the entire experience has left me scared. My report entitled 'the demise of my right Kidney cradle to the grave' made interesting reading.

This is a 'sample of my experiences throughout the life of my Kidney Stones experience, however the Surgeon and investigation Team cannot be 'faulted', but something went badly wrong on this 'journey'.

My suggestion that 'volunteers' even family members could be used to deliver a service (feeding) at mealtimes would not only safe money, but would ensure those unable to feed themselves received essential nourishment.

Old NHS employee

Comment date
21 March 2018

Fantastic article. I totally agree with Dr Umesh Prabhu. Having worked in a marketing function supporting CCGs (on a contract), I can say hand on heart that there is a problem of not prioritizing recruitment of talent from outside NHS. There is a whirlpool of long-serving, mono-skilled and de-motivated NHS staff, being saved during consultations, so it is very difficult for talented, fresh-thinking and upskilled staff to break into this land and offer fresh thinking, solutions and strong business acumen gained in the 'harder-nosed' commercial world.

Promoting and shifting staff internally just because jobs are at risk is not the way to improve the services and communications to meet these higher targets. I cannot see how the NHS can even help itself, despite the public negativity, unless these barriers come down.

Helen Sanderson

Head of Professions and Quality.,
Comment date
23 March 2018

What a refreshing article.
I have been saying for so long now that unless our patients and relatives are informed and truly understand the plight of the NHS nothing will change in a hurry. Chronic underfunding, political smoke and mirrors and a target driven culture (not all are bad) have left staff and their teams exhausted, demoralised and leaving in droves.
I absolutely believe that the governments tactic is a deliberate 'run down' of the NHS in its current form so the knights in white chargers can come along and save it. The public need to start thinking differently about the use of the resources, what absolutely needs to undertaken and when, what can you wait for and what actually you may have to and should fund yourself possibly outside of the NHS - but of course that is a completely different then political argument. The public needs to do everything in its power to have and educated, informed and where possible un-emotional debate about the future of the service.
An open culture, complete honesty and stable leadership with caring, considerate and determined people is vital but we must have the resources, time and training to grow this with a decent structure wrapped around teams to deliver the longevity required to make long lasting an sustainable change to the system.
Change is needed, change is welcome and an informed public could absolutely make this happen.


Comment date
23 March 2018

Thank you, Laura. The openness and honesty so sadly lacking in much of the NHS. I have even heard an NHS Manager say 'What do 'they' expect? It's not as though 'they' are paying for it'. I thanked the Manager for working for no salary - the consequence of working in something that no one pays for.
I too thought cancer services would be good and caring. Round one - timely but awful experience. Then monitored by someone without an oncology specialty. Complaint took 3 months and was the most stressful experience of my life. Some solution for me but silence about any action to help others or review the quality of the experience. Round two - the new Consultant wants urgent surgery for suspected recurrence. No timeline and tracker if you are not a GP referral. You wait with fingers crossed for a cancellation. Targets for one thing means that others become the lengthy waiting list. Is it really surprising that our cancer survival rates low? Please can we have openness and honesty. Praise the many good staff and do something about those who let the side down. The NHS is a public service, not a religion. To criticise it is not blasphemy.

David Peach

Comment date
23 March 2018

LAURA you trusted the NHS once :-Since Major put trusts in place, that started the decline caused often mismanagement and nepotism to certain private services i.e. Nurses Bank. This New NHS Model catering for a quagmire of quangos is going to run the NHS into the ground with Red Tape. I heard that they were going to base it on the American Healthcare system as we know millions of American are suffering JAMES HUNT his aim is political mainly because the Conservatives hated this great British institution because of it being a Nationalised organisation. If they had not destroyed the NHS CONSTITUTION it still would be the best in the World.

Harry Buckland

Retired GP principle,
Comment date
23 March 2018

1) The Kings Fund should distribute to every house hold in the UK their impossibly complicated organogram showing the multitude of quangos having input to CCGs.
2) They should expose the way in which members of these quangos are selected.
3) They should make the salaries of CCG members public. To my certain knowledge the lead GP is paid £90,000 to £100.000 per annum thereby trashing their claim to objectivity.

I do not really expect publication of this comment since the Kings Fund is a charity dependent on the government for it's funding

Mary Morris

Comment date
23 March 2018

The NHS is a monolithic organisation inundated by tiers of Band 6/7/8 managers who don't manage; it’s also plagued by 'management consultants' who are paid quite scandalous sums of taxpayers money to give ‘professional advice’ year after year after year…..I suspect the NHS has kept many a management consultancy afloat for the last quarter of a century!
Leadership and management is always the underpinning of a successful organisation and a minority of the NHS do get it right. I’ve worked in the NHS and private sectors for 40 years and can make objective comparisons. Recently I’ve visited many trusts across the country in a working capacity and seen considerable displays of bad practice with the odd flashes of excellence. Those organisations who follow the mantra of 'overworked and underpaid' are usually the poor performers whose staff are steeped in negativity, lack leadership and any sense of direction.
Bad practice, poor performance should be eliminated not covered up; this catechism of 'learning from mistakes' needs to highlight the 'mistake' has usually cost some patient their life!

John Carlisle

Comment date
26 March 2018

I am an altruistic kidney donor and have thus been through more than a year of exposure to the NHS from application to discharge at the age of 70.
I am happy to be interviewed or to write an article for you about my experiences, which included an emergency admission after discharge.


Clinician, manager, educator, healthcare leader,
Prefer not to state
Comment date
26 March 2018

Thanks, Laura for a raising what is the 'elephant in the room' in such a well written piece and for Kings Fund to choose this theme.

I am a medic but am writing this as a father of two, who has lost a child during child birth and a husband who has seen his wife suffer through labour on three occasions.

Cliched, but I HAVE seen both sides of the coin - and it's not a nice picture on either side!

As a carer, I have witnessed, what can best be described as sub-human treatment of women on labour wards. I was shocked to witness a senior Obs/Gynae trainee (ST6) slap my wife saying she needed to push harder to 'save her child'. Thanks to the intervention of a sensible ST3 who care to examine my wife that the baby's head had rotated in the birth canal and they had to call the consultant and use forceps to assist in a successful delivery. Am sure the outcome would have been different if she had persisted with slapping. A complaint was met with an iron wall. A few years later, in the same hospital, we were sent home during labour as 'there was plenty of time and no worrying features' (when my wife was classed as a 'high risk pregnancy') during a course of 12 hours we lost our baby. They were discussing it at the bedside of my wife and within my hearing distance and we were 'informed' later. It is not possible to determine outcomes with certainty but the probability of a medical intervention while in hospital and on a fetal monitor versus being at home is anyone's guess. The ongoing behaviour and dealing with complaints is another story all together. To save myself the pain, I am not going into details.

As a clinician, manager, trainer and researcher I face the 'resource crunch' mantra everyday while what I experience is lack of training in improvement science - which is thought of (by the majority of healthcare workers) as a 'tickbox' exercise. Rationalisation of services is met with personalities and attitudes rather than data. On the otherhand, while the mantra of "being open" and "inclusive" is being chanted constantly, dare you raise anything that shows lack of competence in understanding the problem at hand or does not comply with published 'strategic views'. Competence is 'rewarded' either by being overburdened with work or by being sidelined.

It is difficult, no, it's actually impossible to confidently raise a concern and know it will be given a fair hearing/listening to.

I have heard (more than I would like to hear) "patient engagement", "patient centered care" etc. being used at meetings, education conferences, etc. but have yet to see a meaningful application of this across a hospital system.

There is a lot of goodwill in the system and I have seen staff perform upto 50-100% more that what is in their job description and what they get paid for. But this is not sustainable and is being worn out. It will eventually lead to more mistakes. Above all, this is not and should not be used as an argument or justification against putting the service under the microscope and planning for improvement.

Policy, implementation and service delivery, staff development need to be analysed and above all the workforce should be trained and supported to deliver clinical leadership and have control of clinical budgets.

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