A portrait of the NHS’s founding father, Nye Bevan, hangs on the door of neurosurgeon Ludvic Zrinzo’s office in London. “It’s a huge inspiration to me,” he says. “Even when this country was bankrupt there was the political will to establish free healthcare for all at the point of delivery. The NHS is a huge ideological symbol of our humanity. But healthcare can be a bottomless pit, and there are difficult decisions to make.”
Those difficult decisions are examined in a major eight-part series that looks at the pressures that at times threaten to overwhelm NHS services. Filmed over one day by 100 camera crews at NHS locations all over the country, it’s a thought-provoking portrait of the world’s largest free healthcare system at work.
Zrinzo does the kind of cutting-edge surgery that still makes the NHS the envy of the world. He specialises in treating Parkinson’s disease (as can be seen in a future episode) and other conditions with a surgical technique called deep brain stimulation at London’s National Hospital for Neurology and Neurosurgery. But even his service isn’t immune from anxieties about resources.
“In cash-strapped times people start thinking about cutting the expensive procedures first. Because this sort of therapy is expensive and is sometimes used to treat rare diseases it doesn’t always get the priority that other conditions do. We have had instances where we’ve felt that a patient who suffered from cluster [also known as ‘suicide’] headaches really deserved a shot at surgery but the funding authority has refused because the evidence is not deemed strong enough. That is heartbreaking.”
The day we met in his office, which he shares with four other doctors, neurosurgeons were visiting from France, Germany and Spain to observe a worldwide first – a new technique that allows his team to perform deep brain stimulation on two patients in one day. “We’ve doubled the number of patients who can have this type of surgery using the same theatre resources without sacrificing quality,” he says. “The high demand for limited NHS resources was one of the driving factors. But it was only possible because our hospital management are forward-thinking enough to invest money in equipment to make the service more efficient.”
He is frustrated by false economies and short-sighted “savings”. “For example, if there is not enough money in the system to recruit enough nurses and retain the experienced ones, it’s difficult to provide patients with the support they need to make a speedy recovery.”
But the highs of working in the NHS far outweigh the lows. Zrinzo moved to London after qualifying in his native Malta. He was inspired to become a doctor after his neurosurgeon father saved the lives of five hostages who had been shot in the head, one after another, on a hijacked Egyptair jet in Malta in 1985.
During his neurosurgical training Zrinzo worked in the US, an experience that only made him appreciate the NHS more. “The resources in the US are fantastic, and neurosurgeons there can earn millions. But the healthcare US patients receive if they have money is very different from if they don’t. It’s awful if a patient’s insurance doesn’t provide full cover. Money drives the system. Here it’s someone else’s job to deal with the money. Clinical decisions revolve around the patient’s needs without any competing financial interests, and there is no financial incentive to perform unnecessary or more expensive procedures. That is a real plus.”
A key aspect of Zrinzo’s work is research. But his investigations into rare disorders can be hampered by the reluctance to fund clinical trials that may run into millions of pounds. “Nobody is going to invest that sort of money in looking for treatment for a disorder that affects 30 patients a year. It makes much more sense to invest in something like breast cancer research, because many more people have the disease. Yet every time we operate on the brain it is an opportunity to learn more about how it works and what causes these rare diseases. Our work with deep brain stimulation could lead to breakthroughs in the treatment of dementia, for example.
“The cash-strapped NHS may find it increasingly difficult to fund emerging treatments. On the other hand, research bodies cannot provide funding for trials without evidence that a particular treatment is promising. The challenge is how to creatively bridge this gap between clinical practice and research. I have always felt privileged to see at first hand how the NHS can change lives. Once we stop looking after the people that Nye Bevan set out to help, then perhaps we’ve lost a little bit of humanity.”
Nicholas Timmins on dilemmas facing the NHS
“The National Health Service,” the Conservative former Chancellor Nigel Lawson remarked 20 years ago, “is the closest the English have to a religion.” He might have added to that the Scots, Welsh and Northern Irish. And any suggestion that things might have changed was dispelled by the central role the NHS took in Danny Boyle’s Olympics opening ceremony.
Britons cling dearly to the founding principles from 1948: that a tax-funded service, largely free at the point of use, should deliver the best available care, everywhere, to everyone, without the fear of bankrupting medical bills. Plenty of European countries manage something very similar, without their health system producing the same patriotic fervour.
That fervour can blind us. For the NHS, despite its title, is not one organisation but many. Each has its own culture and ways of doing things. It provides some of the best healthcare available anywhere in the developed world – in hospital, in general practices and in the community. But it also provides some of the worst. Witness the events at Mid-Staffordshire between 2005 and 2009.
It also contains within it the same dilemmas that all health systems face – some of which are thrown up sharply by Keeping Britain Alive: the NHS in a Day. Balancing finance with quality. Asking doctors and others to take responsibility for the resources they use, as well as the patient in front of them. People – patients – taking responsibility for their own health and not abusing a free service. Being honest about the quality of care that is actually being delivered, and not just treating doctors and nurses as heroes and angels.
We do, peculiarly, think that the NHS is all about hospitals. There are approaching 200 hospitals or groups of hospitals in the UK. But there are also 10,000 general practises with more than 40,000 family doctors in them. On a typical day, there may be 160,000 patients in hospital and 125,000 outpatients visiting hospitals. But three times as many people – approaching 850,000 – go to their general practice, and almost 400,000 receive other care outside hospital.
Twenty per cent of the most complex patients consume more than 80 per cent of the resources, much of it in the last year of life. Better ways have to be found of managing that, and indeed of having a conversation about how officiously and expensively we strive towards the end of life – when it seems most people would prefer to die at home, not hooked up to the latest technology in a hospital bed.
All this needs confronting as the NHS faces the fiercest sustained spending squeeze in its history. Expenditure doubled over the past decade as waiting times tumbled and services improved. With 1.7m people, it is the biggest employer in the country by far. It now costs around £2,000 per head, or more than £100bn a year, and it takes around 8.6 per cent of all national income – more than the European average, but appreciably less than, say, France or Germany.
How far the NHS remains sustainable will depend partly on how much the nation is prepared to pay, individually and collectively. But getting the right answers to some of these other issues will be at least as important if the service is to continue to provide equitable access to good health care.
Nicholas Timmins is a senior fellow at charities the Institute for Government and the King’s Fund