Written evidence submitted by Dr Barry Monk, MA, FRCP, Consultant Dermatologist (RTR0005)

About me: I began working for the NHS as a seventeen-year-old laboratory assistant, before qualifying in Medicine from Cambridge University in 1975. I was a consultant dermatologist in the NHS from 1987 to 2020, and continue in private practice, including a substantial amount of medicolegal work, mainly acting as an expert in medical-negligence cases. In 2021 I published a book, LIFELINE, which has achieved considerable public acclaim, about the managerial, regulatory and political failures of the NHS.

My evidence:

In my opinion, difficulties of recruitment and retention of medical staff (I do not feel qualified to express an opinion about nursing and other staff) are at heart caused by a complete breakdown in trust between doctors and managers. This has reached a point where doctors no longer feel valued or even involved. For an intelligent and motivated doctor, the NHS has ceased to be a desirable place to work.

Dr John Reid[1] served as a minister in several government departments under Tony Blair, before, in 2003, being appointed Secretary of State for Health and Social Care. It was reported in Private Eye magazine that he had greeted the news of his new job with the words, ‘Oh f*ck, not health’. Reid subsequently served as Minister of Defence and then Home Secretary, but his reaction was understandable. The Minister of Health is ultimately the person where the buck stops when problems arise in the NHS. They get blamed when things go wrong, and are rarely thanked when things go right, as they do much of the time.

Being the Minister of Health is a challenging position, but it is one that is not made easier by the short time that most of the incumbents have stayed in post. Since the founding of the NHS, there have been 30 ministers.[2] Several were in post for less than a year, and most have lasted less than two. It is all too easy when things have gone seriously wrong, for a minister to announce, often to a fanfare of approval, that there will be a public inquiry. Almost inevitably, however, by the time the inquiry reports, there will be a new minister in post and the issues which were fresh in the mind when the inquiry was established will have faded from public awareness. As happened with the Francis and Kennedy reports (into the problems at Stafford and Bristol), to name but two of many, recommendations for future action can be quietly ignored. Indeed most doctors now recognize that when a politician or a manager says ‘lessons have been learned’  in reality nothing will happen.

Every new minister, when asked for his plans, says, ‘The last thing that the NHS needs is more organisational change’. This is followed shortly afterwards by yet another re-organisation, or the creation of yet another supervisory body. The Commission for Health Improvement (CHI) was turned into the Healthcare Commission which, in turn, became the Care Quality Commission (CQC). Monitor became NHS Improvement, and then disappeared completely. The NHS Litigation Authority was re-branded as NHS Resolution. GP Fundholding and primary care trusts (PCTs) came and went. The NHS Trust Development Authority (NHSTDA) was established in 2012 and then suddenly vanished.

Even the title of the government minister has undergone repeated change. It was Minister of Health until 1968, Secretary of State for Health and Social Services until 1988, Secretary of State for Health until 2018 and then Secretary of State for Health and Social Care. Each of these organisational changes was no doubt expensive and disruptive for those involved, but did not, as far as I can establish, help a single patient to receive improved care. What it did do, however, was allow ministers to show that they were ‘doing something’, although they were rarely around long enough to see the fruits of their labours.

It was all very different from the extraordinarily streamlined system established by Bevan when the NHS was created. A management committee ran the hospitals and they, in turn, were under the direction of a number of regional health boards. Essentially, the role of the latter was to organise more specialised services that could not be provided by every hospital. Within hospitals, the managers were administrators, tasked with ensuring that the medical and nursing staff had the resources to do their work. A ward sister, who was always insistent on exemplary standards, ran each ward. A matron toured the hospital on the lookout for any deficiencies. Each consultant surgeon or physician was allocated a ward and a team of junior doctors, called a ‘firm’. Patients knew who their consultant and his juniors were, and there was a benign competitiveness between firms to be regarded as ‘the best’ which helped maintain standards of care.

Consultants had an additional vested interest in being well regarded by their patients in that GPs invariably referred their private patients to the consultants who had developed a reputation for providing good care to their NHS cases.

This may seem to be a nostalgic view of a distant past, but it was certainly how I remember things in my first few years as a consultant. Additionally, we had a consultants’ dining room, where we had lunch together, often joined by local GPs. Problems could often be identified and sorted out over a quick sandwich and a cup of coffee. The NHS has not been helped by the fact that now, patients are frequently unsure as to which consultant is responsible for their care, and rarely see the same GP twice. Nor does it help patients that, nowadays, the GPs and hospital consultants scarcely know each other.

Not only do patients no longer know the name of their GP or their consultant, they would also struggle to recall the name of their hospital. Guy’s Hospital has, after over two centuries, become Guy’s and St Thomas’ NHS Foundation Trust. The London Hospital is now The Royal London Hospital - Barts Health NHS Trust. Bedford Hospital, where I worked for many years, has suddenly become the Bedfordshire Hospitals NHS Foundation Trust. It must be a boom time for signwriters, and as for the cost of printing new, headed notepaper across the NHS, it does not bear thinking about.

A fundamental change in the NHS, and one from which many of its subsequent problems arose, occurred in 1983, when Margaret Thatcher asked Roy Griffiths,[3] a director of Sainsbury’s, to write a report on how the NHS should be run.

Griffiths proposed a much more ‘managerial’ structure for the NHS. He wrote to Norman Fowler, the minister, stating, ‘If Florence Nightingale was carrying her lamp through the corridors of the NHS today, she would almost certainly be looking for the people in charge’. Suddenly, hospital administrators began calling themselves ‘Chief Executives’, usually with enormously enhanced salaries. They were soon followed by a new breed of manager with a perplexing range of job titles such as ‘chief operating officer’, ‘patient experience co-ordinator’, ‘chief people officer’ and so on. Titles often ended with the word ‘champion’, ‘navigator’ or ‘facilitator’, but what they actually did was almost always entirely unclear.

In fact, to be fair to Griffiths, this was not his intention. He had visualised a system in which senior doctors took on most of the management roles. What he didn’t really appreciate was that the genius of Bevan’s original creation was that it was so simple that it ran itself. The last thing that most doctors wanted to involve themselves with was endless management committees.

To make matters worse, the new breed of manager invented an entirely new language, almost incomprehensible to the outsider. Their lexicon was littered with phrases such as ‘out of the box’, ‘in the box’, ‘fishbone analysis’, ‘the seven levels of why’, ‘operationalise’ and ‘sweating the ocean’. As for what any of it meant, none of us knew and few of us cared.

As a consequence, managers began to spread the fiction that doctors were resistant to change. This was completely untrue. Doctors like change and are good at it. The evidence is clear from the dramatic changes that we have seen in medicine and which have readily been embraced. What the medical profession is against is pointless and disruptive change. Some managers chose, no doubt through insecurity, to victimise any doctors who had the temerity to speak out. Griffiths had suggested that NHS managers should have the same sort of professional standards and accountability as doctors and nurses, but that has never happened. Those who failed were able to bounce from one job and one catastrophe, to the next. I know of one manager who had been a failed medical student, and who didn’t disguise her disdain for doctors. It didn’t make for a harmonious working environment.

The situation created a form of anarchy, where it was often impossible for doctors to engage with managers, and so found themselves unable to effect change when it was self-evidently required. Managers, in turn, all too often found expert medical opinion an inconvenience, which they were happy to ignore.

Inevitably, this chaotic situation would eventually end in tears. In the early 2000s, politicians decided that it would be a good idea to reduce hospital waiting-lists for surgical operations and instructed managers to take action. From now on, patients were not to be on a waiting-list for more than 18 weeks. Contrary to popular opinion, doctors don’t like having waiting-lists, but we are all trained to attend to the most urgent cases first, and if that means less serious cases waiting a little longer, so be it. However, that cut no ice with the powers that be.

The process began with the managers asking surgeons to do extra operating lists on Saturdays and Sundays. Surgeons like operating, it is what they do best, but if you do masses of operations at the weekend, then come Monday morning all the beds will be full, and all the cases booked for Monday and Tuesday will have to be cancelled. It had been totally predictable, but unanticipated by the management.

Facing pressure from their political masters to achieve the required targets for waiting-lists, they began squeezing more beds into wards. The importance of keeping beds well separated had been known since Florence Nightingale had nursed the wounded soldiers in the Crimean War, but the warnings of doctors never deterred the new style NHS manager. Soon, NHS England was being overwhelmed with a particularly nasty form of hospital-acquired infection, Clostridium difficile (C. diff), a highly infectious bacterial infection of the gut, which causes an unpleasant and potentially lethal bowel condition. The management of it involves strict isolation of affected patients, and ensuring that no-one else is admitted to the ward until it has been deep cleaned and the risk of further cross-infection eliminated.

Squeezing more than the safe number of beds into a ward was creating the perfect scenario for the spread of the infection. But shutting wards and leaving beds empty was affecting the ability of managers to achieve their targets. In 2006, there were 50,000 cases of hospital-acquired C. diff infection in England, with an estimated 5,000 deaths. The figures for 2005 and 2007 were just a fraction lower, yet, in many hospitals, managers ignored the expert advice of their own infection control teams to shut infected wards.

Curiously, the problem did not occur in Wales. This wasn’t because the River Severn and Offa’s Dyke have some peculiar antimicrobial effect, they don’t, but because NHS Wales had not embarked on the ill-judged attempt to artificially reduce waiting-lists, and had not over-crowded wards.

Over 12,000 patients died of hospital-acquired C. diff infection on NHS wards in England during those three years, as a consequence of an obsession with politically convenient targets. A couple of hospital managers in Maidstone and Buckinghamshire were dismissed as sacrificial lambs, but no-one in the Department of Health or at Ministerial level ever accepted responsibility.

The NHS is a wonderful organisation, with extraordinarily dedicated and skilful staff, but it cannot succeed when there is a virtual civil war between the doctors and nurses on one side and the managers and politicians on the other. It has now reached a point where highly trained doctors, dedicated to patient care, no longer find the NHS a place in which they are valued or respected. Bullying by managers is rife; the disgraceful saga of the West Suffolk Hospital, recently in the news, is just one example, The lives of highly experienced and capable doctors are ruined, and senior managers just bounce from one job to the next. Similar stories can be told from all over England (I have less knowledge of Scotland, Wales and Northern Ireland, although recent reports from NHS Highland do not make happy reading).

My evidence is based on a lifetime dedicated to patients; if you wish to read more, please look at my book, LIFELINE, which is available from most online book sellers.

January 2022