Demand

Is the NHS under-resourced to deliver what is asked of it? Estimates from august think tanks and national audits describe that it is, the scale of the under-resourcing and the deficits in staffing and infrastructure created. The Darzi report identified a £11.6bn backlog in capital expenditure in the NHS in England. We have fewer beds (2.4 vs 4.3 per thousand), doctors (3.2 vs 3.7 per thousand) and scanners (19 vs 41 per million) than our OECD comparators. To keep pace with demographic changes, new technologies and drugs and the increased use of some surgical procedures, it’s estimated healthcare provision should increase 4% year on year. All OECD countries struggle with increasing healthcare spend.

Radiology services are on the sharp end of this demand growth. Imaging demand is increasing year-on-year at about 5% in the UK. For complex cross sectional imaging, demand growth was 11% in 2023 alone. Unplanned and out-of-hours imaging demand has increased 40% in 5 years. It’s rare for a clinical initiative or guideline to suggest we need less imaging, or less urgent imaging. Getting it Right First Time usually requires early imaging to make certain an uncertain clinical picture. The development of new therapies often mandates more, and more frequent, imaging. The Richards Report indicated that a 20% increase in imaging delivery was needed.

Can we control this healthcare growth? The idea of demand control in healthcare is fraught with complex ethical and moral dilemmas about access to treatment, the nature of the doctor-patient relationship and the needs of the individual versus those of the collective. The language we use (‘rationing’, ‘postcode lottery’, ‘playing God’) and powerful stories about individuals or groups denied care on the basis of decision making by ‘faceless bureaucrats’ means that rational debate about demand management in healthcare is challenging. Demand management calls into question what we mean by comprehensive healthcare and how society should respond to the needs of vulnerable people.

Even discussion about prevention and public health, effective and on-the-face-of-it uncontroversial ways to improve population health and thereby control demand long term, is freighted with unhelpful language (‘nanny statism’) and arguments about personal liberty and choice (the latter supported by powerful corporate lobbyists whose interests are risked by state interventions for smoking, alcohol and obesity). Initiatives targeting the most needy and aimed at equitable (rather than equal) resource distribution are sometimes denigrated as ‘woke’.

In the financial year 2022-23, the UK government spent £239bn on healthcare (mainly on the NHS), 18% of the total public-sector spend and 11% of GDP. At 4% growth in 10 years time this figure will be (a back of the envelope calculation) 50% greater. Healthcare spending, often protected, has already increased at the expense of other government departmental spending (especially defence – see figure) with little further room for cannibalisation of other budgets. The often advocated narrative of economic growth to deliver spending resource seems a forlorn and remote aspiration given anaemic growth figures for the UK and most other advanced economies over the last decade.

Health (green) and defence (magenta) spending as share of GDP 1955-2021

Figure source: Institute for Fiscal Studies Taxlab. What does the government spend money on?

There are undoubtedly productivity gains to be made and in radiology many potential solutions are well rehearsed: comprehensive and careful request vetting, electronic systems to support it (and to feedback to referring colleagues), decision support tools (such as iRefer) at the point of request and visibility of requests and booked scan appointments within the electronic patient record are all technical innovations that can improve a requesting culture, reduce duplication and deliver marginal reductions in demand. Skill mix and better use of radiographer reporting can help with workload and is already well established for some teams and imaging types (especially ultrasound and plain film imaging). Perhaps artificial intelligence will finally deliver its promise? Will this be enough? I doubt it.

So how can we deliver? With our current model of healthcare, ultimately, we will not be able to. The spending graphs for healthcare as a proportion of GDP extrapolate to this inevitability. Without rethinking the model, services will fail, little by little and around the edges at first in a myriad unplanned ways. The deterioration will manifest as longer waiting times and failure to meet constitutional and other standards, increases in falls, failures in infection prevention and control, loss of access for marginalised groups, estate degradation, workforce crises, increased complaints and litigation and in other, sometimes immeasurable, important ways. Does this sound familiar? It’s happening already. The irony is that as we spend more on increasingly expensive, process focussed, fractured and technology driven healthcare, we deliver less health and the experience of service users deteriorates. Healthcare delivery is more than just logistics.

We cannot address delivery without controlling demand in a systemwide manner. This especially applies to complex new therapies, imaging and drugs (which are the primary drivers of increased spending). Practical demand management is hard because we assume more healthcare equals better health, are beguiled by technology, no longer understand risk and are wedded to pathway solutions that reduce some of the intangibles of the human interaction between a patient and a healthcare professional to nodes on a decision tree from which every branch results in more to do. It is also hard because our political structures rely on promises made in a brief electoral cycle, subordinating the ability of our institutions to undertake long term planning. Complex decisions like those that are needed to equitably and ethically address demand are ignored because there will be politically unpalatable losses in the medium term while the wins may take many years to manifest.

What’s the solution? A massive funding pivot to primary care and its ability to resolve many simple issues quickly, cheaply and effectively? Removing healthcare delivery from governmental control altogether, sacking the Secretary of State and assigning a fixed proportion of GDP for 25 years to allow long term planning? Addressing the social determinants of health: education, housing, lifestyle choice, opportunity, inequality? Robust implementation of cost-effectiveness principles in healthcare design? Public education about risk? Promotion of a stoic understanding of what it means to live a good life, knowing that death is inevitable?

If all that seems too far outside your zones of control or influence then perhaps in your day-to-day practice take a moment to consider the things you can change. Each time you make a decision, ask yourself: is this test, treatment, referral or innovation really needed? Who am I treating, the patient or myself? Is it easier to do the wrong thing than the right thing and if so, why? Am I too busy to think about this? Am I too proud or too anxious to ask for help? We all have a role to play in identifying pointless, wasted or supplier-induced demand. Making better small decisions every day is achievable and accumulations of hundreds of thousands of tiny marginal gains can have a big effect. This will not be sufficient on its own, but it’s necessary, vitally so.

Demand. It’s the elephant in the room of healthcare funding. Ignore it and sooner or later we’ll all be trampled. It’s our urgent responsibility as healthcare professionals to act to control demand, even if our government seems unable to.

Excellence, or is good-enough radiology good-enough?

Some questions:

You have a new MRI scanner that can provide lots of additional sequences that increase diagnostic sensitivity slightly but also increase scan time by 25%. Do you implement them?

A trial identifies that a new cancer surveillance protocol improves recurrence detection rates but involves twice as much imaging as the previous protocol. Do you agree to its introduction?

You review non-urgent overnight inpatient imaging and find that next-morning reporting rarely (but not never) results in harm. How much expensive overnight resource do you allocate to manage this risk?

The RCR Quality Standard for Imaging provides a starting point in setting out a comprehensive quality baseline for a radiology department with detailed descriptors across many domains. It describes a service fulfilling the imaging need of the population it serves quickly, safely, effectively, collaboratively and with dignity. A excellent imaging service should (arguably) also provide its workforce with a career structure that allows them to personally and professionally flourish with interesting and stimulating work and the opportunity to innovate or spread the innovations of others.

Does an excellent service require decisions such as the ones I’ve outlined above? Could it deliver more out-of-hours reporting without impact on daytime capacity? Would it have the redundancy to increase scan times for some imaging by 25% and the funding to cope with twice as much imaging as the previous protocol? Or would a service implementing such change without challenge be an un-fundable and undesirable fairytale lacking understanding of the wider societal context of resource allocation?

Where do we draw the line at good-enough? Does it matter if a particular decision might expose a small number of patients to harm if it will mitigate other operational risks? Is the potential stifling of innovation (for example by not funding new devices or drugs, preventing the use of new imaging sequences) reasonable if money is productively diverted elsewhere? Does a culture that accepts good-enough inevitably eventually lead to degeneration into a rump or failing service? What do our patients and their relatives think? What compromises are they willing to make or willing to allow us to make on their behalf?

I doubt many go into healthcare to offer a good-enough service. There is no inspiring vision in the average nor stirring narrative in the adequate. Healthcare is seen as urgent, heroic, saintly, uncompromising: ’Going the extra mile’, ‘Doing the right thing’, ‘Pulling out all the stops’. If we place limits on healthcare professionals’ autonomy to manage patients and services as they think appropriate, does that reduce them to highly-skilled pieceworkers, moving from one patient to the next, constrained by the mandates of a system they have limited power to alter. What does that do for professional satisfaction, identity and social role?

And yet much of healthcare is repetitive and mundane piecework. In radiology it’s the backlog of thousands of routine scans, the GP reporting basket, the waiting list for an image guided biopsy or a fistulaplasty. This work is not sexy or cutting edge but that does not mean it’s not fundamental to what we do and who we are. And of course, each of these mundane events is a source of considerable anxiety, and may even be life changing, for the patient involved.

Lots of questions. Paragraphs of them. To reach an answer needs an exploration of ethics and morality, an understanding of organisational psychology and a wider conversation about what we consider important. Philosophers have wrangled with these big questions for centuries without definitive conclusion. Yet decisions, like the three examples at the top of this blogpost, need to be made and need to be made now. They will not wait for a psycho-sociocultural analysis of how modern society approaches moral philosophy or even for a cost utility analyses. How then do we make them?

The answer, I think, is to recognise that while the questions (and many others in healthcare) seem simple, almost binary (implement or not), in fact they are wicked. A wicked question has a number of characteristics including the lack of a clear definition, the involvement of many stakeholders (with different priorities, ethics and worldviews) and the lack of clear criteria for determining whether the answer arrived at was ‘correct’. For example, implementing the new surveillance program described above might be enthusiastically welcomed by patients with the particular cancer involved, but not by others who see resource diverted. It might we embraced by clinicians excited by the opportunity to improve their service, or resented for the increased workload. A review describing the number of additional recurrent cancers identified and the number of additional scans undertaken might equally be interpreted as identifying a great step forward in care or a colossal waste of money.

Management of wicked problems can be undertaken in a variety of ways from the imposition of a solution by those who wield power (and who may- or may not- own the consequences of their decision) to broad collaboration and iterating to an outcome where the driver is agreement on a solution rather than the solution itself. We might want to implement the new cancer follow up protocol, or we might not, but all stakeholders should feel able to contribute to the decision and at least be satisfied that their voice has been heard and understood, even if the ultimate decision made was not one they favoured.

So where does this leave excellence in radiology?

It means that excellence is not fixed, it’s constantly moving, changing and adapting. It requires ongoing conversations: with the people who deliver, pay for and organise the service; with the people who use it; and crucially with the people who experience it – our patients. It means exploring what we can offer and then delivering it well. There may be agreed metrics or standards and these may change over time – but these metrics need to be meaningful for everyone, else they will be resented or ignored. Excellence, however, does not mean we need to do or offer everything. What we choose to do is up to us to decide. Good-enough can be, and often is, excellent.

This collaboration and shared purpose is the protection against the professional disenfranchisement associated with the mundane. Feeling part of a bigger whole, of a movement, drives engagement and job satisfaction, as the (well rehearsed and possibly apocryphal) story about President Kennedy and a cleaner at NASA illustrates. The RCR QSI document sets exacting standards for good-enough which protect against mediocrity. Collaboration in their implementation and beyond will drive services to be better, not worse.

Excellence is not an endpoint, it’s a process. It’s bigger than the individual decisions made about whether or not to do a particular thing. Decisions about increasing our sequences, adopting a new surveillance strategy, resourcing overnight reporting and a myriad of others require us to work together.

Working together for a common goal. That’s excellence in radiology.

NHS workforce and the reality distortion field.

The process of designing the first Apple Macintosh computer in the early 1980s was an arduous one. The exacting demands of Apple co-founder Steve Jobs resulted in his employees and colleagues describing a ‘reality distortion field’ around him and the people who came into his orbit, within which the impossible became possible. Rectangles with rounded corners when the processor couldn’t draw a circle? No problem. A device with a footprint smaller than a phone book when everything else was three times this size? OK. Shave half a minute off an already streamlined boot process? Yeah, we can do that.

Jobs was able to bridge the gulf between expectation and reality by the clarity of his idea assisted by the sheer force of his personality, his drive, his obsession and a large dose of behaviour one might describe as bullying.

In today’s NHS we see a huge gulf between expectation and reality. Amongst other laudable aspirations NHS England [NHSE] expects to eliminate elective waits of over 65 weeks by March 2024 and increase diagnostic activity to 120% of pre-pandemic levels by April 2023. There will be improved cancer waiting times and outcomes, delivery of 50 million more GP appointments, upgraded maternity services and more, all delivered within a balanced budget.

And yet as I write, emergency departments are full to overflowing and secondary care is snarled up as social care cannot take discharges. High cost resources like theatres stand idle as hospitals grind to a halt. Primary care is drowning in demand. Much infrastructure is ageing. Estate is frequently tired, cramped and unfit for purpose. In this context, a reality distortion field with the metaphorical power of a black hole is required to make NHSE’s objectives seem even remotely achievable.

There are things that can be done: waste can be reduced and unnecessary bureaucracy eliminated; skill mix can be improved and workforce better deployed; estate can be upgraded flexibly to allow for new ways of working; services can be made more responsive to the needs of the people the NHS serves. Perhaps demand or public and political expectation can be managed. Maybe artificial intelligence or other technocratic solutions can finally deliver on their promise. We can refresh our NHS and make it comparable again with the best of our neighbouring nations.

To achieve all this requires money. This is necessary but insufficient. It also requires people.

Without a motivated, engaged, enthusiastic, driven workforce, recovering from the current crisis will be impossible. It’s the staff of the NHS and social care sector who identify the blockages and inefficiencies and create the solutions needed to improve at all levels: from district nursing team to quaternary hospital service, from clinic to Integrated Care Board. This is not a new concept: Kaizen methodology with continuous improvement driven by all staff is well established in business and healthcare. It is the staff who deliver.

Jobs recognised the importance of people in delivering his vision. He surrounded himself with people he described as his ‘A’ team. They achieved what they did because while he was a martinet character, difficult to work with, prone to bouts of anger, rudeness and extreme condescension he was also inspiring, he imbued loyalty and belief. People wanted to work for him, to deliver for him.

Given the strong vocational ethos in the NHS workforce, it should be easy to motivate its staff. But instead I perceive a disillusionment and learned helplessness that I have never known before. This is corrosive to initiative and problem solving. Motivating the workforce means paying people appropriately, recognising that pay and compensation have a salient effect on morale and on the recruitment of new colleagues and the retention of old ones. It means publishing a long overdue workforce strategy. It means listening, and understanding the daily frustrations that erode professionalism and vocational drive. It means appreciating that working in ageing buildings with ageing equipment will inevitably breed apathy. It means transformative investment.

But more than this the NHS needs a transformative vision, akin to that seen at its inception. This means having the bravery and honesty to start a public discourse on how to fund the NHS and social care long term: what we can (or choose to) afford as a country and what we cannot (or choose not to). It means confronting difficult policy decisions about cost-effectiveness and service rationing with public, professionals and industry. It means addressing both demand for- and supply of- healthcare. Everyone I know in the NHS recognises the fact that we cannot go on as we are spending more and more on increasingly marginal outcomes.

And this is where the reality distortion field can help: because with the development of a transformative vision and a clear commitment to transformative investment I believe the NHS’s staff will deliver the solutions required. It has happened before and can happen again. Even before the money flows, the idea that the government understands and is committed to action will empower the workforce. It will allow the distortion field to develop and the gulf between expectation and reality to be bridged. But until the vision is developed and the investment begins there will be no reality distortion in the NHS. Just a grim reality.

Where might the vision come from? It’s clear not from our current government who seem to only have a wish-list of near-future outcomes expedient to help with their prospects at the next general election. To me, the only option seems to be a long term collaborative effort across successive Parliaments and political ideologies and involving all public, private, patient and professional stakeholders to co-create it. Whether there is the political will, executive structure or inspiring leader to facilitate this remains to be seen. Steve Barclay is not Steve Jobs.

Moral hazard in a failing service

I go to see a woman on the ward to tell her that, again, her procedure is cancelled. I see, written in the resigned expression on her face, the effort and emotional energy it has taken to get herself here: arrangements she made about the care of her household, relatives providing transport from her home over 70 miles away and now unexpectedly called to pick her up. A day waiting, the anxiety building as a 9am appointment became 10, then lunchtime, then afternoon. The tedious arrangements to be necessarily repeated: COVID swabs, blood tests, anticoagulation bridging. All wasted.

She smiles at me as I apologise. She is kind, rather than angry, understanding rather than belligerent. And yet she has every right to be furious. This is, after all, the second time this has happened. And she knows as well as I do that my attempts at assurance that we will prioritise her bed for the next appointment she is offered are as empty and meaningless as they were last time she heard them.

Such stories are the everyday reality for patients and clinicians within the NHS, repeated thousands of times a day across the country, each one a small quantum of misery. At least my patient got an appointment. Some don’t. Ask anyone with a condition that is not life threatening or somehow subject to media scrutiny or an arbitrary governmental target about their access to planned hospital care and you will likely get a snort of derision or a sob of hopelessness. Benign gynaecological conditions (for example) can be debilitating but frequently slip to the bottom of the priority list, suffered in private silence, without advocates able to leverage the rhetorical and emotional weight of a cancer diagnosis.

This is not all COVID related. Yes, COVID has made things worse but really all the pandemic has done is cruelly reveal the structural inadequacies that we have been working around in the NHS for years and years. ‘Winter pressures’ have reliably and predictably closed planned care services even if it took until winter 2017 for the NHS to officially recognise this and cancel all elective surgery for weeks. Estate is often old and not fit for purpose. Departmental and ward geography does not allow for the patient separation and flow demanded by modern healthcare. Staffing rotas are stretched to the limit with no redundancy for absence. Old infrastructure and equipment requires inefficient workarounds. Increasing effort goes into Byzantine plans for ‘service continuity’ to deal with operational risks, while the fundamentals remain unaddressed.

Efficiency requires investment. You cannot move from a production line using humans to one using robots without investing in the robots to do the work and the skilled people to run them. You cannot move from an inpatient to an outpatient model of care for a condition without investing in the infrastructure and people to oversee that pathway. You cannot manage planned and unplanned care via a single resource without adversely affecting the efficiency of both. You cannot expect a hugely expensive operating theatre or interventional radiology suite to function productively if the personnel tasked with running it spend a significant proportion of their day juggling cases and staff in an (often vain) attempt to get at least a few patients ready and through the department. Modern healthcare requires many systems to function optimally (or at least adequately) before anything can be done. Expensive resources frequently lie idle when a failure in one process results in the entire patient pathway collapsing.

The moral hazard encountered by people working in this creaking system is huge. How can we feel proud of the service we offer when failure is a daily occurrence? When we, the patient facing front-of-house, are routinely embarrassed by – or apologetic for – the system which we represent. We can retreat into the daily small victories: a patient treated well, with compassion, leaving satisfied; an emergency expertly, efficiently and speedily dealt with; teamwork. But these small victories seem to be less and less consoling as the failures mount. Eventually staff (people after all) lose belief, drive and motivation. Disillusionment breeds diffidence, apathy and disengagement. The service, reliant on motivated and culturally engaged teams, becomes less safe, less caring, less personal and even more inefficient as staff are no longer inclined to work occasionally over and above their job planned activity. A bureaucracy of resource management develops and teams become splintered. Process replaces culture and a credentialed skill-mix replaces trusted professional relationships.

The moral hazard is compounded by the seemingly wilful blindness of our political masters, the holders of the purse strings, to comprehend the size of the problem. Absent any real prospect of improvement, we learn to accept the status-quo, the cancellations, the delay, the waiting lists. And our patients accept this too: how else does one explain their weary stoicism. Meanwhile our leaders cajole us to be more efficient, to embrace new ways of working, to do a lot more with a bit more money. It remains politically expedient to disguise a few percent increase in healthcare revenue spending as ‘record investment’ but I argue that most people working at all levels in the NHS recognise the need for transformative generational investment on a level not seen since the inception of the service. Such investment requires money and money means taxation.

More than that, there needs to be the political bravery to open a considered debate about what we mean by healthcare, where our money is most efficiently targeted and what we, as a society can (or are willing to) afford in amongst other priorities for governmental spending. Shiny new hospitals providing state-of-the-art treatment may make good PR but are meaningless without functional well funded primary care. Investment in complex clinical technologies will not improve our nation’s health if the social determinants of this (poverty, smoking, diet, housing, education, joblessness, social exclusion) remain unaddressed. Such a discourse seems anathema to our current politics with its emphasis on the individual, on technocratic solutions and on the empty promise of being able to have everything we want at minimal personal, environmental or societal cost.

Until our leaders start this debate, and until we, as members of society, understand the arguments and elect politicians to enact its conclusions, ‘our NHS’ will continue to provide sometimes substandard and inefficient care in a service defined by its own introspection rather than by the needs of the community it should serve. Our healthcare metrics will continue to lag behind those of comparator nations. And I will continue to find myself, late in the afternoon, apologising to women and men for the inconvenience and anxiety as I speak to them about cancelling their procedure, hating myself for it but helpless to offer any solution or solace.