Last week (after a three-week wait) I went to see my GP, a senior member of a very busy and ethnically diverse central London practice. Knowing the surgery was scheduled soon to relocate to a big new redevelopment nearby I asked when the move would happen.
Usually brisk and businesslike, this time she sighed. She looked knackered. ‘We don’t know,’ she said. The practice needs to move, she explained, because it is running out of space in the grand but inconvenient Georgian townhouse it currently inhabits, where in any case the lease runs out in eight years’ time.
The reasons it is running out of space are twofold and very much of our time. The first is that more and more medical care is moving out of hospitals and into the community, and extra space – not to mention GPs, nurses and support staff – is needed to accommodate it.
The second is that another local practice, unable to cope with the mounting pressures, recently closed down (which it is perfectly entitled to do, since GPs are private contractors to the NHS, not employees). Its patients have to re-register somewhere else, and there are financial penalties for a surgery that chooses not to take them on. In effect, our surgey is in a cleft stick: it suffers if it doesn’t take the new patients on, and if it does it needs more GPs and space.
The snag with moving, however, is that rents in the new development are sky high – and the current landlord will invoke a penalty clause if the centre vacates the premises early. To sum up: the cost of the move is £500,000, which the practice doesn’t have. So relocation, and with it the future of our harassed but functioning and proactive practice, is in limbo. In the meantime, the pressures grow: ‘This is why you have to wait a month to see me’. (My sister tells me that her practice, also in London, books no more than a month ahead, so if that month is full, you can’t make an appointment at all.)
‘Anyway, in eight years’ time it will be someone else’s problem,’ the doctor said. ‘I never thought I’d say this, because I love seeing patients! But I’m 54, and there’s no way I shall stay a day after I’m 60. I’m already doing a four-day week, because of the pressure’ (she uses the other day to catch up on paperwork and read the medical journals). ‘My colleagues of my age are all the same.’ The NHS is doing nothing to induce senior GPs to stay on, she says, and fewer and fewer students are choosing to go into general practice – not because it is unattractive in itself, but because of the pressures and diktats raining down from all sides that make it impossible to do the job with any kind of satisfaction.
This is the moment – with the NHS’s stresses and strains all over the front pages and its deficit predicted to rise £30bn by 2020 – that David Cameron chooses to decree that by the same date all GP practices will open seven days a week. My doctor concedes that better out-of-hours access and possibly Sunday working are desirable, but their arbitrary imposition without discussion or any idea of the demand or resources needed fills her with despair. For many, like the closed neighbouring surgery, it will be the last straw.
In Out of the Crisis, W. Edwards Deming wrote: ‘If you have a stable system then there is no use to specify a goal. You will get whatever the system will deliver. A goal beyond the capability of the system will not be reached. If you have not a stable system, there is no point to setting a goal. There is no way to know what the system will produce: it has no capacity.’ Poor NHS. It’s not just that it has no capacity. Constantly tampered with by ministers and civil servants who have no idea how systems work, or people within them, it is being made almost daily more unstable, more difficult to manage. They are making matters worse.
It takes some doing, but we have somehow managed to contrive a situation where UK public services instead of pointing forward simultaneously unite the worst features of Soviet-style central planning and unreconstructed market capitalism: on one side detailed ministerial micro-management (dictating details of how services should be set up and run – wrong in principle as well as method chosen, since it stifles desperately-needed innovation and locks in today’s Kafkaesque inefficiencies), to the profit of private outsourcers and IT consultants whose priority is not citizens but shareholders.
It is a system riddled with waste, inefficiency and conflict of interest bordering on corruption that harassed and dedicated professionals like my doctor manage to make work, more or less, in spite of itself. They have to fight the system to do the right thing. Given the constraints of these system conditions the wonder is not that there are so many lapses and scandals, but so few. ‘There may not be an NHS in eight years’ time,’ my doctor said quietly as I left.