Maisie: Page 94, the Private Eye Podcast.

Andy: Hello and welcome to another episode of Page 94.

My name's Andrew Hunter Murray, and I'm here with Helen Lewis.

Adam McQueen and our special guest, Phil Hammond.

We are here for, I mean, there's gonna be an election at some

point, an NHS Pre-election special.

Which will become relevant at some point in the next 10 months.

We are assuming.

So, uh, Phil, we wanted to ask you all sorts of questions.

Uh, Adam's got a growth that he wants you to look

Phil: at.

Um, it's cancer and you'll be dead in a fortnight.

Andy: no, we, we just thought it would be fun to get you in kind of like a reverse.

What's my line?

That's a good reference for the younger listeners there.

Keeping it real.

Yeah, absolutely.

Yeah.

Um, but Phil, you, you, you are MD as, as listeners of this podcast will know

already, , we wanted to get you in, ask you, first of all, uh, you've written

something really interesting recently about privatization and there's a lot

of discussion of NHS privatization.

Is it being privatised by stealth, is it not?

What's your take

Phil: on it?

Well, the particular article I wrote, I was sent a leaked email from the

President of the Royal College of Ophthalmologists who was making the

point that over 50% of cataracts are now done by private providers, and often

it won't go anywhere near an NHS GP.

So you can go to Spec Savers now and they pick up, you've got a cataract and

they can refer you to a private provider.

The issue there is that some of the private providers have links to.

Spec savers and other private companies.

And so as with all private medicine, there's a vested interest in overtreating.

You treating you too early, giving you three cataract

operations when you only need one.

The other issue with the outsourcing of of work to the private sector

is that they've tried to change this, but generally there isn't an

obligation to do training of NHS staff.

So if all the cataracts are on the private sector and we're not training future

ophthalmologists, then who's gonna do it?

So you cherry pick the easy cases, you make your profit, but

there's no duty on you to train.

And that bit is missing as well.

But whether that means privatization, depends on how you define privatization.

If you say this is taxpayer's money.

And contracted out to the private sector.

Some people will say that's not privatization.

Helen: So cataract operations, as I understand it, your lens gets cloudy.

Yeah.

And it's a relatively simple operation.

They take that out and they put in a, A replacement.

Yeah.

So.

It seems to me that that the reason that's such easy pickings for

privatization is because it's day surgery.

It's relatively uncomplicated.

You can do it at volume.

Yes.

Is it a kind of unique case or might we see the same kind of thing

happening with other, are there

Phil: other surgery?

No.

Well, the thing that's been going on the longest, probably that's been

going on for so long we don't talk about is private psychiatric care has

been going on for years, and some of the most serious cases are outsourced.

The private sector and the Royal College of Psychiatrist president talked to the

Guardian podcast recently and said we'd be lost without the private sector.

They're sort of codependent on each other.

We'd been reliant on them for so long.

If you suddenly said we weren't gonna use the private sector of psychiatry,

the NHS would be completely stuffed.

So that's the issue.

You might say, in my heart, I want all public services to be

publicly funded and publicly provided and publicly accountable.

The reality of the situation is that we've been outsourcing to

the private sector for so long.

Now, if we suddenly pulled up the drawbridge waiting list, we go through

the roof and that's clearly not something that Labour would contemplate.

So whether ideologically you think it's a good idea or not, it's happened for a

long time and it's probably here to stay.

My argument is if you're gonna do it, at least make the private sector do

some training or pay a levy for training because they're using generally our NHS

doctors working privately to do the work.

We need to train the next lot of junior doctors 'cause they're

really angry at the moment.

If you hadn't noticed, I've got another

Andy: basic question just before we get into any future ones.

So with the example you give of Specsavers recommending you go to a

private provider, how's that recorded?

Is that, does that get into statistics of people who've had cataracts?

Yes.

So that is, it is sort of, is known.

Phil: You're not picking off the, because it's NHS, it's

private treatment on the NHS.

But that's included when the statistics, which is why the president of the Royal

College of Ophthalmologists could say whatever he said, 56% of S are now

done outsource the private sector.

Andy: And I, as the patient, I'm paying for that.

Or it's the NHS paying, paying the NHS privately for it.

So the NHS pays for it, but they're paying maybe a higher rate because

it's your ophthalmologist or your surgeon is, is being paid a higher

rate 'cause they're working privately.

Phil: No.

Okay.

Not necessarily a higher rate.

In the old days when Labour introduced this, because they were desperate to, this

is under Tony Blair, they were desperate to encourage new entrants into the market.

They gave the private sector guaranteed contracts, whether

they did the work or not.

It's a bit like P-F-I-P-F-O is a terrible deal that HUD gave us huge mortgages.

These days actually we're a bit more savvy.

There's much less of a purchase and provide a split.

Now, Simon Stevens sort of got rid of that, but there still are these contracts.

Um, and the profiteering is probably less than it used to be, but you

would argue that the private sector take the easy cases that aren't gonna

need an NHS Intensive Care unit.

They're not people with loads of multi morbidities or whatever,

so they take the easy stuff.

And they're able to make a profit.

Uh, but it's not as hideous profiteering as it used to be.

Okay.

Helen: and that happens with lots of outsourcing generally, where the kind

of easier bits get cherry picked off by the private sector and therefore

deeply flatters the private sector.

And people say, why is the public sector so unbelievably inefficient?

And it's, as you were saying.

Lot of people with really difficult comorbidities or they're doing

more high risk work or whatever it might be, and it just, you know, it

makes it very hard to compare like

Phil: for like it does.

And that's the other thing that needs to happen.

If something goes tits up in a private operation and they need to come back

to an NHS Intensive Care unit, the private sector should pay for that.

And in the past it hasn't always, it's used the NHS as a safety net for when

its operations occasionally go tits up.

Is the

Adam: problem, the one that we an awful lot of, um, uh, uh, private eye

stories eventually seem to come back to is that the people we've got in the

public sector who are negotiating these contracts seem to be about as efficient

as kind of candidates on The Apprentice?

I mean, I would say the, the, the, the lead story we've got, the, in the last

issue was about Frank Hasa, you know, the Tory party, uh, pet racist at the moment.

but the, the figures in that are just absolutely eye watering.

the contracts he had with the NHS.

you're talking about companies pre-tax profits of 48 million

on a turnover of 76 million.

I mean, that is doing very, very well.

It's not surprising he's got tens of millions to splash

around on the Torry party.

Yes,

Phil: I think that's true.

And of course we saw that during the pandemic with all the, uh, PPE fast

lane to mates kind of thing, and people will say it was desperate times.

Prices are very high.

The, the NHS has a sad history of not.

Negotiating with public money terribly wisely.

but I come back to the original point is we are, we are, we have waiting lists of

seven 8 million now, and I can't see any particular quick way of getting them down

without involving the private sector.

Although the Times has had a health commission and one of their.

Recommendations is to have these hubs that work continuously round

the clock over certain weekends.

You take a big unit and they'll do round the clock stuff to do a massive

amount of hernias or cataracts or something to try and make an

inroad into the private sector.

And kind of like a changing

Andy: rooms or ground force thing.

Yes.

Where you've got 24 hours.

To fix as many hernias as

Phil: you can.

When they do that, they do that in India, they have mass heart surgery,

mass hernias, mass, whatever.

Yeah.

And actually people who will come to this aren't necessarily fully

quite doctors, qualified doctors, but just do hernias or something.

They're good with their hands and they, they were good at

carpentry at school or something.

So sometimes in some of the Indian places, they're not necessarily all their

technicians who've learned to do, or their nurse practitioners who've learned to do.

Endoscopies, hernias, whatever.

Okay.

So that's another interesting point.

Big question.

Does that work?

Does it, I mean, it seems to, yeah.

Okay.

But that's all they're doing, right?

Yeah,

Andy: yeah, yeah.

So in terms of the, the argument about privatization by stealth,

all of this as Helen ask, is this.

Going to go further.

Is it the next easy operation is the knee operations, which all get

farmed out to the private sector because that's a big concern

Phil: for people.

No, it's already happening.

Yeah, it's already happening.

So the Royal Hospital where I live in Bath, has taken, sort of taken

over the local Circle hospital.

It's now called Les.

And they use that and a lot of it's operations are done there.

So it's, it's already happening.

And even there are quite a few consultants, uh, consultants who

have shares in private companies.

They've set up their own concerns.

And Is that allowed?

Yes, I think so.

And they, and they're referring, they can refer patients to private consorted that

they have a financial vested interest in.

Is that allowed?

Well, what it should happen is you should declare it to the patient.

So the one thing I think private providers are here to stay,

but the patient should know.

And be told perfectly clearly, whether it's a private provider or not.

So what happened in the past is private providers used the NHS logo when

they were providing private services.

And some people complain saying, I don't want to, I think fundamentally

it's wrong to outsource the private sector, and I don't want to be

treated there, and you must tell me.

So I think that's the issue.

We've just gotta be honest with people and say, look, we're in

such a mess with waiting lists.

We're having to outsource the private sector.

But we will tell you, and if you choose not, you can.

I think that's the best we're gonna get in the foreseeable future.

In terms of the

Adam: actual costs, just on a practical level.

So my experience this recently was taking my dad for, not, for a cataract

operation, for a complication he had after his, um, cataract operation,

which he had in an NHS high hospital.

Um, I'd written this down 'cause the posterior cap capsular opacification,

uh, which apparently is something that happens quite often after cataract.

He was given the option of kind of three different places where he could

have this and told that the shortest waiting list was at a private clinic.

I have to, it was the most extraordinary experience.

Once it had.

Huge leather sofas.

It had a real log fire in the, um, in the waiting room.

It was so impressive.

did it cost the NHS more for my dad to have that, that very brief laser

surgery done there than it would've done to have done at the at the

Phil: NHSI hospital?

I dunno.

Possibly.

I mean, that's one of the things I believe is that you should

be able to follow the money.

We should publish all this and you should know precisely, you should be presented

with a bill at the end of the day for precisely what your NHS care cost.

Not that you are paying for it, but just out of interest.

This is what the GP thing costs, this is what that costs.

This is what going to the private hospital have the complication.

I don't know.

It's pretty opaque at the moment, so it is possibly, it could have been.

It's worth pointing out.

If you look at the, uh, the ONS latest figures on health spend in the uk, there's

quite a chunk of private health spend.

So they look at total health spend when they compare us to other European

countries and we're spending whatever it is in the England, maybe 150, 160

billion on the NHS and about, there's about 40 billion spend on private.

Lots of people are doing pay as you go.

That's the biggest chunk of it.

And there's a bit on, on, um, insurance.

So already within the NHS, it's not just the NHS, the private sector is a

significant provider of private practice as well as doing NHS work as well.

So they're doing really well out of, that's the waiting list.

So what we're

Andy: talking about there is people taking themselves out

because they want to pay for their

Phil: own chemotherapy, whatever it might be.

Yes.

If told yes.

But if you were told, you know, you had a really unpleasant hernia

or something, you were told it was gonna be, uh, two years on the NHS.

And you had the money to go privately, you'd probably go privately.

Helen: Things like hip operations, knee operations, things that are grinding the

unpleasant on a day-to-day basis, but aren't fundamentally gonna finish you off.

And it Yeah, those are the, those are the lateness that are really

Phil: long.

Right.

And it's not just the pain, it's the fact that you are economically unproductive.

The bit that that the Tories never really understood is that investing in

the NHS is investing in the economy.

'cause you get people back to work

Helen: quicker.

And that is a problem we've really got, particularly post covid, the

number of economically inactive people.

I think the thin, the 50 to 64 bracket, particularly, you know,

people maybe coming towards the end of their careers, but they still in

other circumstances would have a lot of good years left of working, just

not now economically active at all.

There's a, you know, there's a huge.

A huge drain.

And I think the other thing is that you're right about being more transparent

about the money, which really help.

There was some interesting recent polling about would you pay high taxes for NHS?

And this is a problem for the conservatives.

'cause the people who by and large said yes they would.

Were older people who use it more.

Mm-Hmm.

People age 25 to 30 often don't have that much contact.

With the NHS.

If you don't have kids yet and you're a healthy 20 something, you

don't actually see a lot of the NHS and those are the people who think,

well, why should I be paying for

Phil: this?

The trouble was a limited tax take.

There's always an opportunity cost, so if you're putting more into the NHS, that's

money that could have gone into education.

If you asked me what gives you the biggest bang for your buck over the years?

I'd say put it in education.

There's a lot of evidence, the better educated you are, the

healthier you are and the less reliant you are in the future.

But that, that manifests itself over 10, 15, 20 years.

Yeah.

And the thing we've always failed at prevention.

Everyone's talking about prevention now, but prevention

is a boring b generally silent.

It's the dog that doesn't bark.

So you don't know when you prevent a stroke or a heart attack.

And it requires, uh, about a 10 or 20 year view that no political party has ever had.

So if we serious about prevention, every party, we've gotta have a

cross party support for a 20 year.

Getting us all healthier.

Plan.

Mm.

And we've never had that yet.

And actually that's the main reason why waiting list is so high.

About 70% of the illness, or at least 50% is part.

Potentially avoidable, preventable with better lifestyle.

It's also

Helen: quite intensive, isn't it?

Prevention.

I mean, I've been doing some work on, um, Ozempic Wavy, Mount Jra, the new

class of GLP and agonist drugs that are the, the weight loss drugs essentially.

Mm-Hmm.

And you talk to doctors about 'em.

Some of 'em have concerns, but some of 'em also say it is for the first time

I have something that actually works.

Yeah.

We used to have people come to the surgery and we'd say, your BMI is 30.

Your life expects you much longer.

Your quality of life would be much better if you could lose that weight.

And then the thing is, please come back when you lost it.

And almost no one ever did because it's really, really hard

Phil: to do.

Yeah.

But, and they do work and the drugs are promising, but they're not the answer.

The answer is it's a social problem, and we need moving up the chain and looking

at the corporate determinants of health, such as what the food industry does to put

this highly calorific shine in our food chain in the first place and advertise.

You know, you see, I was talking to Claire Gerard the other day, who I'm doing a.

Show at Edinburgh with, and she was just, she came out of her surgery

watching kids come out of school and all of them went out of school and

went to a shop and, and bought a highly calorific snack straight out of school.

And she reckoned each one was about two 3000 calories.

These massive, great lumps of sugary shit.

And that's happening day in, day out.

Kids coming outta school, having a big mouthful of sugary shine

and then going home and it's, you know, until you move upstream and

start that, yes, the new drugs are encouraging, but we need to move up.

Adam: I think it's really interesting the point you made about being

presented with a bill 'cause you, you end up with no idea of how much

any sort of treatment actually cost.

I wanna remember it was George Osborne, wasn't it, who came in and

said, you know, every year with your tax bill you are gonna get a sort of

breakdown of what it's being spent on.

But actually

Helen: this kind of.

You do get that now you can go to HMRC website and the, one of the

scary things is that now repaying the national debt, um, debt is, is 12%.

Those interest rates are so high.

Yeah.

That's really, uh, that's really gone up.

But yeah, I think you're right.

It's the same thing when you look at Americans who obviously have to pay

things outta pocket, you know, simple admission to accident emergencies running

into the tens of thousands perhaps.

I'm not sure that, but simple.

I

Adam: mean, prescription costs are, are standardized, so you have

no idea whether the pills you're paying for are costing the NHS.

You know, thousands of pounds or, or, or thousands of

Phil: pennies.

It's, it's really difficult, isn't it?

I mean, I live in a fairly affluent area and I see people coming outta the

surgery who I know are very wealthy with a retired, with a massive,

huge grant carrier bag full of prescription drugs and you know that

they could afford to pay for them.

We know that the administration of taking away free prescriptions is, and

it's politically unpalatable, but it's, it's really interesting that, you know,

some people get an absolute bargain of the NHS and some have, you know, it

should be some way of making a voluntary contribution back to the NHS saying

that, I've just gone to the doctors, I've got 4,000 quid worth of prescriptions

to get me through the next couple, but it's like the winter fuel payment.

I'm gonna give you a couple of yes.

It's, yes, the same thing should apply the

Adam: people or pension that actually, politically this would be so

incredibly difficult and means testing is kind of anathema to everyone.

Andy: But they don't so argue.

They've paid in and they argue they've paid in.

They might've paid in in higher taxes and they've probably paid for a good chunk of

the drugs they're carrying out, I would

Phil: imagine would be there that point.

Yes, that's exactly what their argument would be, but unfortunately that

Adam: means the younger generation just really look forward some

really good drugs in old age.

That's how you're paying in now.

You're gonna get the benefits.

So Phil,

Andy: can I check?

I, I would love to know how bad I should feel.

Let's say I need something done on my hip.

I've got the money to pay for it.

I, I get the operation done on my hip.

Have, have I, what have I, what have I dodged there or have I made

things worse for someone else?

By doing that?

By going private you mean?

Yeah, by going private.

I'd love to know because I, I, my, you know, my life is mostly working out how

bad I should feel about various things.

Okay.

And so tell me

Phil: please, it's not as simple, even Jeremy Hunt, if you Oh, lovely.

Jeremy Hunt, who we've all got to know and love, wrote this book called Zero,

about Zero Avoidable Harm in the NHS.

And he says very clearly in there, outsourcing to the private sector

isn't the answer because it's the same staff that are serving the

NHS generally, particularly the consultants, not always the nurses.

Who are also treating you.

So it doesn't cut the waiting list as much as you think.

Thatcher always used to say, right?

She, when she had a JuveTress done, she stood outside the private

hospital and said, I encourage people to go private to take the pressure

off the NHS if you can afford it.

But it's not as simple as that, largely because it's the same staff.

If we had loads of doctors and you had separate doctors privately

in NHS, it would be different.

But at the moment, yes.

But having said that, if I was in terrible pain from hip arthritis

and it was a two year waiting list, I'd pay to go private, right?

And feel slightly guilty, but.

I'm hopeless with pain as many men are.

Andy: Another thing we should talk about is the staffing levels and

situation and everything in the NHS.

And one thing that you've written about recently, Phil, is this actually not that

new position of physician associates.

These, this is a, a class of, uh, staff in the NHS.

They were introduced in the early two thousands.

Basically, they are not doctors.

They don't prescribe.

Drugs.

They don't prescribe X-rays, but they are able to do things like they can

order various tests, they can conduct examinations, develop treatment plans.

The idea is that they work with doctors and there are a few

thousand of them, and there might be

Phil: more soon.

Yeah, the NHS plan wants to rapidly accelerate the number of them, but

the key takeaways, they're not doctors and they need to be supervised, and in

that context, they're really helpful.

If they're out on their own, I would say a bit more dangerous.

I know some, um.

Uh, operating department assistants and who work brilliantly for ages who've

become anesthetic PAs and are brilliant.

And my consultant colleagues say they, they're indispensable because they worked

in theaters for ages and now they're doing this and they have a certain

defined role and they are indispensable to the running of our unit, but often

their people who've had science degrees and decide they want to do it, and

it's generally a two year degree now.

but they're, they're also going to do some on the job training as well.

Andy: they're kind of like paralegals to borrow from another industry.

Yes.

They are not doctors, but they

Phil: are medically trained in certain areas.

Well, they called P assistants, the doctors and

the general, the Royal College.

And the doctors liked when they were physician assistants 'cause that made it

clear that they were assisting the doctor.

Right.

The name then chain to a physician associates, and this is where

it's all got slightly murky.

They're not supposed to prescribe and they're not supposed to

order ionizing radiation, x-rays.

But because the NHS is so short staffed, there have been issues where they've

been put in positions where they're seeing undifferentiated patients.

So what's supposed to happen is you as a doctor say, look,

I've, I'm gonna triage this.

And this patient I think is relatively uncomplicated and the physician, um,

associates gonna see them for us.

Because the shortages of doctors and strikes and all the rest of it, it's

Helen: so the condition that might apply to, are we talking

Phil: sort of, you know, well, people will always say, weren't they what?

So if you're saying, I've seen this and I think this is a straightforward

tonsillitis or something, and I think you can deal with this, then

in in general practice, you triage.

But if it's something a bit more complicated and you're worried

it might be sepsis or whatever, that's something a GP should see,

a doctor should see, because that's

Helen: blood poisoning that can escalate

Phil: very quickly to fever and pain.

Yeah, but the trouble is you can't always spot these things, and there's loads of

examples that I've had in my life where I thought something was relatively trivial.

It turned up, is really serious.

So you can't always predict.

It's come to a head because very belatedly.

The government has come up with a staffing plan for the NHS, which

it should have done 75 years ago.

And it's trying to accelerate through the number of physician associates

who are gonna increase them to five or 10,000 or whatever in 10 years time.

So, and we should say for

Andy: listeners who are also not familiar, there are at the moment about 3000.

Yeah.

Not very many across

Phil: the whole, no.

And they're trying to accelerate them as part of their plan, which is fine,

but you need a commensurate acceleration in doctors, particularly the doctors

who's gonna train and supervise them.

Now doctors in training are already saying, we don't get enough training

and supervision, and they're nicking our training opportunities.

Now because they hate the government and they don't trust them.

They say, what I think is happening here is that they're increasing,

these physician associates are gonna be used as doctors on the cheap.

So there's some evidence now that the government is, is scaling back a

bit on its desire to train far more medical students and have doctors.

'cause it's thinking we're putting 500.

Thousand quid in and the buggers are going to Australia.

So you can bugger off.

We're not gonna train more of you.

Uh, we're just gonna have physician associates.

So it's going to, what we learned interestingly in the junior doctor

strike is that the more senior person you see at the front door,

the better treatment you get.

So rather ironically, when the consultants had to come in and cover the junior

doctors, emergency patients often got better care 'cause you had a more

experienced person making critical decisions in short spaces of time.

If you flip that up and you say you have physician associates the least

experienced with the less training.

Mm-hmm.

Seeing undifferentiated patients, that's likely to lead

to avoidable harm and error.

But the thing I don't like about it is it's got really unpleasant that people are

warring within themselves, or a physician associates who've gone off sick with

depression and I, you know, whatever.

Right.

And the whole atmosphere is horrible.

With an election coming on and strikes up, it's being politicized.

In a way that isn't particularly compassionate.

I

Andy: some people saying these people are not proper doctors.

They shouldn't be allowed near patients, or they're not

Phil: trained to work well.

They're clearly not proper doctors and they're not pretending to,

although people are discovering pits where a physician associate

has awarded an X-ray or done this.

So there's people who have kept logs where physician associates

have gone beyond their role.

Right.

But they are, I think

Andy: they're instructed to say, I'm not a doctor.

You know?

Yes.

I'm a physician associate.

I can help with these certain things.

Yeah.

So they do

say

Phil: that to patients.

So then the next issue is who's gonna regulate them?

They weren't initially going to be regulated and then they

were going to be regulated.

And then the General Medical Council has taken it on and doctors are saying no.

If you, if the GMC does it, they're gonna be further confused with doctors.

And I think it, you know, somebody else should be regulating them.

It's

Helen: a very interesting, delicate issue, isn't it?

Because there is a sense of particularly the, BMA that doctors as a kind of guild

and not exactly a closed shot because obviously they, you know, you have to go

through a lot of training, but balancing the fact that doctors can be quite

resistant to change because they see change inevitably as someone trying to.

Dumb stuff down and bring in people.

But it's really interesting.

At the moment we're talking, there are two plays on in London n at the

National Theater with Michael Sheen as Nye Bevin, uh, and the Human Body

at the Mont, both of which are about the creation of the NHS and doctors'

opposition to it fundamentally.

And the fact that they had to be really talked into it.

And I think some of these discussions are quite hard to have.

'cause I think even sort of saying that, that some doctors are

resistant to physician associates.

Will put some people's backs up.

But that is part of the story, isn't it?

And, and not for, you know, not for ridiculous reasons, but there is a,

a tendency, I think, particularly as you say, when doctors feel so at odds

with the government of feeling Yeah.

Very resistant to change.

Because you assume really that all change is going to be bad.

Phil: Yes.

I mean, I would rather, as a medical workforce, we united and we welcomed nurse

practitioners and people at all roles of different things doing different jobs.

The issue is how do we train them properly and supervise them?

Um, and that's a fair point.

There was an emergency general meeting at the Royal College of Physicians the other

day, only the third and its history where they debated this and the motion that

there will be a vote on possibly by the time the next eye goes out is to whether

there should be a pause in this rollout.

And the difficulty is associates.

Yes.

Yeah.

And particularly, and the Royal College of Physicians has a vested

interest 'cause they're being paid to, to do the training and evaluation.

So they're doing the educational program for them.

Right.

So if it was paused or reversed, they'd lose a lot of money.

Okay.

So there's a really interesting spat going on the fellows of

the Royal College of Physicians.

but it's interesting 'cause it hasn't really percolated much into the

mainstream media 'cause people are, They just wanna be treated by someone.

But I think there's a danger, that if it's, if they're not properly

supervised, they will dumb down.

But when they are properly supervised, they're indispensable

and a brilliant part of the team.

Yeah.

So are we

Adam: not in danger of hitting the same problem that we had

before in if we train up thousands and thousands of these position

associates, they'll do the same thing.

They'll all bugger off to Australia where they can get better paid as well?

Possibly.

Phil: I think that's possible.

I don't, I dunno what the market

Adam: learning, learning from history might idea.

Phil: Just look in the back of the BMJ for the, I mean, clearly.

Whatever we do to the NHS and social care, let's say, there are more

vacancies in social care than there are in, in the NHS, and that's probably

just as important to sort that out.

But whatever we do, we have to make working in health and social

care a more attractive proposition.

If we're gonna retain people, we've got to make it a, a better place

to work for all sorts of reasons.

And that's part training, part supervision part, how stressful

the job is, et cetera, et cetera.

As

Helen: someone whose doctor relatives have in fact bugged off, uh, elsewhere

to Australia and New Zealand, I think one of the issues is you just get

paid a lot more as a doctor elsewhere.

So they, um, part of this story is a story about cost, right?

Mm-Hmm.

So this is about trying to fill those roles and trying to offer, you

know, if you only got a very tight pool of doctors and, and not very

much to pay them, it makes sense.

You know, and I'm not sure the pressure is quite so acute on the Australian health

system and that, so maybe I'm wrong.

Phil: No, and they're probably a bit fitter than we are.

There's a fair amount of obesity in Australia and

obviously lots of skin cancer.

But, it's interesting to see how this plays out.

So it could be that all the junior docs are really angry about

the conditions at the moment.

The ones who stay in the UK end up saying, I don't wanna work in the

NHS, I'm just gonna work privately.

We, we still have to scour countries who need doctors and nurses more than

we do to nick their doctors and nurses.

And they'll be providing the bulk of NHS Care.

Right.

And we really will have a.

Do tier service.

There's a possibility that that may happen as well, that people say, I just

don't find the NHS safe to work in.

It doesn't support my work life balance.

I can't afford a house in London, so as soon as I can get my qualifications,

I'm gonna prioritize my private work and do as little NHS work

as possible that that may happen.

If they say, you know, you're not gonna even restore our pay to what it was

in 2010, I'm not gonna work for you.

Right.

They're that militant.

And fair play to them.

I say I probably would've been like that at that stage, but

Helen: to give people an idea of the figures for a newly qualified doctor

who's done five, six years of training taken on will be now repaying that when

they get to a certain level at 9% of their, their income, the London salaries

for that junior doctor, I even once you have London waiting, I'm really not.

That much more than the UK average median wage of any sort.

Are there they and never line the idea of buying a house in London where the average

house price is, you know, 500,000 pounds.

Yeah, I think, I think people get very confused.

'cause I think senior doctors do, you know, do earn what is a

competitive professional wage.

But, but the first couple of years of your practice, a junior

doctor, are really seriously

Phil: tough.

It's difficult, isn't it?

'cause.

I think I'm getting older and I want there to be a health service for me

as I get older and it's, you know, I know, for example, I know Adam K fairly

well and I know lots of consultants who took their kids to go and see him.

The hope that he would put them off a career in medicine.

So he's the one who's really anti now saying, oh, this is just terrible.

'cause he's given up.

He's saying, oh, bloody hell.

Just get out.

This K wrote, this is going to hurt.

Okay.

Andy: Yeah, yeah.

Just become an enormously successful memoirist instead of going

Phil: Exactly.

It's played by Ben wish.

That's the trouble is that you need, we need doctors and, and everything

because of the election and because of the strikes, we're accentuating

the negative to such an extent.

How are we gonna attract people?

And there's evidence that nursing.

Applications and medical school applications going down, right?

'cause it's relentless wall to wall.

This is a shy job and it's not a shy job.

It's actually a really rewarding job.

I mean, I survived it by doing it part-time.

So I'm a bit of a cheat.

But I did this podcast recently for, for the BBC called Doctor,

doctor, where I particularly sought out people who'd worked in the NHS

all their lives and enjoyed it.

And some of them were younger, to be fair.

So we need that voice as well.

Not saying health and social, Gary Shy.

It is an amazing job.

But yes, we need to reward people better and retain them and give

them better living conditions.

Adam: Essentially Charlie Fairhead, who's just left casualty after 38 years.

Getting back pretty atypical.

Phil: No.

Sister Duffy.

She was another one, wasn't she in casualty?

Yeah, they killed her off though.

Did they?

Okay.

Andy: well, maybe we should counterbalance that with the, the

another recent piece of yours, which is about whistleblowing and the, what

it's like in the NHS if you do spot.

Harm being done, or, or, or whether it's malpractice or

mis practice, whatever it is.

You, you tend to have a

Phil: pretty unpleasant time.

I believe you can do, again, a bit like prevention, isn't it?

You don't see the cases that have gone.

Right.

So there might be cases all across the NHS where they, people listen to

concerns and they act on them and they're sorted out and you never hear about 'em.

So the trouble with the, the, the stories that reach Private Eye or reach the media,

they're generally stuff that's gone wrong.

Mm-Hmm.

And the thing that's probably gone wrong is that the Public Interest

Disclosure Act was never quite fit for purpose in that you had to prove

that you'd been discriminated against or suffered victimization as a

result of your whistleblowing, which could have been miles down the line.

And the trust hospital, it's generally a hospital could always afford 10 kcs

or a huge number of barristers, and you were left either representing yourself

or I know one bloke, whistleblower we covered in the eye who had a bit of legal

insurance on his household insurance.

So he got.

You know, legal representations is his employment tribunal.

Oh, great.

But what they tend to do is if they don't want to answer the concerns,

they'll, they'll counter investigate you.

They'll find areas in your work.

They'll say you, the reason you're raising these concerns

is not that they're genuine.

It's because you are trying to cover up deficiencies.

You're a difficult person to work with.

It's an employment issue.

We're gonna suspend you, we're gonna give you 40 erroneous reports of the GMC and

we'll see you at the Employment Tribunal.

Now, I'm not saying that's widespread, but there's enough of

it happening to say that there is.

There is.

We, we still haven't, I mean, things will always go wrong in healthcare because

it's so fast moving and complicated and difficult, and we still haven't cracked

the nut of, of owning up early to errors and trying to nip them in the bud.

Maybe part of that is because the managers are saying, well look, you

know, we are 20 nurses down, or we're 15 doctors down, and you are blowing

the whistle about short staffing and people dying in the back of ambulances.

But I can't do anything about that.

So I'd rather cover it up than see it in the front page of the local newspaper.

So I, I have some sympathy.

'cause every year we know, for example, finance managers cook the books.

They're given ridiculous plan by NHS England to balance their

books, and they come up with something that's absolute bollocks.

It's a lie.

And then basically towards the end of the financial year, we suddenly

realize it's a lie and they're suddenly, you know, 2 million in debt.

And there, there still isn't.

The honesty within the NHS to say lots of people are being harmed.

Avoidably, we are going into debt because we are overloaded and, and the

best way just to give us an easy life as to try and cover it up in silence.

The whistle blows and, and that's still happening.

Yeah.

Helen: I mean, I think that, um, the new NHS England guidance came out

on, uh, puberty blockers for gender nonconforming children last week.

And to me that is apart from anything else, once you put aside the kind

of noisiness about it online, a story about whistleblowing.

So David Bell, who was one of the staff governors.

10 staff came to him.

So that's a th about a third of the people working in that very small, um, tavistock

bit of the gender identity service there and said, we got concerns about this,

this treatment and about the huge pressure of waiting list or the size of waiting

list balloon, they felt a real pressure to get through cases and you know, it

just took a lot of time for that to get.

Through and that message didn't really get through.

Um, this safeguarding leads Sonya Applebee one, an employment tribunal about the

fact she'd raised concerns as well.

And you know, it's kind of often presented in these very culturable

terms, but fundamentally that is a story of intense NHS waiting list pressure.

Yeah.

And whistle blowing that wasn't attended to because as you say,

there were other concerns there.

Were kind of, but, but we need to see these, these children

are in genuine distress.

No one's arguing about that and we need to help them.

So let's just keep running this train in the way we are.

Not look about it and not think about the kind of all the stuff that's going on

Phil: round it.

The thing that saddens me most about that is that whether it's gender blockers or

not, you should not be using any drug anywhere in the NHS if you don't know

what its long-term safety record is.

If it hasn't been properly trialed, unless it's within the context

of a randomized control trial, that people are consented to the.

So whatever the drug was, we shouldn't have been using it in that context

unless it was in a control trial and we could monitor what the effects were.

You can't just say, we're gonna do it, and then hopefully it'll be okay.

And then suddenly you discover people can't have orgasms

or et cetera, et cetera.

It affects their brain development.

It, you know, we, we shouldn't have been using it in the first

place in that context without it being as part of a control trial.

Helen: Right?

So it was being Lupron and these other drugs were being

used off-label essentially.

So they, you know, there is precocious puberty when a kid starts going

through pubb eight or nine mm-hmm.

They were licensed.

You know, people have got an idea about that.

But the idea was that then you went back to your puberty at the

same time as all your classmates and that you would obviously,

obviously have your then puberty in your kind of, in your natal sex.

And it somehow migrated across to this very different use case immediately

followed by cross-sex hormones, which, as you say, when you block puberty

at Tana Stage two, really early on, development seemed to affect both sexual.

Function and also fertility.

And the question then being, as you say, the Care Quality Commission

rated the tavistock in adequate for its records keeping because they just

hadn't collected the data about what the long term outcomes about this were.

So, you know, we, we, at this moment, we can't really say what is the safety

and efficiency of that treatment because actually nobody really knows.

Phil: No, I used to say, and I, I haven't really written about it, partly 'cause.

I was working in a different era of pediatrics.

I was working in me ccf, s chronic fatigue, which is also has its issues.

But I would see kids within that clinic who were thinking weren't

sure what their gender was.

And I would say to them, you'd be as gender fluid as you like for as long

as you like, but think very, very carefully before you outsource your

gender, either to the pharmaceutical industry or to a surgeon, because we

dunno what the long term outcomes are.

And it may do far more harm than good and you may regret it.

Carry on being as gender fluid as you like, and occasionally you'd meet someone

who did have, uh, a lot of interventions and treatment and surgery and stuff,

and they'd be absolutely delighted.

Mm-hmm.

Occasionally meet someone who would deeply regret it.

So the issue then comes as is how do you have enough time and therapy and

understanding in an overloaded clinic with so many people to explore the issues

and try and spot the people who will benefit from the people who won't benefit.

Adam: Half of the problem is taking

place against such a febrile atmosphere,

and I thought it was really revealing that last week when essentially this, this

kind of considered guidance came through on the use of, uh, of puberty blockers.

Liz Trust, Liz Trust for God's sake, was also trying to introduce a

private member's bill in the commons.

To ban them and, and, and add in sort of all of the other smorgasbord

of culture war issues over that of single sex toilets and, and

pronouns and all that kind of stuff.

So it, it, it's quite hard to kind of detach the, kind of the medical

argument from the political, for want of a better word, argument.

Helen: Cassie's, very senior pediatrician, was commissioned to

carry out a report and her interim version came out and it said yes,

only as a randomized controlled trial.

It now looks, it might be even slightly more restricted even than

that, but it was to address exactly that point that Phil said, which is.

It would be very helpful to know whether or not this is a kind of a good idea.

Really.

And, and as you say, you meet people on both sides of the eye.

People very happy with their treatment, very unhappy with the treatment.

You can't rely on anecdote in, in medicine.

It has to be about data.

No, I, I

Phil: think what's changed, I mean the shift in the balance of power in

medicine, it's been fascinating to me when I first trained, we often wouldn't

even tell patients their diagnosis.

We use euphemisms.

You're a bit flopsy bunny, or it's time for a short walk back to the pavilion.

So a third of patients weren't told they had cancer.

We often wouldn't tell people they had motor neuron disease

or multiple sclerosis grief.

This in the eighties.

I mean, just imagine now it's the pen has gone completely the other way where

people are self labeling themselves.

So they're not getting a diagnosis from the doctor.

They're looking on the internet and they're saying, well,

they're seeing something on tick.

They're saying, this is me.

Mm-Hmm.

This is the label I'm appointing to myself and I want a

medical expert to sort it out.

So by the time they reach the doctor, they've jumped the diagnosis stage.

'cause they've already done that for themselves.

Mm-Hmm.

And whether that's right or wrong, it's creating a huge extra pressure on certain

specialties and it's, it's something new.

Andy: And just one last thing on the.

staffing conditions for doctors.

So one thing that Labour have certainly, I think they've said they support the

idea or maybe it's just worth treating.

Who said he supports the idea is an independent office of the whistleblower.

Mm.

And Scotland adopted that last year, I believe.

Are there any early

Phil: indications as to how it's gone?

I don't know.

I only found out recently that Scotland has adopted it and

I, I dunno what the answer is.

I think what's needed when we did shoot the messenger, which is now

available on the I website with Andrew Belfield in 2011, special report,

we said, yes, there should be some.

And something like an independent officer of the whistleblower that.

It gives them legal advice early to make sure that they're raising

a disclosure in the public interest and they get proper legal advice.

Mm-Hmm.

But the other thing, which I think is more important is we, we call it

an independent medical inspector.

Basically, a crash investigation team that goes in for the most serious

concerns raised by staff or patients, and investigates really quickly.

And it's free from the NHS Brotherhood, free from the Care Quality Commission.

It's just there to pull the notes, look at it, see what's happened.

And reach a judgment.

If you did that early on, you wouldn't need to persecute your whistleblowers

'cause someone would've come in really quickly and gone boom, yes or no.

There's been

Helen: a lot of discussion and things like that, hasn't there?

The one that it's often compared to is airline safety and the kind of black

box, because it's in everyone's interest really, that airplanes do not fall

out the sky, but you wouldn't wanna necessarily leave it to the airlines

themselves to investigate it, but you could have a similar process in the

NHS and, and also to abstract it from.

From a kind of question of blame, I guess, and to be like

a more of a learning exercise.

Yes.

Yeah.

Phil: There is a lot to learn from the airline industry, but any house

sector you says to me, we need to be more like the airline industry.

Yeah.

They should be forced to pilot a plane with a hole in the fuselage,

one of the wings missing three members of crew down and all the passengers

have dementia and then they'll have to land it in a busy thing with air

traffic control on a sick break.

the point that we've.

The patient safety people may is that a jumbo jet load of patients fall

out of the sky in the NHS every week from potentially avoidable deaths,

and we hardly bat an eyelid because we've become so desensitized to it.

Whereas it happens a whole plane, you will shit yourself.

There was a slightly mean phrase that was if if doctors died with

their patients, they might take a bit more care, just a little bit unfair.

There may be something instant when you get buried in the pyramid of your patient.

Andy: So I suppose the final thing we wanted to talk about with you,

Phil, is you mentioned the health secretary a couple of minutes ago.

What are you expecting or would like to see in manifestos as we head at

some point towards the election?

I think I've asked you this probably in

Phil: 2019 and maybe 2017 as well.

I must have done it for years.

Must be same things, no majors, top down reorganization.

Don't need any more of those.

Okay.

Uh, I wouldn't waste time arguing about the funding structure of the NHS.

You know, I think that's a red herring tax funded is, is fairest

and easiest to administer.

I like the focus on prevention personally.

Labour's gone for it.

It's bottom up, but it's a 10 year plan.

It needs cross body support and it won't get immediate results.

The thing that worries me about Labour, Labour's published stuff in

the most detail, and they're doing the thing that Blair had to do.

They're committing to reducing waiting times as well as committing to prevention.

But the trouble is, I'm not entirely sure that they can do both.

Right.

Um, and we dunno whether they'll get a second term if

they wanna promote prevention.

You need at least two terms to see the results for that.

You've

Andy: always been a

Phil: a prevention.

Yeah.

If I do, yes, Desmond do too.

Instead of pulling people outta the river, wander upstream and stop the falling in.

Right.

That's, but it's schools, houses, hospitals, 90% of prevention

has nothing to do with the NHS.

Decent housing, decent food.

Give money to local governments as well as education so they can have playing fields.

It's all that stuff.

Not very sexy, but it's where the money needs to go in my view.

Helen: I, yeah, I, I wanted just to end on this 'cause I thought this might be

upbeat, but I, but I think, um, west Street is certainly one of the ablest

performers in that Labour shadow cabinet.

But when you look at the structural problems of an aging population,

an overweight population, you know, all of those kind of things

that, you know, the NHS and also fundamentally go back to 1945, the

NHS is just doing a lot more Mm-Hmm.

Um, you know, and one of my colleagues at the Atlantic was just

writing about the fact that, um.

Cystic fibrosis essentially.

That was, you know, that used to be a death sentence in leukemia, something

in early childhood, and now where people living well into adulthood.

There have been these wonderful advances, but at the cost of.

Expensive drugs.

So the NHS is just being asked to do a lot of things it wasn't

ever conceived to, to do.

Phil: We have done some good stuff.

We've eradicated cervical cancer in Scotland using HPV vaccination,

but the, the final thing to say is that they looked at, recently looked

at since 1960, life expectancy globally is increased by 19 years.

Isn't that fabulous?

Quite incredible, but the proportion of your life lived

healthily hasn't increased.

So the same proportion of people are living in ill health or with poor health.

So what we've done is we've made a lot of people live longer, but half

of them are living with diseases that previously would've killed 'em.

So it's chronic disease that kills you.

It needs lifestyle change and decent house, decent hose every time.

Phil, you give with

Andy: one hand and you take

Helen: wait, wait, wait.

Because I remember something that Phil once said in a column, I think you

wrote from me when I was at the New Statesman, which you said the best

health advice you could say is get a dog.

Yeah.

Yeah.

So as you go out for walks with it, so you get some exercise, you get someone

to like talk to when there's no one else around, uh, you've got a reason

to kind of, you know, be up and about an active, they look at you, your

Phil: husband Doesn, look at you, your partner doesn't look at you.

And if you're too depressed with your pants on in the morning,

they lick your testicles.

You don't get that at the doctors.

Right.

I think we should stop this

Andy: episode right now.

If you do, you should definitely record.

Phil: Did I say I was back at the Edinburgh Fringe?

Can you put that in as well, please?

Two shows at the Edinburgh Fringe.

Everyone you've been listening to

Andy: page 94, thank you so much.

I hope you've enjoyed it.

We'll be back in two weeks with another one.

go and get a coffee of the magazine and read more of these

pearls of wisdom from Phil Hammond and, and all of his colleagues.

Uh, this episode, as always was produced by Matt Hill of Rethink

Audio, and we'll see you next time.