Prescription for Change: An NHS Doctor's Case for Privatisation

It's time to be honest.

Reckon Labour will improve things for you lot?

That’s a question I’ve heard time and again since the current government swept to power with their 33% vote-share ‘landslide victory’ in July.

The answer, of course, is no.

Like many of my junior doctor colleagues over recent years, I have participated, albeit intermittently, in several industrial actions organised by our union, the British Medical Association (BMA).

At first, the excitement and novelty of it all was palpable. Bear in mind, the last time British doctors went on strike was in the mid-70’s, driven then by remarkably similar concerns as today: excessive workload, health and safety, poor overtime compensation, and above all - low basic salaries due to high inflation eroding the real value of wages. As a result, the pay junior doctors received was increasingly seen as inadequate relative to their responsibilities and the cost of living.

For context, in 1975 the average annual salary for a hospital registrar was around £5,000, equivalent to £170,000 in today’s money. The average house price back then was a mere £10,000. Junior doctors could therefore buy a decent house outright for just two years-worth of wages - an aspiration made easier still by the fact they graduated absent any student debt whatsoever… And still they went on strike.

Today, a specialty registrar in Britain can expect to earn between £50k - £60k a year. Higher than the national average, sure, but certainly not what one might expect after consistent academic excellence, five years (minimum) of medical school and four years of clinical practice.

For even more context, that’s roughly the same as what a manager at Burger King makes in San Diego. While equivalently trained doctors in the local hospitals are on upwards of £200,000.

The average UK house price is now 6-7 times the annual salary of junior doctors, probably closer to X10 in the South-East of England, whence I myself hail. At last count my student debt was just over £60k. I actually graduated with £59k, but apparently the interest has outpaced the hundreds of pounds automatically taken from my wages each month since I qualified four years ago. I sincerely doubt I’ll ever repay it.

Thus, with matters objectively and subjectively far worse than they were in 1975, we chose to emulate our Cold-War comrades and strike.

Yet the enthusiasm has noticeably waned since the spirited zeal of yesteryears. Turnout for the 2016 ballot was a rather impressive 76% of eligible junior doctors, with 98% voting in favour of industrial action. Fast-forward, past a Covid-induced hiatus, to the ballot of January 2023, and though the ratio of yeas and nays was identical, turnout had dropped to 72%.

Nine rounds of strikes, disruption and payslip deductions later, and turnout for the March 2024 re-ballot was down to 62%.

There are now growing murmurs in the air that should the latest contract offer be rejected, turnout for future ballots may well dip below the mandatory 50% of eligible union members required for any legally-protected industrial action.

I’ve seen the aforementioned offer, and I must say it’s underwhelming. But even if the government gave us everything the BMA demanded, and pay were restored to 2008 levels (in real terms), it won’t make a difference. There will remain far graver, deeper problems with the system itself.

At this stage I honestly believe it would be better to burn the NHS to the ground and start from scratch, than allow this bloated, decaying zombie to continue lumbering on. As an NHS doctor myself, I’d be the first to pile up the kindling and upend the barrels of gasoline.

One of the commonest accusations levelled against the previous Conservative administration, mostly by their political adversaries, is they were trying to dismantle the NHS… would that that were true. Personally I didn’t realise it was scientifically possible for an organisation to be so inefficient until I started working in it.

The whole structure is broken, and more money is the last thing it needs. Indeed, I suspect one could divert the entire national budget to the NHS, and it would swallow it up and ask for more. At present it is being held together by rubber bands, Blu Tack and sellotape, along with the remarkable good will of its long-suffering clinicians.

Middle/upper managers (often with Labour ties) on six figure salaries are rife. Their very existence is predicated on pushing bureaucratic papers to one another and wrapping the organisation in as much red tape as possible, but have little to do with improving patient care.

The other query I’ve heard countless times - from patients, colleagues and members of the public is: ‘Why in God’s name are you still here?’

It’s a good question. People have an image in their heads of what life is like for junior doctors in this country, but the reality is invariably grimmer. A chaotic, failing system; endless night-shifts, evenings and weekends on-call. Where every decision you make, however seemingly innocuous, could one day lead directly to a courtroom facing a bereaved family and their stern-faced barrister… all for around £14/hour.

There is an ongoing exodus of British doctors leaving for warmer, mostly Antipodean, climes in the past few decades, many of my own friends amongst them. I’d estimate that out of my graduating cohort, at least 40% are already practicing abroad. Several have left medicine altogether, reasoning, quite correctly, that far more money can be made for far less sacrifice in other sectors.

The truth is that the government, regardless their colour of rosette, could scarcely care less if we do go. They know an unlimited supply of cheaper doctors from India or Pakistan or West Africa are waiting in the wings, lining up to take our place and more than happy to work in poorer conditions for less pay than their British counterparts. Politicians see us as cogs in the machine, easily replaceable, names to fill in rota gaps. Such is the mentality that arises from prioritising short-term savings over the long-term wellbeing of one’s citizenry.

Not that they are necessarily worse doctors than those trained in the West - although evidence suggests they do make more mistakes on average - rather it is about consistency. Many of the best doctors I have ever encountered hail from the Indian subcontinent, but so are many of the worst. When you hear that in certain Indian provinces, an individual can literally bribe their way into and through medical school, this is hardly a revelation.

In England meanwhile, a minimum standard must be attained to pass final examinations, both written and practical. The bar is set high, as it should be, and good luck trying to bribe your examiner to get over it. They make it hard on purpose - there are lives in our hands.

The wider world recognises such obvious facts - that not all doctors on Earth are made alike, that there are multiple tiers of quality. It is for this reason that British-educated clinicians are so highly sought after. Australia prioritises Western-educated doctors as they only want the best of the best caring for their people. To practice in America one must pass the USMLE, arguably among the most rigorous assessments of medical knowledge going.

A British consultant can earn over half a million a year in Saudi Arabia, tax free. Leaving aside the considerable ethical misgivings, the point is the Saudi’s are not offering such lucrative contracts to, say, Nigerian doctors.

In the UK however, anyone in possession of a questionable medical degree and semi-understandable English is welcomed with open arms.

Amidst all of this is the fact it is not a national health service at all, but an international one. People come from far and wide to take advantage of our generosity, laughing all the way here and even harder on the way back home. Most of my colleagues seem to think this an entirely reasonable arrangement (at least publicly). I’ll admit we doctors, as a species, tend to be appallingly PC, and care not a jot about any wider opportunity costs, rather on treating the patient who happens to be in front of us.

Though as much as health tourism is an issue, and a bigger one than many would like to admit, it pales in comparison to rising population as a whole.

I recall attending a lecture in med-school about supply and demand pressures. Our professor made many perfectly valid points about the increasing costs of medical technology, an ageing population, etc., but I felt a rather obvious, key factor had been glaringly omitted. Towards the end, as it became apparent the issue would not be discussed else-wise, I raised my hand and asked whether surely the unprecedented scale of mass-immigration over recent decades was having an impact in increasing demand, and therefore waiting times and budget pressures.

The lecturer looked at me as though I had just proposed resurrecting the Third Reich, admonishing it as a totally inappropriate question that should not even be asked. The NHS runs on immigration, she informed us, and would collapse without it.

I wanted to riposte that perhaps we wouldn’t need so many foreigners working in the NHS if there weren’t so many using it. But open mouthed and red faced, I held my peace.

You learn your lessons fast when one’s entire career is at stake. Older doctors, closer to retirement, are more comfortable pointing out the morbidly-obese elephant in the room, they have less to lose. But for those with our careers ahead of us rather than behind, it is safer to keep one’s head well below the parapet.

Yet the emperor is bereft of clothing whether it is pointed out or not. One of my (black, as it happens) colleagues working at an obstetric ward in East London confided in me that, in her entire four-month placement, she saw but one baby delivered to a white, English-born mother, and her ethnically Greek.

The NHS forks out over £70 million a year on translation services to aid communication with the legions of non-English speakers accessing our healthcare system. If I were to take ill in Tunisia or Thailand or most of planet Earth for that matter, I would be expected to pay for my own interpreter; but here, as ever, everything is provided for you courtesy of Mr and Mrs England. They charge by the hour, and I have personally witnessed them arrive, conduct a five-minute conversation and leave… that will be £50 of taxpayer’s cash if you please.

There are further gripes I could make - the rise of woke ideology for one, growing and metastasising daily. Last year alone, NHS management thought it eminently wise to spend the better part of £46 million on diversity and inclusion officers. Indeed, staff must now attend mandatory DEI classes to teach us how all of the world’s woes can be laid at the feet of the pale, male Untermensch.

Or the fact the NHS has become a political sacred cow, impossible to criticise without being decried as a blasphemer. The mistake (often deliberately) made, is to confuse the institution with the people who work for it. The latter are, on the whole, dedicated, compassionate and hard-working - the former is an obscene monstrosity. I wouldn’t put much hope into bipartisan cooperation any time soon either, the day the Labour Party stops weaponising the NHS is the day they stop being the Labour Party.

But the main, insurmountable problem is that the NHS is the only game in town, and they know it. Ultimately, only competition drives efficiency, yet private healthcare is extremely rare in the UK compared to equivalently developed nations. With no competition, there is thus no incentive to become more efficient. Behind the curtains, the sheer scale of waste and redundancy is truly indescribable. It's almost as if they're deliberately trying to squander as much resources as possible. After all, it’s not their money.

I long ago lost count the number of times I’ve been sat in a clinic documenting one DNA (Did Not Attend) after another, sometimes with consultants on £200/hour locum rates. Not that it’s their fault, they express as much frustration as anyone, it’s simply that patients rarely face any negative consequences for not showing up. We just rearrange the appointments for them. I guarantee if even a 50p deposit was collected beforehand, we’d see drastically fewer no-shows as a result.

The solution is obvious, but frustratingly, whenever one proposes even partial privatisation, idiots invariably point to The States. As though the US healthcare system is the only alternative out there - ignoring Switzerland, Japan, France, Holland, etc. etc., where the private sector is fully integrated into the system as a whole, and most people have health insurance as routine. If America is too far one end of the ‘privatised-socialised’ spectrum, and I would argue they are, then we are most certainly too far the other.

Take Canada for example: a mature, competitive insurance market means that premiums are relatively cheap, and over two-thirds of the population has some form of private health coverage - it’s a normal part of employment contract negotiations over there. To supplement this, Canadian citizens also enjoy an excellent public safety-net for those without insurance.

Naturally, this takes tremendous pressure off their state healthcare system, which makes it infinitely more agile and efficient as a result. Meanwhile in Britain, the system is the safety-net, which is why every part of it is tearing at the seams, and why we’ve been ‘saving the NHS’ for over half a century.

There is a very weird stigma against private healthcare in this country. Less that 10% of the population have cover, and little competition between insurance companies results in sky-high premiums, meaning only the super-rich can afford it and exacerbating a negative cycle of unaffordability.

I fully understand the knee-jerk instinct to retain free-at-the-point-of-use, but think of it this way, would you pay £50 to see your GP the same day you needed them? Would you pay £500 to ensure your knee surgery is next month rather than next year?

I suspect for many people the answer is - where do I sign?

Needless to say the NHS is not free, indeed, it is phenomenally expensive. Well over £150bn in fact, more than the entire national defence and education budget combined. £3,840 a year for every man, woman and child in Britain. Oh you pay for it alright, it’s just that the charges have moved from brightly-lit hospitals to far murkier and malign channels.

I suspect there is a bigger appetite for frank honesty amongst the general public that our politicians appreciate. The real question is - how do we get the most bang for our buck? If integrating the private sector with the public one does that, as proven to be the case in many other developed nations, then what are we waiting for?

During my elective in Australia, the other doctors mocked the NHS as a cult. No other clinicians in the Free World would put up with such poor working conditions for such awful compensation, they said, and it’s only the goodwill of the indoctrinated cult members, along with a bottomless supply of public funds, keeping it afloat.

Their own hospitals are shiny and new, and packed full of expats broken free from the commune. Many reported they had no idea how bad the NHS truly was until they got out. The more I've experienced of it since qualifying myself, the more I’m forced to agree with them.

In the 17^th Century, the French statesman, Count Mirabeau, observed of his teutonic neighbours, ‘Some countries have armies, but the Prussian army has a country.’

Three hundred years later, and while some countries have a health service, the British health service has a country.

There is a better path, if only we had the courage to take it. I shan’t hold my breath.