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There are three key stakeholders to the NHS outside of the medical profession; patients, politicians and the media. In this article, the role of the public, its perception of healthcare services and its attachment to the NHS shall be discussed.

Imagine a country of informed debate, in which the public can study a topic dispassionately, the media can refrain from alarmist headlines and politicians can put aside short-term political advantage for the sake of long-term public benefit.

I wonder if you can.

Imagine a country which encourages open debate on the future of public health, free of the shackles of political hysteria.

Perhaps one day the UK may then have a health service it is proud of, like its European neighbours.

Apologies to the memory of the late John Lennon but imagining such a utopia is an interesting exercise when considering the future of UK healthcare provision.

However, just for a moment, imagine such a utopia. Would it not be so much better for our NHS?


It is imperative that the UK health service maintains the founding principle of ‘‘free at the point of use.’ However, there is more than one way that this can be achieved and as I said in my previous article, it is unrealistic to expect any organisation to reach 75 years in age and not face a debate as to its future.

However, is the public sufficiently informed enough to participate? Are they too emotionally attached to the NHS in its current state which prevents them from potentially accepting reforms, to their benefit? Is the British public even aware of the alternative healthcare models used in Europe, as any talk of meaningful reform are curtailed by partisan politics?

It can be argued that emotion and uninformed opinion are helping to hinder development of British healthcare and inadvertently contributing towards the crises in the NHS.

Considering its role in our lives, it is only right that patient groups remain at the centre of any debate into the future of the NHS. However, public opinion must be dispassionate and objective, reaching a conclusion based upon an argument’s merit.

Education lies at the centre of this debate; to properly explain alternative health systems, to better the understanding of the challenges facing the NHS, and how patients can better utilise NHS services so that patients do not inadvertently add to the challenges.

It is important that we do not confuse “emotional attachment” with affection; current patient satisfaction shows anything but affection for the NHS. Emotional attachment can be negative; disappointment, anger, annoyance, dislike. Even negative emotions must be shed, decisions must be made based purely upon logic and reason.

Politicians must now set the example, refraining from short-term electoral cycles within a national debate framed within the parameters of sensible reporting by national media, so that conclusions can be reached which are both mature and sensible.

This is perhaps too idealistic a utopia.

The challenges facing GP surgeries are a good example of public perception.

It is worth noting that the first draft of the above sentence initially read “The crisis facing GP surgeries.” However, using the word “crisis” in this context is an excellent in how policymakers and policy advisors can exacerbate a problem facing an important part of the NHS.

The long waiting times for face-to-face meetings with GPs (average 10 days) has an almost weekly slot on news channels and in newspapers. At first site, the 10 day wait does appear to be unreasonably high, especially compared to Germany’s 4 day waiting time. However, the UK’s average time appears more favourably with Denmark, Belgium and Holland, which all average around 7 days.

Undoubtedly, UK patients have to wait longer, which is unacceptable. However, it is apparent that public expectation (fuelled by the media) for an instant appointment with a GP is difficult to achieve, even in countries whose healthcare systems are regularly reported to be more efficient.

A quick study of the statistics may provide some explanation of the longer waiting times.

The number of full-time GPs has fallen by 6.2% between December 2016 to January 2023, from 28,375 to 26,629. The government announced in 2020 that 6,000 more GPs were to be recruited by 2024; it is projected to miss this target by 2,087. However, the number of patients each GP is responsible for has increased by 348 since September 2015 to 2,286, an 18% increase.

In February 2022, patients booked 25.3 million appointments with their GPs. In February 2023, this number was 27.3 million. Unsurprisingly, patient satisfaction levels for GPs had reached a record low in the most recent NHS patient survey; 38% in 2021 (published in 2022), a 30-point reduction from the previous year.

This has a knock-on effect with the rest of the NHS provision, including delay in referrals, greater use of the non-emergency 111 number and the use of A&E.

These statistics make for sobering reading, and can be explained by issues in funding, work-life balance and recruitment. However, it is reasonable for policymakers to ask whether there is anything the public can do to help alleviate this problem. As it is our NHS, the public cannot be absolved of responsibility.

As was discussed in the previous article, pharmacies can play key role in relieving the pressure on GPs.

Pharmacists can share the burden of being the patients first point of call, reducing the GPs workload. Pharmacists are well-qualified, extremely knowledgeable about public health and are excellent source of advice to patients. The rise of Healthy Living Pharmacists and the limited scenarios in which pharmacists can now prescribe antibiotics illustrates that the government acknowledges this.

This would free up GP time, improving waiting times across the NHS.

For this to be achieved, pharmacists must be trusted by the politicians, the media and the public, and responsibility must be shared by all three stakeholders. Politicians must introduce a first-class publicity campaign for greater public awareness, the media must limit itself to only constructive criticism and the public must want to accept this change.

However, community pharmacists are currently underutilised. Unfortunately, for many patients (especially men) the perception of the pharmacist remains that of a dispenser of prescriptions, OTC medicines, toiletries and contraceptives.

With over 90% of the 11,688 community pharmacists having private consultation rooms, now is the time to encourage the public to use pharmacies. We have all no doubt seen a GP where the advice received was “let’s see how we go for another couple of days” before taking antibiotics. How much better would it have been to be told this by a pharmacist, freeing up that GP appointment for another patient with potentially more acute symptoms in need of a referral.

Patient responsibility must not be limited to only this one part of NHS debate; indeed, public attitude helps to shape the actual debate itself. This is the vicious cycle of how all the stakeholders are effectively encouraging each other’s opinions.

For example, in the most recent patient survey, 78% of respondents said that the principle of maintaining healthcare to be free at the point of use had to be kept. This is a massive percentage, indicative of just how highly the principles of the NHS are held. However, 80% of respondents said that the NHS faced a spending crisis and overall patient satisfaction fell to 36%, a 17 point decrease from the year before.

These figures demand closer inspection.

Are the 80% who said the NHS faced a spending crisis actually convinced of this? They may not be aware that NHS funding will increase up to £160 billion a year after April 2023. Afterall, it is very easy to say that there is a funding crisis if you have just read this in a newspaper or have just heard an MP argue this point merely for political gain.

Understandably, some patients may look at their ageing hospital and wonder where the funding is being spent.

The problem, though, is that despite patients’ best intentions, this statistic will now be used as part of a bidding war by politicians and unions. As per the saying, “the public gets what the public wants.” But extra funding does not necessarily equate to better results.

The issues surrounding funding illustrate the importance of patient responsibility of furthering their own understanding before participating in such an important debate. To be a constructive member of the debate into funding, patients must first understand how the NHS is funded and how healthcare is funded abroad.

At the heart of the debate, is the argument between public and private.

It is completely understandable, especially in the current cost of living crisis, that patients are given the surety that they will not have to pay additional taxes for healthcare. Nor should they have the fear of not being able to afford treatment or being asked for surety of payment before treatment is administered, the perception of certain foreign health systems.

Once again, we must ask if the public really understands the concept of “free” when the principle of “free at the point of use” is being debated.

The founding principle of “free at the point of use” is one of the greatest fallacies in healthcare. Yes, patients are not billed for their hospital treatment, which remains “free.” But are patients that naïve to think that at no stage are they paying for the NHS?

If the NHS is free, then would not be funded through taxes and PI contributions.

To think that healthcare provision in the UK is free is completely erroneous.

Likewise, the concept of “private” healthcare can be completely misunderstood. Patients’ fears of privatisation and the Labour Party’s mistrust of it is indicative of a misunderstanding of the concept, intentional or otherwise.

Consider Germany, whose healthcare model has influenced just about every other European model except for the UK, Norway and, to some extent, France. In Germany, private healthcare is mandatory, with a proportion of income being collected as tax to fund their private health cover (50% is paid for by the individual, 50% by their employer). The self-employed, unemployed and pensioners without private health cover join the government scheme, which tops up the individual’s health cover depending on size of income.

The individual has the right to choose their own private health insurer, and the patient can choose where and how they are to be treated, and by whom.

As with all European healthcare systems based upon the German method, the patient must provide proof of insurance cover (which every patient has in one form or another) at the point treatment is sought. Treatment is then free.

This follows the same method as the NHS in the UK, except that UK patients must provide their NHS patient number rather than their medical insurance. At no point are European patients required to prove they can pay for their treatment; one of the main fears of privatisation.

In the UK, there is a natural distrust of anything labelled “privatisation,” the perception that under an alternative healthcare model, only the wealthy would receive medical care as they would be the only ones able to afford the insurance premiums.

However, this does happen in the alternative European models, and politicians and other commentators can be often very disingenuous with the facts, feeding the public’s fears.

The very term “privatisation” is unhelpful, as it is a debate about funding and the role of the state, as opposed to private commerce. “Funding” is perhaps a better term.

A major concern over any talk of additional “funding” is that the taxpayer would have to pay an insurance premium on top of their current tax liability. However, Europeans do not pay tax for an NHS-like model on top of their insurance premiums, and it need not happen in the UK.

It would therefore be a reallocation of tax-funding. The current tax contribution made by the taxpayer for the NHS would be re-spent on private health insurance, so there would be no additional cost to the taxpayer.

Of course, this reallocation would require government support and it is perhaps unrealistic to expect the government to implement a policy maintaining the level of current taxation.

There are no qualms or fears in Europe over private healthcare; it is seen as a more efficient form of healthcare provision, and different model of funding. Treatment is “still free at the point of use.” It is not even privatisation as the UK knows it, but rather another term for tax collection and spending. In many countries, it is nothing more than difference in definition; the UK has its NHS, Germany has its health unions.

The debate must also establish exactly what it is that patients want to get out from its NHS. It is not as simple as saying, “to be cured of an illness” or “to receive the best care” or “for my loved one to be well cared for.” These are accepted as part of the debate. But the issue is how the NHS works.

The last article spoke of the changing attitude of society, and how patients now expect to be cured rather than treated.

There is an additional societal change; the expectation of choice. Consumers in any market now expects a gluttony of choice, which would have been incomprehensible to anyone living in 1948.

We have an unprecedented level of choice in our daily lives; from methods of transport, to news outlets, to television and radio channels, to landline providers. This level of choice forms part of the debate into the future of another British institution, the BBC, and questions remain over the validity of the licence fee when most licence fee payers only use only a minimal amount of BBC output.

Healthcare provision seems to be the only area within British society in which we do not seek choice, with patients willingly accepting how where and by whom they will be treated. For some patients, this is appropriate and acceptable. For others, the availability of choice may improve treatment, quality or the duration of life.

Perhaps institutional rigidity in the NHS goes someway to explain patient dissatisfaction. The only way of settling the debate is by fully explaining the implications of a differently “funded” NHS in a non-partisan, apolitical, dispassionate manner. This will allow patients to make their own decision.

This article started with an invitation to imagine a perfect world.

In a perfect world, public awareness of these issues discussed would be much greater than it is. Those to the right of politics would have the courage to explain the difference approach to “funding” whilst those to the left would not be so reactionary to the prospect of change. Their respective supporters in the media could help by refraining from headline hunting.

Patients will therefore be able to join the debate with opinion based upon fact rather than through partisan influence.

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