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BOOK REVIEW: Free for All – Why the NHS is Worth Saving

By Hector MacKenzie

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by Dr Gavin Francis

Profile Books (Wellcome Collection)

Softback £7.99

Free for All: Why the NHS is Worth Saving.
Free for All: Why the NHS is Worth Saving.

THERE's undeniable logic – and a great sense of urgency – at the heart of this impassioned love letter to the NHS.

The Scottish medic, who has worked across four continents as a surgeon, emergency physician, medical officer with the British Antarctic Survey and latterly as a GP, takes the pulse of the treasured service some 75 years after its launch.

And he doesn't mince his words over the prognosis. Referrring to previous talks of crisis, he writes: "The gravity of the service's problems are different this time: like a patient on life-support, the NHS hangs in the balance, at the mercy of our politicians and of us, the electorate. There's still time to save it, but if I had to break the news to loved ones, I'd say it's touch and go whether it will pull through."

In 1948, the headlines read ‘Free For All’ as the birth of the NHS pioneered a model of healthcare based on the principles of justice, dignity and care for everyone. So how has Britain’s best loved institution come to offer such poor service for patients today?

That's what he seeks to find out – and provide a solution to – within an admirably concise 166 pages.

Healthcare professionals in the NHS continue to work under immense pressure, despite chronic underfunding, near-zero capital investment, negligent workforce planning, political infighting and a drift towards privatisation, he observes. The health service’s ‘new normal’ is a permanent state of crisis; senior government officials now acknowledge that the NHS is close to breaking point. But, he insists, it doesn’t have to be this way.

Dr Gavin Francis.
Dr Gavin Francis.
A health service free for all at the point of use, based on need rather than on demand, is an expression of what's best in our society, and we'll get the success of what's best in our society, and we'll get the NHS we're prepared to insist on.

He examines the reasons why NHS standards have fallen to such a historic low, taking in the views of his medical and nursing colleagues and his own 30-years’ experience as a GP. He shares stories that illustrate how poorly the NHS is working right now and offers suggestions for how things could easily improve.

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Francis deploys facts and figures sparingly but effectively in marshalling his arguments.

On the eve of the Covid-19 pandemic, the Royal College of Nursing estimated that the UK was short of 43,000 nurses. Six in 10 nurses felt they couldn't do their jobs properly because of staff shortages.

He writes that within the space of a few short months, patients went from offering spontaneous expressions of support for the NHS by clapping healthcare workers from their doorsteps to "cursing and criticising the same people for service failures that have their origins in political decisions, not clinical ones".

And from his personal observations from the workplace, he notes the degradation of the NHS is such that some of his patients "are now obliged to turn to commercial providers and private clinics because the NHS is no longer able to provide them with a service that's fit for purpose. That must change, and with the right pressure on our political representatives, it can".

He says the clinical attribute with the greatest currency is trust. If private providers with profit as their bottom line are allowed to take over, trust evaporates.

Revealing the challenges of life as a GP, he notes that someone in later life could potentially be taking up to 20 tablets a day.

He argues that GPs provide "an extraordinarily good service in terms of value for money" but that demand for appointments has "overwhelmed" the number available and that there are not enough GPs coming through to do what's asked of them.

In a 10-minute appointment he says he's routinely asked to deal with three or four different problems ("my record so far is nine") and that for the NHS to be saved, general practice needs to survive.

Large parts of what we ask GPs to do can be done by other members of the wider healthcare team. He says: "It's urgent that we ask of each encounter: which of these tasks requires someone with a medical degree and 10 years of training, and which tasks can be done by someone else?"

His solution includes calls on elected representatives to benchmark the NHS against other comparable European nations "and insist they commit to funding our service adequately, so that we can keep up".

Yet he manages to maintain a positive tone while admitting that the caring professions in Britain right now "could do with a bit of care – and some hope".

An urgent national conversation, possibly through citizens' assemblies, would help determine people's priorities. One difficult question that may need answered is what can the depleted workforce stop doing to free up capacity and time?

While there is scope for smarter working, provision of an expensive service helping an ageing population to manage increasingly complex conditions will inevitably come down to resources and priorities.

Francis refuses to give in, arguing this is an institution worth fighting for: "A health service free for all at the point of use, based on need rather than on demand, is an expression of what's best in our society, and we'll get the success of what's best in our society, and we'll get the NHS we're prepared to insist on. I hope you'll agree it's worth saving."

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