Brexit and the NHS: Just the Facts. Part 4: Show Me The Money

In a multi-part series looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the impact on the supply of medicines, in Part 2 we examined the barriers to importing nuclear isotopes and in Part 3 we examined the current NHS staffing crisis through the new lens of a No Deal Brexit.

In this final part, we look in-depth at the NHS books and ask do we have the resources and funding to survive a No Deal scenario?

Before going any further, it’s important to establish a few key facts about NHS funding.

Firstly, as a publicly funded institution the NHS budget is set centrally by government and various affiliated semi-government bodies. In addition several charitable and research organisations donate money and resources for specific NHS services.

Secondly it’s vital to understand that the NHS requires more money each year than the previous, to maintain the same standard of care. There are many reasons for this, the smallest of which is an expanding population. Currency inflation is another. However, the main reason is something called “health inflation” – above currency inflation, this is the concept of the continuous rise in costs in any state of the art healthcare system. This takes into account things like the rising cost of new medicines and new technologies, an ageing population, and more and more people surviving conditions that previously would’ve been fatal, therefore going on to require more complex and advanced healthcare. This has been the case for 70 years. Since the beginning of the NHS activity has increased by roughly 4% every year, and the NHS budget on average has risen by 3-4% every year in step.

So what’s going on right now with NHS funding?

Since 2010 there has been a near funding freeze on the NHS, with the budget rising just 0.9% every year, while demand and activity relentlessly grow. The NHS ran a surplus of £1.5bn 2010/11, it now runs an underlying deficit of up to £5.9bn in 2017/8. Increasing service activity have been paid for by a combination of backroom cuts; selling assets like land and transferring investment budgets into day to day running costs, as well as front line cuts: mental health nurses, closing maternities and A&Es, cutting nursing bursaries. Year on year the NHS in England has had to stretch more and more from the same budget, for 8 years.

Wasn’t this a good thing? More efficiency right?

The NHS was already ranked one of the most “efficient” healthcare systems in the world in 2012- mostly due to primary care triaging, the lack of insurance paperwork and payments bureaucracy and use of generic medications.

There is always room to improve however, especially in an organisation with a budget of £115 billion a year. The Carter report suggested getting rid of unwarranted variation in procurement and practice between hospitals could save as much as £5billion (albeit correcting some of the identified areas would take significant investment itself).

However, there is only so much fat to trim, in what was already a comparatively lean system. Relative to inflation the NHS has already cut pay to its staff for the last 8 years, in some staff groups as high as 25%. The land has already been sold, all the clever accounting cards already played. The deficit is £6bn and the NHS already predicted it needed £30bn by 2020 just to keep the lights on, and has only received £4bn to date.

Everywhere the alarms are suggesting there isn’t much more to give: A&E waits are the longest ever recorded and the target has been scrapped, operation and cancer waiting times are at all time highs and staff morale is at rock bottom.

This was the situation BEFORE Brexit.

How does a No Deal Brexit change any of this?

In addition to the additional costs to import medicines and isotopes across new borders, and the agency fees to fill vacancies we cannot recruit to, No Deal Brexit will hit the NHS in the one area it is threadbare; it’s pocket.

A No Deal scenario effectively removes the U.K. from the free trade area of the EU, an economy worth 22% of global GDP, and the 60+ countries the EU has FTA agreements with: Canada and Japan most recently. Once out of FTA trading these countries would be obligated to charge tariffs on exported goods and supply chains based in the U.K including car manufacturing, farm produce and pharmaceuticals. With loss of the financial ability to “passport” services to the EU the financial services sector, 6.5% of our economy, would be hit very hard. The Department for Brexit’s own figures estimate a No Deal to cost £159bn to the U.K. economy by 2030. That’s the entire NHS England and U.K. schools budget combined.

But can’t the U.K. just make our own trade deals?

Potentially yes, but there are multiple barriers to making that a reality: negotiation time (usually years), the approval of the other WTO states and even potentially the approval of the EU with countries like Canada and Japan as part of their FTA in the first place. Most of the “high profile” trade deals we are courting lately; South Africa, Canada, Japan, are all countries we ALREADY have excellent trade deals. For example, the South Africa-EU FTA allows us tariff free trade on 90% of everything we exchange: a deal that’s already increased bilateral trade by 120%. If we do renegotiate we do so from a weaker position; a much smaller individual economy, with weakened buying power, in a desperate position. Secondly pretending these are deals which will equal the loss of trade between the U.K. and the EU in the event of No Deal doesn’t add up: 50% of foreign trade is done with the EU, our next largest partner is Germany by itself, at just over 10%. The USA is close behind with ~10%. South Africa is <1%. If we lost 20% of trade with the EU we would have to increase trade by 100% with the USA to compensate. Countries we already trade with and many that we have free trade agreements with right now.

So a No Deal Brexit will hit the economy a little, what’s the big deal?

In healthcare money means lives. Less money leads to less resources which in turn causes more harm and more avoidable deaths. An analogous scenario is the 2008 financial crash. Fraudulent banking practices in the US housing market triggered a worldwide recession as major banks that had bet heavily on dodgy mortgage products lost, and went bust in the process. Worldwide in countries where healthcare was linked to employment, there was a spike in cancer deaths, estimated at 500,000 excess deaths that otherwise wouldn’t have occurred.

In the U.K., due to the NHS model, we were insulated from this effect. The decision of the Tory coalition however to impose austerity in response to the financial crash had its own effects. A study in 2015 and a further study in 2017 concluded that as many as 50,000 “excess” deaths occurred between 2010-14 and up to 150,000 by 2020 due to cuts in health and social care. With the lack of staff, lack of resources and general decline in every outcome measure of safety and quality this is no surprise.

We are in the exact same scenario as 2008 once again, except this time the NHS is not in good health going in. Despite all this, the current government seems unwilling to countenance the realities. Theresa May even linked her proposed funding increases for the NHS, £20bn a year extra by 2021, to a Brexit “dividend”. *Sigh*.

Is there a Brexit dividend?

Short answer: No

Long answer:

Each year we pay £13bn into the EU and get around £7bn back as an immediate rebate, and then further subsidies, for example to British farming, leaving £6bn going to the EU each year, or £120m a week, or 26p a day per person.

For that amount we have access to 27 Free trade countries worth £350bn a year to the U.K. in trade, as well as 60+ further countries via EU agreements. The CBI estimates this is worth £3000/year per household, or £2 a day per person, eight times what it costs.

In the event of leaving the EU, we gain the balance contribution, but the trade we lose has to then be factored in, the corresponding hit to the economy and the subsidies we would then have to pay ourselves to our own industries. The OBR already estimated we have lost £15bn in economic activity due to the Brexit vote, and even if that were not the case and there were really was a Brexit dividend the government has already promised to spend it several times over.

Specific post-Brexit spending has been promised to: a U.K. satellite system (£100m), a new customs solution and border infrastructure (up to £20bn), storing 6 weeks of medicines (£2bn), a “divorce bill” (est. at least £18bn by 2028), several thousand more civil servants and customs officers, new staff for an expanded civil aviation authority, a new border solution in Northen Ireland, an entirely new authority for food and animal trading and new lorry waiting parks to mention but a few.

On top of that the missed opportunity of firms taking a look at the chaos and uncertainty and deciding to contract elsewhere. Whatever tiny amount we get back from the EU is going to be lost in a deluge of direct and indirect losses.

What does that have to do with the NHS?

Despite promises of another “£20bn” for the NHS, budget after budget will have black holes that need filling, and the chance of any new money, let alone current funding, becomes more and more remote.

Meanwhile, demand will continue to rise. There will be 3,000,000 more over 80s in the U.K. by 2037, a group of patients that costs an average around £7000 a year in healthcare. Increased survival, technology, wage inflation and likely higher currency inflation will all continue to increase the cost of the service we currently have.

Are you done now?


To be very clear, the crisis state of the NHS is not the fault of Brexiteers and voting Leave was not a vote for this. Be that as it may, a No Deal Brexit reality will throw up new barriers to importing medicines and isotopes for cancer diagnostics, push existing EU staff away and stop new staff from coming, and throttle any hope of new funding. Worse, when we should’ve spent two years debating about how to fund the health and social care system we have, how to staff it and supply it, we’ve been talking about Brexit. All other political issues have also been put on hold; teachers, policing, welfare. Brexit isn’t the root cause of the NHS’ problems, far from it, but it may prove to be the straw that broke the camel’s back, a No Deal scenario even more so.

Informed consent is the absolute bedrock of medicine. It’s my job as a professional to fully inform you of the options and you then make a decision knowing every risk and benefit. I’ve never heard a position on Brexit that involved Euratom, the EMA or EU nursing applications. Who knew this stuff? I have to admit, I didn’t. Find me someone who voted Leave that did. I haven’t so far. We can now see the shape of Brexit, for the NHS at least, you are now properly informed. Democracy requires everyone has the same set of facts before they make their opinion. Here are the facts.

The question is what are you going to do about it?



Brexit and the NHS: Just the Facts. Part 3: We, The People

In a multi-part series looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the potential disruption to the supply of vital medicines, and in Part 2 we examined the barriers to importing nuclear isotopes essential in many treatments including cancer.

In this part we look closely at the largest and arguably most important resource the NHS has, the staff.

What’s going on with NHS staffing in 2018?

The NHS is the world’s fifth largest organisation, in England alone it employs 1.2million people. Since 2010 staff numbers across multiple areas have fallen, leaving large gaps. To maintain current services we need 40,000 more nurses, 10,000 more GPs, 11,000 more hospital doctors and 7000 more mental health nurses.

What has the government done about this so far?

Short answer: A lot of words and little else.

Long answer: During the coalition years the government cut nursing training numbers and nursing staff posts in hospitals, as well as cutting 6000 mental health nurse positions. Meanwhile demand and activity in the NHS relentlessly grew every year by ~3%, increasing the pressure on the remaining staff and creating a situation where more staff are leaving than joining.

Despite promises of “5000 more GPs by 2020”, the number of GPs have actually fallen by over a thousand. Growth in nursing numbers is equally negative, as more leave the NHS than join. Despite proposing 15,000 more nursing places to train “homegrown” staff, so far those extra places have not been filled. Funding for places may have increased but bodies have not followed; applications fell by ~10,000 in England last year, meaning the number of nurses in training actually dropped. This is due to the government cutting nursing bursaries and charging full tuition fees from 2016. Similarly, the government has announced an expansion of doctor training places by 1500 per year from 2020, but these new doctors won’t be on the shop floor until 2025, and won’t be new GPs until 2030 or new hospital consultants until 2033.

What has that got to do with Brexit?

We have a worsening staff crisis coupled with a failure to train our own staff to deal with it. We are therefore 100% reliant on recruiting trained staff from abroad to fill the gaps, in recent years from the EU especially. Of the NHS 1.2 million staff, approximately 5% are currently from the EU, 10% of doctors and 7% of nurses.

How have things changed since the Brexit vote?

The official number of self-reported EEA staff has actually risen slightly from 58,698 to 61,974 between 2016 – 2017. This is partly because 10,000 “unknown” nationality staff members in 2016 became “known” in 2017. In specific groups, such as nursing, there has been an 89% drop in the number of new EU nurses, and a 67% rise in those leaving.

Are EU staff leaving?

Short answer: Yes

Long answer:

Staff in the NHS come and go as with any very large organisation, it’s the relative balance that is important. The total percentage of EU staff leaving has increased, and the percentage of EU staff joining has decreased. 10,000 EU staff left the NHS last year, an increase of 42% on the year before.

The BMA surveyed 1700 EEA doctors this year- 50% were considering relocating, and 20% had already made concrete plans to leave. Although this is bad, the major issue is recruitment.

Since 2016 EU recruitment has flatlined, for nurses especially. In addition to new language tests, new EU nurses also face a falling exchange rate, dropping the effective starting salary by 12%, and prolonged uncertainty about their working conditions and residential status. Applications for EU entrants into nursing have dropped 96% since Brexit began. Where 6400 new EU nurses joined in 2016, only 800 joined in 2017, a loss of 5400 nurses we sorely needed. The number of doctors also joining the register from the EU declined by 1000 between 2016-8.

Overall since 2009 there has been a steady rise in nursing and medical staff from the EU, a rise which levelled off after the EU referendum and hasn’t resumed. The balance of recruitment to resignations has shifted dramatically, so as a source of manpower to solve our staffing crisis the EU has dried up.

Why is this a big deal? What’s a few less nurses?

Statistically there is a direct correlation between staff numbers to patient ratios and the chance of survival. For example, the higher the number of nurses per patient the more likely stroke patients are to survive. Less staff = more deaths and more patient harm. The NHS recruits in large drives to plug these gaps from the EU; Spain, Portugal and Ireland in particular, but no longer. That shortfall will undoubtedly lead to patient harm.

How does No Deal change any of this?

The No Deal Brexit papers specifically do not mention EU citizens status in the event of No Deal. Whether a tactical omission or a political misstep, the lack of concrete reassurances for EU staff is deeply troubling. Bear in mind many of our EU NHS staff have lived here for years, have children in schools, support dependent relatives and have long-term careers. The looming threat of uprooting and even deporting, however distant or vague, should not be underestimated. If you were in the same position of uncertainty, unsure if you might have to pack up your whole life in six months time, would you buy a house? Would you move to a new job? It seems unlikely you’d come to a country that was so unsettled currently.

The additional predicted further drop in the value of the pound, the uncertainty over basics like pensions and healthcare access in the event of No Deal, will only compound that. As a father with a young family I certainly would not move here if I were in that position, and I can’t say I wouldn’t be thinking of leaving myself. Would you?

Is the government doing anything about this?

Dominic Raab, the current Brexit Secretary, has “reassured” EU residents no one will be “turfed out” in the event of No Deal. However, as already mentioned, they haven’t published anything tangible on this as yet.

There is a pilot programme in the North West for up to 4000 EU students and NHS staff to apply for Settled Status, initially for those in 12 NHS trusts. Although a digital process this pilot will require a face to face Home Office appointment. The Home Office has already stated it does not have sufficient staff currently to process 3,000,000 applications, and the initial launch of the “app” in June did not function on half of smartphones, so it remains to be seen how the remaining 60,000 NHS staff will be settled in this way. Whether these terms will change in the event of No Deal is another question hanging over everything.

What about future EU recruitment for the NHS?

The drop in recruitment due to Brexit is creating a worsening shortfall in key departments, increasing the pressure on existing staff and exacerbating increased numbers from all groups leaving the profession or retiring early.

In a No Deal Brexit the U.K. remains a less attractive destination: relatively less pay, new barriers to the immigration process including visa caps as a third country and uncertain settled status.

So in summary the NHS is already in an understaffing crisis, created by under-resourcing and poor workforce planning, exacerbated by cuts to posts and bursaries for recruitment, meaning hopes of new “homegrown” staff to plug the gaps are a decade away. EU staff have been invaluable to maintaining a functioning service but since the Brexit referendum recruitment has dropped off a cliff. A No Deal scenario will only compound the haemorrhaging of staff, in a system where staff numbers are a literal matter of life and death.

With a shortage of medicines, diagnostic isotopes and vital staff, we will require a massive influx of resources and funding to keep the service going.

Resources and funding we do not currently have. If you’re still with us, read on to Brexit and the NHS: Just the Facts. Part 4: Show Me the Money. (coming soon).


Brexit and the NHS: Just the Facts. Part 2: Going Nuclear

In a multi-part series looks in-depth at the potential impact a No Deal Brexit will have on the NHS.

UPDATED with the latest No Deal planning paper from Govt. “Civilian Nuclear regulation if there’s no Brexit Deal”.

In Part 1, we looked at the potential disruption to the supply of vital medicines. In this part, we will look closely at the use and supply of radioactive isotopes in the NHS, and how a No Deal Brexit specifically will impact this.

What do you mean radioactive?

We use radiation a lot in medicine. The term conjures images of radiation burns and nuclear warfare, or perhaps super-powered arachnids, but in controlled doses for the right reasons radioactive substances are a vital part of many types of healthcare. We can use radioactive therapies to diagnose conditions, monitor treatment, and even as treatment itself. From breast cancer to heart disease to thyroid cancer there are dozens of uses for nuclear derived radioactive material.

Where does it come from?

Nearly all nuclear material for medicinal use is imported. The commonest, Technetium-99m, is made in several reactors in Europe. We perform over 600,000 radioactive imaging procedures a year involving Tech-99m alone. The production, transport and storage of radioactive material is obviously very heavily regulated. The agency responsible in Europe is called EURATOM.

What is Euratom?

The European Atomic Energy Community is responsible for the safe use and distribution of all nuclear material- from the tiny diagnostic isotopes we use, to the nuclear reactors that generate power for cities. Unlike the European Medicines Agency, we currently do not have a local equivalent in the U.K.

Why is that important?

Well, in a No Deal scenario we have no equivalent agency of infrastructure to manufacture, import and export, distribute and store, radioactive isotopes.

UPDATED: in the latest government technical paper on civilian nuclear material, responsibility will move to the Office for Nuclear Regulation. Importing nuclear materials, as with medical isotopes, still has no plan at this time. Under the relevant header the paper reads: “importers may need to obtain an import license” and will “provide further guidance” at an undisclosed interval. So, still no plan as yet.

The Lords voted to stop our withdrawal from EURATOM in 2018, but a No Deal scenario would leave us out regardless. The rationale for leaving EURATOM as its “legally joined” to the EU has been derided as dubious as best. Currently it’s unclear what will happen in any Brexit scenario.

To illustrate the potential impact on the individual let us look at a specific example: the use of Technetium-99m in breast cancer, in a technique called Sentinel Lymph Node Biopsy. When diagnosing breast cancer we need to know several things: is there a tumour there, how far advanced are the cells in the cancer process, how far it’s spread in the breast itself and how far it’s spread to other places, firstly the lymph nodes in the armpit. These ‘sentinel’ nodes play a huge part in prognosis, and determining the need for chemotherapy and radiotherapy. Sentinel Lymph Node Biopsy uses radioactive isotopes to very accurately diagnose cancer spread to the armpit, determining the need for chemotherapy and radiotherapy. Without the isotope the potential to miss spread to the armpit skyrockets, as the next best diagnostic test is far more likely to make a misdiagnosis. Missing spread and reducing treatment means a curable cancer could become an advanced one, or even a deadly one. These are the stakes at play here.

Have these isotopes ever run out before?

Yes. There was a series of reactor maintenance stops in 2008-9. At the time there was sufficient supply for most units to delay or borrow isotopes from other hospitals. There is also a predicted shortage from 2016-2020.

Why is No Deal Brexit different?

The scale of the issue this time has never occurred before. Additionally the new requirement for customs infrastructure will have major implications as these isotopes cannot be stockpiled- they decay to become non-useable after a number of weeks. Procedures such as thyroid cancer treatment, palliative treatment for bone pain and heart scans would all be halted, temporarily or even long-term while inferior alternates are used.

in summary, leaving EURATOM does indeed appear to be the nuclear option: it’s needlessly extreme with no legal basis and will have widespread and long-lasting ramifications. There’s a high probability you will personally know someone who will be negatively affected. As a doctor, I have to admit I didn’t know most of this a year ago. I’m flummoxed how anyone outside of the industry could have. None of us were “informed”. Until now.

With less medicine and no isotopes we face a rocky future in the NHS. None of that will matter however without any staff.

See Part 3: We, The People (Coming soon)


Brexit and the NHS: Just the Facts. Part 1: Medicine

In a multi-part series looks at the No Deal Brexit scenario and its direct and indirect impact on the National Health Service.

Informed consent is the bedrock of medical ethics. It means I cannot legally do anything to you without your express permission, and for anything you do allow, or “consent to”, you have to know why you need it, the risks, benefits and all the alternatives. Such are the legal ramifications of this, if I were to perform a procedure without properly informed consent I could be jailed for the crime of battery.

The absolute irony of the EU referendum, arguably the most important vote in a generation, was the completely backward approach to the decision. The further from the time of “consent” the more informed the conversation has become. In this first part asks, how will a No Deal scenario affect our supply of drugs and medicines?

Will we still be able to import medicine?

Short answer: Yes, but costs will likely rise, and some supply chains will be threatened or may breakdown entirely.

Long answer:

Currently there are no tariffs or border checks within the EU for medicines. Tariffs are additional duties charged at the border for moving medicines between countries.

In the event of No Deal we would leave the EU and become an individual state within the World Trade Organisation, an internationally agreed baseline for trading.

The WTO has its own issues:

1. Although we are currently members our membership is within the EU bloc. We don’t have individual membership yet.

2. The WTO court for settling disputes is currently non-functioning due to a dispute with the USA. If any aspect of our joining or terms is disputed, there isn’t currently a way to settle it within the WTO.

Specifically in regards to moving medicines back and forth between the EU from the WTO, the EU is signed up to the Pharmaceutical Tariff Elimination Agreement, an Agreement to eliminate tariffs on a set list of medications with other WTO countries. We could continue to import tariff free medicines on this list from the EU under this agreement. However, this list hasn’t been updated since 2010- the US are again disputing it and holding up a revision. This leaves many new medicines off, meaning we would have to pay new tariffs on importing those from the EU. Which is a lot. We import 37 million packets of medicines every MONTH from the EU worth £18.3billion. The EU are our largest source of medicines (73% of all our imports), likely due to the frictionless movement and lack of tariffs. Estimated WTO tariff rates would add 5-6% of cost to these medicines. We also leave all the EU-WTO countries Free Trade Agreements we also had access to, e.g Japan, and any agreed medicines tariff reductions included in them.

Worse, UK based companies produce medicines in supply chains that often cross borders multiple times – each import potentially adding an additional tariff without an agreement. This will add significantly to the current £16bn medicines bill for the NHS.

That’s just the additional taxes. The costs and practicalities of physically moving medicines across customs borders will be a huge barrier to importing medicines, so-called “non-tariff barriers”. These govern how medicine is checked, regulated and transported – essentially guaranteeing the drug that’s injected to you has for example been refrigerated across the entire supply chain so it remains safe. Or is actually the drug on the bottle and not a knock-off imported elsewhere.

If we leave with No Deal we also leave the Customs Union, meaning we will require infrastructure at our border and at every exporting countries border to facilitate movement of medicines between our countries.

Not only will this disrupt and delay the import of finished medicines to our hospitals, it will also disrupt our ability to make medicine in U.K. based pharmaceutical companies like AstraZeneca and GSK. Many of these supply chains are time and temperature sensitive. Delays at borders may break the chain entirely and strategies to circumvent these issues, such as building additional storage space, additional supply routes or moving manufacturers, will only add to the final cost of the medicines passed on to the NHS.

Many drugs we also can’t stockpile for very long to prepare for a No Deal scenario. Insulin is a good example. We only make 1-2000 patients worth of insulin in the U.K. each year, while the national need for the medicine is 400,000 patients, the vast majority imported from Europe. We can’t stockpile insulin for very long, and it requires refrigeration and very careful regulated transport.

So, back to our short answer, availability of medicines will be reduced due to customs delays and supply chain issues, while the cost of these new barriers will be added to the medicines alongside any new tariffs for medicines off the list of WTO traded drugs. If this adds even a conservative 8% to the cost of medicines, that means an additional cost to the U.K. of £1.4bn every year.

What about importing future medicines?

Short answer: Leaving the European Medicines Agency will add to the cost of introducing new medicines to the U.K., deprioritising the U.K. for new drugs and delaying the introduction of state of the art therapies, such as in cancer.

Long answer:

Even if we can secure the supply line for our existing medication, in the short to mid-term we will face difficulties bringing new medications to the U.K. We were previously a key member of the European Medicines Agency, an organisation governed by the European Court of Justice. This Government decided Brexit should include leaving the EMA as it’s under the jurisdiction of the ECJ, although passed a motion this summer to include negotiating to stay in the EMA as a non-member. Obviously in the event of No Deal we are out of this entirely.

Why does this matter?

The process to develop new drugs and medicines is unbelievably expensive and time consuming. New medicines have to first be synthesised, tested on cells, then animal models and then a dose and formulation needs to decided upon. That process alone can take a decade and often doesn’t go anywhere at all. Once a drug is stable and theoretically beneficial to humans it has to go through several phases of trials before it can be approved for routine use by any doctor for a patient. Firstly it’s tested for safety in healthy people- unforeseen severe side effects in humans sometimes occur, for example see the “Elephant Man” trial at Northwick Park Hospital in 2006, where six healthy adults took an experimental drug at this phase of testing and all become critically unwell. Once it passes this safety benchmark the drug is then tested in a small group of people who actually have the disease. This is to demonstrate benefit and look at side effects- again, in the real world this may not work at all. If it passes this stage a much larger trial is organised, usually testing the drug against a placebo or the current best treatment in the strictest conditions possible to avoid any possible corruption of the results. These large trials take years to organise and perform and then publish, cost millions of pounds and again, often don’t go anywhere at all. Even once a drug is in the market we have a phase 4, where data is continuously collected from reported side effects. Sometimes it takes two or more of these trials to prove something actually works.

You can see already what a time-consuming and data-heavy undertaking this is. The EMA’s job is essentially to check every stage of this process, to take into consideration of practicalities like how the drug is given and how much it costs, and then to approve and regulate the medicine for use in EU patients.

Without this function there would be no checks on the drug development process, a process already hugely driven by the need for pharmaceuticals to recoup the money they’ve spent on development.

The EMA streamlines this process for the U.K. by allowing a single member state to undertake the approvals process and then applying that approval to all other members. So a drug approved in France is then licensed for the U.K.

Our subdivision, the Medicines and Healthcare products Regulatory Agency, was a leading part of the EMA. EMA HQ was formerly in London, and employed 900 people, but has already moved away post-Brexit vote. Once we are out of the EMA we will have to approve and license every new drug ourselves. As a much smaller market for drug companies than the EU we will be deprioritised for new drug launches. State of the art developments for conditions like cancer will take longer to come here. This might seem a trivial concern; what possible difference could a year or two make for a single drug?

In the 1960s an accidental discovery created an entirely new cancer drug called Cisplatin. Based on platinum, Cisplatin was found to be revolutionary for the treatment of testicular cancer, a condition that was once fatal in nearly all patients, but is now cured in 90%.

Imagine you have been given a terminal diagnosis, perhaps a year to live, when a new game-changing medicine like Cisplatin is discovered. Those few years delay will make the difference between life or death for you. That’s the reality of the unforeseen consequences of such a colossal decision; the knock-on effects domino everywhere, and real people may actually die as a result.

So, leaving the EMA will add to our own development costs and time requirements to approve medicines and delay state of the art treatment in conditions like cancer, where time can make all the difference.

What about future medicines?

Short answer: We are pulling out of research funding and EU-wide scientific collaborations on health and medicine products, which may hamper potentially life saving medical advances.

The long answer:

In the mid to long term, threatening to pull out of the EU with No Deal has already dropped many U.K. applicants from the EU research fund, Horizon 2020. A half a billion pound fund backing health science and technology, we may never know what good that could’ve done, what avoidable harm will now happen as a result.

So a No Deal scenario will have far reaching and damaging effects across nearly every aspect of current and future medicines in the NHS?

Short answer: Yes

Long answer: Very much so. But it only get worse. See Brexit and the NHS Part 2: Going nuclear.


“You are having a heart attack but we will fix it”. If only everything was so simple.

I’m working my second stretch of nights in a week (due to a missing EU doctor, ironically) on the heart attack service. At 3am my bleep rattles next to me and then shouts “Primary Angioplasty. Inferior MI. 10 minutes”.

This means someone is flying towards us in the dead of night with a major heart attack. Inside, a vessel supplying the heart muscle is completely blocked, the muscle beyond literally dying by the second. Needless to say these patients are very unwell.

The patient arrives and her ECG confirms all our fears: a major heart attack. My 3am brain tries to simultaneously take her history, listen to the ambulance handover, scan her heart muscle and consent her for the procedure all at once. She’s looking very unwell and I’m very conscious of how short time we have. “Time is muscle” in cardiology land, and her heart and possibly life is slipping away by the minute. 

I end up simply saying “You are having a heart attack, but we will fix it”. We rush her into the lab and fifteen minutes later we have indeed fixed it. She’s looking much better and is very thankful. I love cardiology.

Simple eh? From the patient’s perspective she’s had some chest pain, called an ambulance, been told she’s having a major heart attack, and then told it’s been fixed. What could be easier?

Well, pretty much everything. The procedure actually takes at least five people to perform properly, all highly skilled and trained and working together seamlessly. Every bit of equipment we use has been developed over decades, rigorously tested in trials involving 100,000s patients, each part carefully evaluated, checked, stored and audited. The techniques we use, even the pathway itself, has been researched and tried and rejected and trialled again. When this technique was first pioneered many thought it ludicrous. Now it saves thousands of lives every year. Even the basic physiology is incredibly complex.

Which is not to say nothing ever goes wrong- far from it. We routinely have patients who we can’t make better, or don’t get there in time, or need even more advanced therapies: pumps inside the heart, artificial lung and heart machines, emergency bypass surgery, even transplants. There is an entire world behind the curtain that very few members of the public will ever glimpse. And even those who do so directly as our patient do so with only the limited and reassuring perspective of a problem that has been “fixed”. With only a tiny cut 1mm long in their wrist, who can blame them?

Which, by a rather roundabout way, leads me to Brexit. Obviously. This week the NHS and Brexit have been in the news on multiple fronts, mostly raising concerns about the implications of No Deal on the NHS and then some unbelievable absurdity about shortening doctors training times after Brexit to “plug staff shortages”.

The issue we seem to have is one of perspective. There’s too little scrutiny, too much wilful acceptance of “I can fix it”, and not enough people asking “how?”. And especially not enough detail for those of us behind the curtain that can see the vast monstrosity of interlocking gears and cogs that makes up the NHS machine. For those of us that worry Brexit, especially No Deal, will be a sledgehammer to a system already straining under pressure.

Take for example the No Deal scenario. Overnight we will leave the Customs Union and European Medicines Agency, meaning importing medication will require new licenses and tariffs, infrastructure we don’t currently have. Insulin has been the much lauded example– used by nearly half a million patients in the U.K., only one small factory in the U.K. makes any at all, enough for 1500-2000 patients a year. The rest (99.9%) is imported from France, Denmark and Germany. On day 1, with No Deal, there would need to be additional customs infrastructure to even EXPORT to us. In places like Germany where there wasn’t before. The new Health Secretary, Matt Hancock, has assured us they are stockpiling for contingency planning for this event. But insulin needs to be refrigerated, and we are talking about half a millions patients a year. I want to see the detail, I want to see the benefits of this plan, I want to see the mechanics of the machine before I accept this is even possible. So far I have yet to be convinced.

Similarly, Steve Barclay, Tory Health Minister, made headlines on Friday claiming that Brexit will be good for the NHS, claiming the EU forces U.K. doctors to qualify in five years minimum and we could shorten this to “plug staff shortages”. But behind the curtain we know nearly all U.K. medical courses are five years already, some graduate entry courses are four years (although some have switched to five now) and count the first year of work as qualification to meet the EU technical requirement. We know we can’t shorten medical school beyond four years due to the sheer breadth and intensity of work, and the reason most U.K. medical schools opted for five years in the first place. This suggestion will have no practical impact on doctor numbers, but might make undergraduate medicine overly pressured or dumbed down, and will only affect <25% of graduates regardless. And no mention of the 10% of U.K. doctors from the EU who already risk losing their right to work, to healthcare and to pensions here in the event of No Deal. It’s this nonchalant and worse, unchallenged, Brexit commentary that doesn’t inspire confidence amongst medical professionals. We doubt that our government understands the dangerous and complex machine they are tinkering with. 

Similarly Theresa May proposed a welcomed £20bn injection of funds into the NHS, but then predicated that on a “Brexit Dividend”, a dividend nearly every single economist agrees doesn’t exist, a dividend for which no legitimate cases has been made. It’s hard to trust a government that seems to speak to us without any substance. No wonder a majority of U.K. doctors support a referendum on the final terms. 

In the healthcare profession we have a pathological abhorrence to unsubstantiated claims. To b******t. Colleagues that say they will do something and then do not are unreliable, and unreliability is dangerous. Bald-faced lying is even worse, and the GMC hold us to a standard far higher than any politician. A lack of basic probity will get you suspended or struck off, such is the bedrock of trust that the practice of medicine requires. Trust between ourselves and our patients, and trust with each other. And the highest sin of misinformation? Wasting the most precious resource we have; time. Time is muscle. Time is life. Time I waste with you I could infuse into someone else, time that could make all the difference. And for Brexit time is running out. 

Despite occasional appearances suggesting otherwise, medicine teaches you a universal truth: nothing is simple. Absolutely nothing worth doing is easy. The Brexiteers waving away the potential healthcare disasters ahead think they are riding a tricycle down a garden path, that they can flick a wrist and change direction on a whim, when really they are aboard a runaway freight train, heading for a cliff.

We need to start hearing some practicality, we need to start seeing some understanding of the complexity of the machine, of the extraordinary stakes ahead. We need less of the perception “everything is simple”, and more of the reality: this is complicated, this really matters, lives are literally in the balance.

Please fix it.

Family separation is beyond inhumane, this is state sponsored child abuse

My daughter’s first pair of shoes were a present from her aunty. A palm-width long, green-grey dotted with gold stars, white sole, single Velcro strap. She’d been running around with that manic toddler waddle for a while, the eye watering one where every step seems to just save them from face planting to the ground. Probably a little overdue, her shoes were an instant passport to a whole new world of roaming. She could now run unhindered in the playground, in the shops, down the street to her aunty’s house. As you can imagine her shoes brought her unfettered joy, the innocent happiness of a child. She loves her shoes, she grabs them at every opportunity and rushes to the door, even grabs my trainers and tries to put them on my feet if Daddy is too slow.
My daughter looks down at her feet in the exact same way the little girl in this picture does. Her mop of wavy dark brown hair looks just like hers. When she cries, my heart breaks. When I look at this little girl staring down at her shoes, and moments later crying for her mother, I see my own little girl. I cannot stomach it.

The US-Mexico border has been a contentious issue in US politics since before Trump began his populist anti-immigration drive that propelled him into the White House, but his ever-escalating rhetoric has led here. The chants of “build that wall” have morphed into a horrifying reality: children and even babies in actual cages. 

Despite the Trump administration protestations that “this is the law” the legal situation that has suddenly seen thousands of children taken into state custody and separated from their parents is not quite as simple.

Entry into the United States outside of a recognised port was previously prosecuted in civil court. Pre-trial incarceration used to be the exception, not the rule. Child caring responsibilities are supposed to be a mitigating circumstance AGAINST jailing parents. Children are only removed if there is concern they are being abused. Imagine being arrested pending trial for not paying parking tickets, your child forcibly removed to state custody, a state system without the capacity or will to reunite you. 

The decision to prosecute and hold both illegal entrants and asylum seekers as criminal cases, not civil, is the “zero tolerance” policy of Attorney General Jeff Sessions and President Trump. Children cannot accompany their parents to prison, so they are separated at the border, as stricken mothers and fathers are told their child is being “taken for a bath”. The next thing they are told is they won’t see them again. 

Why is the Trump administration pursuing a policy so inhumane and so cruel? A policy that has created a huge national and international backlash? The party line is “it’s the law”, or “it’s the Democrats law”. These are plain lies. George W. Bush signed the last legislation covering family separation for immigrants, passed overwhelmingly by both major parties. 

Looking beyond this front several officials have admitted this practice is a deterrent, deliberately punishing families that cross illegally. Punishing children, potentially irrevocably so.

Even worse, in response to the international outrage Trump has proposed any new legislation to end family separation is linked to funding for the US-Mexico border wall project. In other words, he will release the children when he gets his money. A United States President, holding children hostage.

At the same time Trump has announced they will pull out of the UN Human Rights Council. For an administration completely lacking in any humanity this seems appallingly appropriate. 

As a doctor, I know the physical and mental cost to the children who are put through such a trauma is heavy. The American Academy of Paediatrics has publicly condemned the practice, equating the psychological and developmental harm this causes to child abuse. 

As a father, I can’t stop looking at this picture of this little girl with her shoes. I cannot stomach the horrifying footage of children in cages. I cannot fathom how any human being of moral conscience cannot see the evil in this, or worse, try to defend it.

The American Civil Liberties Union is currently in the process of suing the government in a national class action suit to desist and reverse the policy of family separation. You can donate here.

President Trump will visit the U.K. in early July. If you believe this policy is a stain on any decent society, come to London or Scotland or wherever he scurries to and let him know.

My daughter’s shoes bestowed a gift of freedom and happiness. This little girl has neither. Our children will one day ask us where we were and what we did during this turbulent period in history. I want to be able to look my daughter in the eye and tell her humanity and decency prevailed because we stood up for it. 

So stand up.

Dear (brand new) Doctor…

To all the new doctors,
First and foremost, I think I speak for our profession, junior and senior, when I say, Welcome.
Tomorrow will be your first day as a doctor. A day you have probably thought about for a decade or more, but perhaps could never quite imagine. 

From Hippocrates to Osler, Galen to Gawande, every medic of every age had a “first day”. Be careful with the advice you listen to, there are as many ways to be a doctor as there are doctors. This is my advice, please feel free to take it or leave it.
1.Looking after humans is a messy business, literally and figuratively. Know where the scrubs are kept. Don’t wear shoes you can’t afford to throw away.

2. There’s always time for lunch. Your stomach won’t thank you for ignoring it, but worse, your patients won’t either. Irritable doctors make crappy decisions. 

3. Look after your back. Sit down to cannulate or bring the bed up so you don’t have to. Your fifty year old self will thank you.

4. Be nice to your fellow F1s. They will be the closest colleagues and friends you will make in your career. You will go to their weddings and hold their newborn babies. Like soldiers on the battlefield you will be bonded for life. 

 5. Be nice to everyone else too- even when others don’t reciprocate. You never know when you’ll need their help. Successful medicine is sometimes about who you know as much as what you know. Learn to know when you should bite your tongue.

 6. And when not to. Ultimately the patient is your only priority. If you need to voice a concern, do so, loudly, coherently and without anger, to whoever, however high up, that you need to. 

 7. Don’t drink too much, if you do. It’s easy to let one glass become two, become three. Don’t drink your stress, find better ways to deal with it. 

 8. Learning from your own mistakes is mandatory. The price of a mistake is high, you must do everything you can to recoup that cost. Better still, learn everything you can about other doctor’s mistakes, so you don’t repeat them.

 9. Find what you’re scared of, and run towards it. I was terrified of cardiac arrests so I used to run to every single one. Now I’m a cardiology registrar. Life is funny like that.

10. If you’re not sure about a drug dose, look it up.

11. Look up anything else too. Google diagnoses when you’re not sure. Don’t be dismayed, your seniors do this all the time, probably more than you. Knowing what you’re talking about is much more important than merely looking like you do.

12. Find a toilet that no one else uses. Trust me on this.

13. Take all your leave. Go on holiday. 

14. Recognise you made a choice to be a doctor, take pride in and be empowered by that choice.

15. But also recognise when you see a patient they didn’t get a choice, and they didn’t choose you as their doctor. You have a responsibility to be the best doctor you can be in that moment, because that patient doesn’t get to choose anyone else.

16. Keep your moving boxes- you’ll need them again.

17. Understand you work at a nexus point in a patient’s life. Patients come in going one way in life, but oft-times leave going somewhere completely different. Sometimes, sadly, nowhere at all. That enormity of exposure to Life can take it’s toll.

18. Talk about it. Cry about it. Commiserate with your colleagues, support and celebrate with them too. Deal with your emotions fully, or they will overwhelm you.

19. Try your best, always.

Feel free to heed or ignore any of the above. Add your own pearls as you find them.
Tomorrow is your first day, doctors, and truly the first day of the rest of your life.

It is genuinely the most wonderful job.

Good luck. You will be brilliant.

This is everything wrong with Jeremy Hunt’s tenure as Health Secretary

Yesterday in the Mail Hunt made at least two completely bogus claims;
1. He ‘won’ the judicial review into imposition and gained High Court backing for the junior contract

2. Post Brexit he is going to remove foreign doctors and replace them with ‘homegrown’ trainees 

There’s been enough of heated opinion lately- so let’s just serve cold hard facts.
1. The Justice 4 Health team took Hunt to court on three premises- that a) he does not have power to impose the contract b) that he acted without clarity and transparency and c) he acted irrationally. Despite a lot of press spin saying Hunt won, he actually just dodged the issue, by claiming that he never imposed and ‘no junior doctor’ thought that he was. As in last week’s blog here is the many instances that Hunt said he was. 

The case pushed Hunt to clarify in law that he isn’t imposing the contract, simply passing the buck to local hospitals. The judge also found he could’ve acted with less ambiguity but found it hard to demonstrate the high legal threshold for irrationality.

So far from ‘winning the case’, Hunt was forced back from claiming falsely he was imposing leaving local negotiations with hospitals now a real possibility.

Secondly, Hunt’s plan to replace foreign doctors with ‘homegrown’ talent is as laughable as it is xenophobic.
We are already in the midst of a workforce crisis- applications to medical school dropped 13.5% in the last 5 years, and increasing numbers of junior doctors are leaving training and the country. On top of this, the existing doctor workforce increasingly cover the work of two or more doctors- 7 in 10 doctors work in departments where at least one doctor is missing, 2/5 of consultant posts are unfilled, and 96% of doctors work in wards with nurse shortages. 
To add insult to injury, health education England, the body that funds training of so-called ‘homegrown’ talent, has had its budget slashed by £1 billion next year– all on Hunt’s watch.

Now around 25% of the doctor workforce are non-UK, and 10-15% of all NHS staff. 

We are well below the European average in hospital beds per person and doctors per person in the NHS as we are- yet Jeremy Hunt plans to push away up to a quarter of the workforce, cut the training budget to train less doctors who are already doing two or more doctors work, and make no plans to actually address the drop in ‘homegrown’ talent already, a direct repercussion of Hunt’s own morale plummeting war against the profession. 
Those are the facts. Unfortunately if you read the Mail comments you will see why Hunt would ignore them; there’s a segment of the populace that laps up this anti-immigrant posturing, even if it’s completely insane as an actual plan. 

This is everything wrong with Hunts tenure as Health Secretary- politics before policy before patients. The NHS will only continue to suffer if it goes unchallenged.

As an NHS doctor, I like Facts. Vote Remain.

I’ve just voted. I voted for the UK to remain in Europe.

Why? Well, here’s been a lot of partisan opinions and dog whistling on both sides of the debate- the level of discourse has been a lot like a mud wrestling much- both sides have smeared each other in so much muck that you can’t really tell them apart, and you stop caring.

That isn’t surprising. We have a government right now built on the principle public relations is more important than policy, that what you say and how you appear saying it is far more important than what you do. Sentiment over substance. Both sides of the Tory schism have led the same way, into farce. The whole thing has descended into an Eton schoolyard spat, with Nigel Farage the slightly odd kid no one plays with suddenly joining in, shouting “get him Boris” and other, more racist, things that make everyone uncomfortable.

So I’ve ignored it completely; maybe you have too. Instead I turned to social media, and through my own research made a decision to Remain, based on facts and figures and nothing else.

What’s my conflict of interest? Full disclosure; I am the son of a non-EU immigrant (who is voting Leave FYI), I was state educated and  trained and am a junior doctor in the state run NHS. I pay my taxes, vote left of centre, and have a cat from Latvia. As a junior doctor no one despises Cameron, Osbourne and Hunt more for what they are doing to the NHS.

So why on earth would I side with them?

As a doctor I like facts. Cold, hard, rigourous facts. I don’t like subjectivity, vagueness or b******t. I also like human beings. I don’t like discrimination, inequality or suffering.

So here are some myths and some corresponding facts that changed my mind. Maybe they will change yours.

Here are some great sources – read them for yourself.

1) Europe is undemocratic and run by faceless bureaucrats

2) Europe costs £350 million a week

  • No. This is the gross payment to Europe, but we rebate nearly half that every year- to farms and universities. So the ‘cost’ is variable, but much less – from £168million/week to £250million/week.
  • £250 million sounds like a lot/ week- but it works out about £4/person per week, or £16/person per month.
  • For £16/month we get easy access to a market of 500million people, which means many small businesses in the UK can sell to the EU as easily as to customers at home. This is a very good thing. We send ~45% of our exports to the EU. 
  • Renegotiating all the deals would be possible but: we would have p****d off Europe, we will have pound less strong against the Euro, and we would still have to allow free movement of labour.

3) We could spend that money better on health, like the NHS

  • This is wrong, but I welcome the support.
  • The NHS is drowning with Tory underfunding- but it’s the fault of our government, not the EU or immigration.
  • In 2008 illegal and fraudulent banking practices crashed the world economy.* As a consequence our Tory government decided that the way to repair the economy was to cut public services, and they took £20 billion out of the NHS in assets, and froze the budget, despite rising demand. They plan to take another £20 billion by 2020 (including their proposed ‘extra’ £10 billion), and create the least relatively funded decade for the NHS in it’s historyThe same banking practices have already started to return by the way, although what this means isn’t certain.
  • The economy will recede again if we leave the EU – I don’t really see how it can’t. Economists worldwide agree : but ignore that fact for the moment. A market we export 40% of our goods into, have extensive trade links and agreements from selling into, and have been a part of for 40 years just disappears from our economy overnight. Yes, perhaps we can recover – maybe we can trade more with Brazil, and China, and the US, maybe we can set up the same agreements again with the EU. In the meantime, which will be years, not months, Britain could lose as much as 10% of GDP – that’s around £180 billion, or 1.5 x the budget of the NHS.
  • During the last period of austerity, worldwide it is estimated 250,000 cancer deaths occurred that otherwise wouldn’t have if the financial crash hadn’t occurred. Let me reiterate that – 1/4 million people DIED, because of financial fraud, in health systems dependent on employment for health insurance. This didn’t happen in the NHS, because of it’s public nature. But if there are further cuts to public spending, further austerity, the NHS will collapse. It might anyway. Money in healthcare means lives- don’t underestimate austerity as merely an exercise in ‘saving pennies’. It saves money from the most vulnerable in our society, and some don’t survive. It’s a crime too big to see.

4) We have to stop immigration and take control of our borders

  • 330,000 people came to this country last year. Half came from the EU, half came from non-EU
  • We already ‘control our borders’- we have full control over non-EU immigration, and all EU migrants have to present ID and passports to enter the country.
  • The arguments over immigration are flawed – read this
  • a) Essentially, leaving the EU won’t alter immigration from non-EU, which may increase
  • b) immigrants contribute more to the economy than they take out: they help us survive periods of austerity and economic downturn, like right now
  • c) 1.2 million British people live in the EU, and around 3 million European citizens live in the UK. If we deported everyone, and all the Brits returned, our population would fall, but we would have replaced 2 million working people with mostly retirees, who will draw a pension and use extensive healthcare and contribute less to the economy than the working migrants they replaced. Good idea?

5) Other rambling

  • We have to bail out the Eurozone all the time. No we don’t – we opted out.
  • The EU is a capitalist wet dream designed to oppress working people. Maybe – but look at the government we have now. (see next point)
  • We must leave the EU to escape the threat of the Transatlantic Trade and Investment Partnership (TTIP). This clandestine trade agreement between the EU and the US has been negotiated for the past five years in total secrecy – public, press and even politicians involved aren’t allowed to look at any materials. The whole thing was recently leaked – and has many scary and ultra-neoliberal proposals for companies to essentially sue governments on issues that affect it’s profits – like health and safety regulation, or state-provided healthcare. The government recently backed down and exempted the NHS from TTIP – but we haven’t seen the detail yet. To be honest I was planning on voting Leave if I thought we would escape TTIP legislation – but remember who our government is. Cameron basically invented TTIP and would sign up to it ‘in a second’. If we leave Europe we will be left with an even more far-right, ultra capitalistic government, and TTIP would just be imposed under a different name.

I may not have convinced you – but that doesn’t matter. Politics in the digital age is changing, it’s up to us to take the responsibility for how it changes. Will it become a divisive society of online echo chambers, neither listening to each other except to engage in Twitter trolling? Or will we grow up, critically seek out and appraise the facts for ourselves, escape the influence of newspapers trying to sell us sensationalist politicised rubbish, and see the world how it really is.

Remember people literally died for your right to vote. Whatever you do today, go and VOTE.


*How? Well, watch The Big Short, but essentially banks were selling mortgages to people who couldn’t afford to repay them, and then selling those debts bundled together to other banks, who then bet on those bundles to never fail, which they obviously, spectacularly did. Imagine your friend set fire to a bit of paper, and said to you “Here, buy this bit of paper, and keep it with your other bits of paper.” Which obviously started a bigger fire, and then you said to another friend “Hey, buy this fire I just started and keep it in your house.” And then someone came along and said to HIS friend : “I bet you £1 billion that house doesn’t burn down.” Sound stupid? This is actually exactly what happened.

How To Sell Off The NHS: A Users Guide

So you want to sell off the NHS? A 65-year old behemoth, part of a raft of reforms that radically improved the quality of life of working people for nearly a century? It won’t be easy, but with this handy step by step guide you too can privatise your health service.

Step One
Know your enemy. In 2010 a Kings Fund poll put NHS satisfaction at above 70% [1]- the highest ever recorded approval rating. The United Kingdom has low child mortality outcomes globally; 5 per 1000 live births, (compared with world number 1 – Iceland at 2 per 1000 and the U.S. At 8 per 1000), long average life expectancy (male); 79 (compared with world number 1 Iceland at 82 and the U.S. at 76) and for maternal mortality the UK has an estimated 8 deaths per 100,000 pregnancies (compared with 1 per 100,000 in Belarus and 28 per 100,000 in the US). As a system the UK was ranked the best in the world for health access, efficiency, effective, safe and coordinated care (Commonwealth fund, Mirror,Mirror 2014). However, it currently spends only 9.1% GDP on healthcare or US$3,598 per person, which is free at the point of service. [2] The US spends over twice as much (17.1% of GDP or US$9,146) and was ranked dead last in the same Commonwealth Fund study. [3]
So, to sum up, you’re faced with a well-liked, efficient, life saving machine. So you won’t be able to try a head-on approach, public opinion will need to be swayed first.

Step Two
Misinformation: the great thing about the NHS is most voters at any given election will not have a vast deal of deep experience of its services. To many people the NHS is for shoulder physiotherapy and antibiotics for a chest infection and maybe the odd stitched wound at A&E. This is to your advantage! Start early on by pervading a helpful message of ‘improvement’ and ‘efficiency’. Steer every news piece towards this same message, regardless of context. Be consistent with this message and quickly this will become the ‘norm’. You will need some national newspapers on side to keep this reinforced. Before you know it the NHS will be percieved as ‘failing’. But that won’t be enough!

Step Three
Divide and conquer! It doesn’t matter what you campaigned on- once you’re elected you only have to apologise occasionally and you can do whatever you want! Push through some major reorganisation as early as you can- use words like ‘transform’, ‘power’ and ‘into the hands’. These will keep everyone in service on the back foot trying to respond. Make sure any change is extremely complex- this has two advantages; A) it makes it difficult for opposition campaigners to create ‘headline’ zingers against you and b) this is your opportunity to lay some legal horcruxes to build your platform!*

Step Four
Wash your hands early! If you want to sell off a national institution you have to make sure it’ll slide away easy. When no one is looking, make sure the government no longer has a legal duty to provide the NHS. But don’t stop there! Now is your chance to plan ahead!

Step Five
Open market! Everyone knows they get a better deal when one supermarket opens next to another one! Despite there being absolutely no evidence this applies in any way to healthcare provision! Use that knowledge to your advantage! Use words like ‘competition’ and ‘drive up performance’ – the more you can paint the NHS like a car the better- people like to sell their cars. Meanwhile once the law has changed,  open up the NHS to private contracts bit by bit. This will mean if anyone kicks up a fuss you can say ‘come on! It’s only 4%! It’s only 8%! Etc’. When the numbers start to get bigger use the relative percentages ‘It’s only increased by 15%!’. Useful phrases here are ‘can we please focus on the bigger picture?’. But then what about the staff on the inside?

Step Six
You do have a problem here: much of the NHS staff will see what’s happening, and people will listen to them if you don’t do something about it! Politicians are the least trusted individuals in the country, while doctors are the most; start early on with subtle denigration of the perception of all NHS staff. Take any news report about A&E or midwives or doctors or nurses and make sure someone high profile gets on a box and sticks it to them. Appoint a health secretary who will regularly inflame the situation- this will create distraction from the sell off! Frequently offer empty re-organisations that both fail to address and belittle any problems. Then get down to business.

Step Seven
The money! Cut it, and cut it hard. People use A&E and the GP the most- keep these areas stripped of cash and drive up demand by demanding people go at any time of day- encourage your health secretary to do exactly this! Once these areas go too far under they’ll sink by themselves- locum agency costs to cover staff gaps will cripple failing departments, and smaller GP closures will domino into bigger ones. Obviously don’t be seen to be thrifty- use words like ‘efficiency savings’ and ‘reform’, and above all ‘austerity! But do cut services away- the more gaps you can create the easier it will be for private companies to fill them! Put pressure on the very front services by cutting departments like a and e and maternity, and sell off the backend like microbiology and biochemistry, because no one really understands this stuff anyway.
Make sure you use this opportunity to crush the spirit of the staff- cut their pay, at least in as boring way as possible, e.g by pay freezes and under inflation changes. In the meantime try to award yourself a huge pay rise- this sell off is hard work you know! Doctors and nurses will leave, temporary agency staff will come, the service will worsen and the People will suffer! Now it’s time!

Step Eight
It’s showtime! If you’ve followed the above steps then this last will be a doddle. You’ve got a demoralised and depleted workforce, an unhappy electorate and you aren’t even spending very much on it all! You’ll need to do some hand-wringing, some lamenting, some explaining away. You will find these phrases useful; It’s ‘an ageing generation’, 21st century demand is too much, and ‘the burden to the taxpayer’. And then roll them in- hopefully by this time you should’ve got private companies into at least 20% of services.

Step Nine
Sit back and relax! All your hard work no doubt has been a lot of stress. And those long hours of drinking and smoking and missing the gym have really taken their toll. You deserve some time off! Don’t worry about the newspaper backlash- it’ll come eventually, and there won’t be a hint of apology as the same papers that supported you will hypocritically tear you down. And don’t worry about that chest pain you’ve been having! You’re insured right? Oh you lost your job? But what about the end game- the cushy seat on the board of the health companies? Oh, you’re politically toxic now and all those backroom offers disappeared? And you didn’t save anything?



Re-printed with kind permission @

*if you have to bridge an election with this still hanging over you just apologise for it! Say it was a big mistake. Then once you’re re-elected you don’t have to do anything about it!