It’s rather fitting, given that Kennedy – chair of the British Medical Association (BMA) in Scotland – believes the health service is “dying before our eyes”.
Kennedy met with The Herald on Sunday to dissect the NHS. He put the health service on the anatomy table, opened it up, and his prognosis is that “the system is broken”.
Patients “are dying” unnecessarily because of delays. Doctors feel no “pride” any more in the service they provide, there’s a “toxic culture” of cover-up, and a collapse in public confidence is “causing people to question the future of the country”.
Scotland lacks “at least 1,000 GPs” and 1,000 hospital consultants. Patients can wait “two, three or even four weeks” to see their GP. Waiting times for “life-threatening” cancers can be “six weeks”.
It’s a far cry from the foundation of the NHS, Kennedy explains, inspired by early experiments in social medicine in Scotland’s highlands. In 1913, the Highland and Islands Medical Service became “the first state-funded health service”.
In 1948, the Labour government replicated the Scottish experiment UK-wide. “When the NHS started, there was a strong sense of pride, unity and vocation. It met the needs and demands of the population. That’s the key thing that’s changed: we no longer meet the needs and demands of the population.
“It was largely doctor led. People had a lot of trust and confidence. It gave a strong sense of security to the public. It was one of the UK’s finest moments and probably the institution we should be most proud of.”
While political decision-making and funding is to blame for the state of the NHS today, demographic change and – ironically – medical advancements have also affected the health service.
“Demand is so great as the population has grown,” says Kennedy. “The population is older, and more complex.”
Kennedy started studying medicine in 1987.
When he was a junior doctor, “people would come to hospital with strokes, heart attacks and pneumonia and they’d die young – in their late thirties, forties or fifties. I don’t see those illnesses in young people like I once did.
“Now we have patients who are older, frailer and survive these illness, and live with five, six or seven long-term conditions.”
These “highly complex” cases often involve people who “don’t have the same social fabric around them” for support as elderly people once did. “They’re more reliant on the health service and social care.”
Dr Iain Kennedy chairs the British Medical Association Scotland(Image: )
However, he adds: “What’s clear is that we simply aren’t meeting the needs of the people of Scotland any more. We’re certainly not meeting demand.
“I don’t think there are many doctors – and there are 17,000 of my members in Scotland – who will say they’re proud of the NHS overall. That sense of pride has gone. Doctors don’t feel in control any more. The NHS is managerially led, rather than doctor led.
“It’s become politicised. It’s a political football now. Our patients are frustrated, angry and struggling to get GP appointments. They’re waiting longer and longer for outpatient appointments.”
Dysfunction
WHEN patients are able to access care, however, they “invariably tell us they get excellent care. So if they access GP appointments, hospital outpatient appointments, hospital inpatient beds, the stories are extremely positive – but it’s accessing healthcare that’s difficult”.
A key dysfunction is that “far too many people stay in hospital for far too long when they no longer require hospital beds”. Kennedy explains the “lack of social care” means the “back door to the hospital is closed”. Elderly patients, in particular, who could go home, can’t go home as there’s nobody to provide social care on release.
“The system is clogged up,” Kennedy adds. “GPs are backed up. Patients are coming back and back to see GPs who are chasing up [hospital] appointments that don’t seem to be happening.”
Patients “frustrated” with being unable to see their GP eventually go to A&E, which in turn leads to hospital overcrowding. The lack of beds – due to elderly patients who can’t be released as there is no social care – means doctors “can’t transfer patients out of A&E” into other wards.
Doctors now report “that they’ve relearned how to do ward rounds in emergency departments because patients are staying two or three days. That’s why we see headlines about long A&E waiting times and ‘corridor care’ because the hospitals are clogged up with people who’d rather be back home or in care homes”.
Kennedy adds: “To be frank, the system is broken. The NHS in Scotland is dying before our eyes. We’ve lost the founding principle of the NHS – that it’s free at the point of delivery – as many people are having to go private and they’re not happy about that.”
READ MORE
Neil Mackay: English nationalism will be the death of the union
Neil Mackay: Humiliate them. Ruin them. Stamp on feral Old Firm ultras, hard
Neil Mackay: How Scotland’s disabled folk changed my view on assisted dying
One-third of Scots, or someone in their household, has gone private in the previous two years, Kennedy says, and 40% are considering doing so in the year ahead. “It’s become commonplace. My patients tell me ‘I went private for my knee operation, my hip operation, my scan, because I just couldn’t wait any longer on the NHS’. People are angry.”
One of Kennedy’s patients recently told him how “angry and frustrated” he was at “paying taxes all his life and then having to fork out” for two operations.
“People are going private as they’re distressed with pain,” Kennedy adds. “They’ve lost confidence that the NHS will attend to them, so they’re reluctantly dipping into their pockets or using their insurance to go private.”
Toxic
A “TOXIC culture” exists within the NHS in Scotland and throughout the UK. “When doctors speak up about matters of patient safety or issues of wrongdoing that they’re witnessing, invariably they experience retribution and retaliation.”
A majority of doctors has “experienced concerns about patient safety or wrongdoing, but only 17% were satisfied with the outcome”.
Kennedy adds: “We have something seriously wrong with NHS culture. Doctors tell me they experience bullying from managers, and their mental health is questioned.”
Doctors who complain “fear referral” to the General Medical Council which could lead to being struck off and “job loss. There’s a culture of fear. Young doctors and non-white doctors are particularly frightened about speaking up because of retribution and retaliation”. An example of the complaints doctors might make about patient safety would be, says Kennedy, “patients dying in A&E departments before they’re seen. That’s a fairly basic one. Another example is doctors who raise concerns about waiting times for their patients, or referrals to hospitals being rejected”.
Is time running out for Scotland’s NHS?(Image: )
Doctors are “experiencing more and more that when they refer patients to outpatients the referrals are rejected”. In Kennedy’s own patch, in the Highlands, “46% of the referrals from GPs to the mental health service are sent back”. Doctors who raise concerns “get sidelined, marginalised and not listened to. The system doesn’t want to hear about the problems”.
Scottish health boards, he believes, “focus on reputational management. That’s the fundamental problem. Their prime aim is to manage the reputation of the organisation rather than focus on patient safety. They pay lip service to patient safety. The health board’s reputation comes first”.
Kennedy puts this down to the “politicisation” of the NHS. “There’s a culture of ‘boss-watching’. Each individual in the structure looks up. There’s a line from the clinicians to middle management, to the executive team, to the chief executive, to the director-general of the NHS in Scotland, to the civil servants, to the Cabinet Secretary for Health, up to the First Minister.
“There’s an axis of power that goes all the way up to the most senior people in the country. That’s why we have this culture problem.”
Kennedy does, though, stress that the current Health Secretary Neil Gray “has assured me that patient safety is something health boards must prioritise”.
Does he believe that a deteriorating NHS, coupled with a culture of reputational management, risks issues of public interest being coveredup? “That hits the nail on the head,” Kennedy says. “Health boards generally want to hide problems. Problems tend to be brushed under the carpet.”
Cover-up
HE has “personal experience” of health boards wanting to avoid “negative media stories about anything going wrong in the health board, or any bad reports going back to government. Those were their priorities”.
He adds that “in terms of “cover-up”, if you use the word cover-up”, he had experience of one health board refusing to “share waiting times” with doctors. “We knew as clinicians that waiting times were getting worse and worse, and they wouldn’t share them, on the basis that other health boards weren’t sharing that information. That’s how bad it was. They were hiding the truth.”
What’s actually going on when it comes to accessing GP appointments? Kennedy says patients in rural practices will “generally” still get “same-day appointments” as there’s “less demand”. But in urban practices “demand is our main problem”.
Kennedy, who still works as a GP, runs practices in both rural and urban areas. In his urban practice, receptionists and nursing staff “triage” calls to decide when patients can be seen. “We can’t simply see everyone who wants an appointment. We’d grind to a halt within an hour.”
That means “there are people waiting far too long to see GPs. Some of my patients are maybe waiting two, three, even four weeks to see the doctor of their choice. Ultimately, it comes down to funding”.
The BMA “is asking for funding restoration for GP practices in Scotland. We’re £290 million short of funding for general practice in Scotland”. Over recent decades, “the number of GPs has flatlined. So the real reason people struggle to see their GP is lack of funding in general practice. That needs sorted urgently”.
Nurses and doctors are under ever-increasing pressure amid a backdrop of cuts(Image: )
Ironically, there are “quite a number of under-employed and even unemployed GPs in Scotland who could come into the workforce. Most of us would take on more GPs if we had the resources”.
If more money was spent on GPs, it would mean fewer patients requiring more expensive hospital care. “We’re at a critical juncture in the NHS,” says Kennedy. “We need to shift the balance of care – that’s the phrase we use for focusing resources in the community rather than in hospitals.”
He stresses that doesn’t mean taking funds from hospitals, which need their resources “protected”. It means additional funding for GPs. The Scottish Government, he notes, has “spoken about shifting the balance of care for almost 20 years, but they’ve done the exact opposite. Most resources have gone into hospitals, and general practice has been starved. We’re reaping the consequences”.
There is no “proper workforce plan in Scotland for doctors and other healthcare workers. We’ve been calling out for that for at least three years”. A workforce plan would “assess the health needs of the population, and work out the numbers of doctors you need and in which specialties. There are almost 15% consultant vacancies in Scotland. We’re probably 1,000 consultants short.
“We’re many GPs short. We’ve practices falling over throughout Scotland, particularly in deprived and rural areas. We’re at least 1,000 GPs short.”
While the number of medical students has increased, “we didn’t increase the capacity of our medical schools and teaching hospitals to cope with rising numbers of students. So students are reporting really poor educational experiences. They can’t even get into the lecture theatres. When they’re getting taught on wards there’s too many for the teaching doctors to cope with”.
Bottleneck
IN addition, resident doctors – formerly junior doctors – “are experiencing a real bottleneck. They come to the time in their career where they’re choosing their speciality and there’s not enough training positions for them”.
Kennedy adds: “So we actually have in the UK and Scotland a situation right now where we have doctor unemployment, as we have all those vacancies.” Around 70% of resident doctors are concerned about unemployment.
He says Scotland needs to change how we “measure the NHS”. He wants a system which focuses on “the quality of patient care, the outcome of care, and their access to care”.
He adds: “As a country, we’ve taken our eye off the ball. There’s been a lack of accountability. There’s been too much siloed thinking, rather than fundamentally looking at the health needs of the population. It’s such a basic thing to do – to look at the health needs that are actually there, and then plan your service accordingly. We just haven’t done that. We’ve sleepwalked into this situation.”
Kennedy says the waiting time crisis in A&E departments “is simply the sign of a bigger problem. It’s the flashing light for the fact the whole NHS system is broken”. More than 800 deaths in Scotland were linked to long A&E waits last year.
He adds the deaths were “associated with long A&E waits before admission” and were “extremely concerning, but sadly not surprising. It’s a tragic but entirely predictable outcome of a system in crisis”.
The problems at the “front door and back door of hospitals” – accessing GP appointments, and delayed discharge from wards due to lack of social care – “are manifesting themselves in the fact that we have long waits in A&E. So piling more resources into A&E is never going to be the solution”.
He adds: “The problems my members report in A&E departments is that patients are dying before they’re seen, and they’re lying in trolleys and corridors. That’s not a nice place to spend a day or two struggling to get your basic personal care looked after.
“There’s a lot of moral injury and distress, where doctors feel very frustrated and guilty about the service they’re providing for patients. We’ve invested more and more in A&E but we can’t continue doing that because it’s just a sticking plaster.”
Are patients dying unnecessarily? “Yes. What my members tell me is that patients would have survived had they been seen sooner. We know that there’s evidence of what we call ‘excess mortality’. The figures show that more patients are dying than should have died because they’ve waited too long. That’s the harsh reality of the current situation. It’s obviously a huge worry and why we need urgency around reform and renewal of the NHS in Scotland.”
Patients can wait “two or three days” in A&E. That doesn’t mean, Kennedy explains, that they’re waiting to be seen for two or three days, but rather they’re forced to remain in A&E “because they can’t get hospital beds”.
Renewal
THE BMA called for a “national conversation on the NHS in Scotland”. However, “the government chose not to do that. They’ve moved forward with plans for ‘renewal’. We really need those plans put into action urgently”.
Kennedy says patients able to access the NHS get “excellent care”, adding: “But where I can’t speak with any confidence positively is about access to healthcare. I can’t speak with any confidence that the right solutions to the future of the NHS will be implemented. There’s been a lot of talk, a lot of reports, over 20 years, but the necessary actions haven’t happened. The majority of my members are angry and frustrated. Some doctors have given up trying to influence anything. That’s a sad state of affairs. They feel people aren’t listening. Ultimately, the solutions must come from those in power, the politicians. The health boards only do what they’re instructed to do by their political masters.”
READ MORE
Neil Mackay: Gangsters are terrorising Scotland, but do our politicians care?
Neil Mackay: For some she’ll always be guilty simply of being Nicola Sturgeon
Neil Mackay: Here’s the secret to how the SNP turned Scotland into a one-party state
Neil Mackay: Scots have a real problem with the truth about empire
However, Kennedy notes: “I believe our First Minister, because he told me personally, and our Cabinet Secretary for Health, do realise how serious the situation is, and I believe they’re serious about change. What I’m not seeing is the urgency to make those changes.”
Is the crisis in the NHS fuelling the far right and leading to anger in society? “The Scottish people have witnessed deterioration across the board in terms of public services. So the deterioration in the performance of the NHS will no doubt be leading to some anxiety and people’s loss of confidence in their future.
“People are seeing that they’re not getting the access they used to get. So it’s definitely causing people to question the future of the country.”
When it comes to waiting times for operations and seeing specialists, Kennedy says his patients are going private due to complaints over issue like “orthopaedics – that’s knees and hips; dermatology, that’s skin problems and skin cancers; and gynaecology. There are huge waiting lists for women with serious issues”.
Patients are waiting “far too long” for outpatient appointments. “It’s not uncommon for me to get letters from hospital departments saying ‘I’ll review this patient is six months’ and a year later the patient comes to see me and says ‘have you heard anything from the hospital?’.
“GPs are constantly chasing up the system. Waiting times for operations are getting longer and longer.”
Waits are also caused by the fact that operation times are now longer, as they are safer, Kennedy explains. Appendectomies once took “maybe half an hour”. Now, it’s “done laparoscopically” – using keyhole camera surgery – “but that takes much longer. So where a surgeon might have done 10 to 12 operations daily, they’re now doing four to six”.
Kennedy highlights waiting times for some cancers, especially blood cancers. “It’s really worrying what we’re hearing about waiting times for people with blood cancers – even with the most serious blood cancers, life-threatening blood cancers. Patients are waiting six weeks to be seen by consultant haematologists.”
Cancer
PATIENTS “with conditions that could potentially become cancerous, that would normally be followed up by haematologists in hospital, are just no longer being followed up”. Instead, GPs are told “can you check this patient once a year and let us know if there are any problems”.
More broadly, Kennedy says, “we have a shortage of oncologists – cancer doctors – throughout the country”. He notes that breast cancer patients in the Highlands could be “referred to Forth Valley”.
“Patients are waiting far too long, way beyond what’s safe for them, and way beyond what they need in terms of getting treatment in the time they need to start treatment.”
He adds: “It’s obvious to any frontline clinician that we’ve a problem with mental health services. The specialties that have been neglected over the past decades have been general practice and psychiatry. We have a huge shortage of psychiatrists and mental health nurses. It’s a Cinderella service which doesn’t get the attention it deserves from the media, politicians or public.”
In Inverness, for example, 46% of mental health referrals are rejected. “I’ve little doubt the system is so under-resourced and under pressure that the only way doctors can cope is by holding back almost half the people who need to see them, and only focusing on the most serious cases.”
Those patients “then end up in A&E departments and interacting with police. Police tell me one of their biggest problems is managing to discharge safely members of the public into mental health services. They find it difficult to find places of safety. We have serious problems with our mental health services.
Kennedy adds: “Much of that’s to do with substance misuse, drugs and alcohol. But much is also to do with serious anxiety disorders, depressive illness and psychotic illness.”
Psychotic patients used to be “admitted to hospital on the day”. Now, there’s a “struggle even to get young teenagers seen by psychiatric services”.
Kennedy believes there’s “absolutely no doubt austerity has damaged the health of the nation. Most frontline clinicians see links between austerity and ill health. Health inequalities have undoubtedly got worse”.
He has personally “had patients who have completed suicide because of reductions in their benefits”. The effects of austerity leave him feeling “helpless. One of the saddest things we deal with is the interface between poverty and illness”.
Due to the crisis in the NHS, staff suffer from verbal abuse and physical violence. “Because of the frustrations of the public and the limited resources, tensions are rising.”
Kennedy has faced violence. “I’ve had to avoid flying chairs in my room on occasion, which is quite frightening.” His office has a panic button. “My room still has the dents in the wall to remind that we’re in a vulnerable position. Violence and aggression occurs far too often.”
Vaccines
THE BMA is concerned by “immunisation rates falling in Scotland”. He says: “We’re seeing falling rates of childhood immunisations. Uptake of flu vaccinations is going down. Vaccinations are safe, save lives and prevent disease. There’s a risk of resurgence in infectious disease. We must get immunisation rates up.”
Referring to Donald Trump scaremongering over vaccines and autism, Kennedy urges the public to “ignore any messages from across the Atlantic”.
“Renewal” of the Scottish NHS cannot wait until after the next election, Kennedy says. “We need to decouple improvements in the NHS from political cycles.” Political consensus on rescuing the NHS “needs to happen now regardless of next year’s Holyrood election”.
Despite “polarisation”, politicians must “get into the same room and make the right decisions for the population of Scotland. It’s too grave an issue to be playing politics”. He adds: “All political parties would do well to listen to the medical profession and take advice from the clinicians who actually deal with patients. We know what’s going on as we live and breathe it every day. They need to find a way to work together constructively and get over themselves for the greater good of the population.”
The NHS should be “clinician led. We currently have managers leading. That’s why we focus on targets and finances rather than patient experience and the access to healthcare that’s so desperately needed”.
Kennedy doesn’t believe the NHS will be privatised in his “lifetime”. With the right investment and reform, Scotland can recreate “the best health service for everyone. I’m confident we can still do that”.
However, he has no “ideological” problem with using private healthcare to ensure patients get treated in time as long as the fees paid by the state for operations are “the same” as NHS costs.
There has, though, “been growth in private healthcare as people are frustrated with NHS waits”.
Any form of fee-paying by patients for healthcare, however “widens inequalities”. America has the world’s “worst system”. Kennedy says he couldn’t work in America. “I couldn’t see patients suffering and dying simply because they couldn’t afford to pay.”
In terms of England and Scotland, we have much better “engagement” between doctors and politicians, “but our waiting times are worse than England”.
Scotland is a “sicker country, and that’s probably getting worse. We have problems with poverty, health inequalities and substance misuse”. The rural nature of much of Scotland is also a contributor.
It’s more difficult to deliver healthcare in rural areas. Prescriptions should remain free in Scotland, the BMA believes. Means-testing “would cost as much to police as any savings made”.
Immigration
ON immigration, Kennedy says that “if it wasn’t for international medical graduates and doctors coming from overseas, the NHS would have already collapsed”, adding: “We’ve a very positive view on immigrant doctors.”
However, “immigration in general does put more pressure on the NHS”, due to issues like translation. “Consultations can take far longer.”
Due to the “bottleneck” facing resident doctors and the connected problems of “doctor unemployment”, the BMA feels “that UK graduates should be prioritised for jobs”.
Scotland and the rest of the UK once had “the best health service in the world. We can’t claim that now”.
Kennedy learned to be fearless when it comes to speaking out in defence of the NHS. A decade ago he raised waiting time issues and was subjected to “bullying”. He eventually went public as a whistleblower.
The bullying was so bad he was treated for PTSD. “It was an extremely traumatic experience,” Kennedy adds. Bullying had created a culture where “nobody was asking questions. It should never be like that”.
However, if doctors don’t have the courage to “speak up”, he says, then “ultimately it’s damaging to patients”.