 Well, good evening everybody, welcome to you all, my name is Graeme Wart. I'm a member of council. It's a pleasure to welcome you to this fourth lecture in the 222nd season of the Royal Philosophical Society of Glasgow. Let me remind you that there are fire exits on the front here and back. Toilets also at the back got on ground level and downstairs. It's wonderful to see such a big audience I suspect that's because tonight's topic is one in which you all have an interest and and a considerable amount of experience and expectation. Our speaker tonight is Gavin Francis, who comes from Fife originally got degrees at Edinburgh University in neuroscience and then medicine. And for 10 years after qualification traveled the world. He's just told me he traveled from Shetland to New Zealand on a motorbike. As one does visiting seven continents here with the British Antarctic Survey. He's written a book about his experiences visiting Arctic Scandinavia. But eventually he settled down into general practice instead of searching the world for experience he sat on his consulting room seats and the world came to him for a different type of experience. And of course if you're in that sort of front row of the theater of life it's a deep well of issues to write about if you can write. Not many GPS are writers but Gavin is the exception he's written nine books nonfiction partly travel partly medical. They usually get nominated for some prize or another he won the observer science book of the year award for his book adventures in in human being. He's a regular contributor to the London review of books the New York review of books the new statement statesman the Guardian writing reviews and essays. He's a fellow of the Royal College of GPs of the Royal College of Physicians of Edinburgh. And unlike most of the people with those two qualifications he's also a fellow of the Royal Society of Literature. And it's a pleasure to invite him to address you now on why the NHS is worth saving. Very generous introduction and thank you all for coming out on such a great November evening. It's a pleasure to see so many of you and I hope I will make the next hour or so worth that expenditure of energy of getting out of your front door. I'm sorry I'm not as smartly attired as most of you. I wish I had a nice tie on like Graham you see but I came straight from the clinic and we're not allowed to wear ties anymore. So, yes, I'm a bit more scruffily dressed than I would like to be. It's a real pleasure to come and speak to you in this city of Glasgow about a medical subject because as Graham mentioned I was trained in Edinburgh. My first two degrees were in Edinburgh and there is remains a little bit of animosity between this city's medical fraternity and that city's medical fraternity summed up by there was a time when I just got back from Antarctica. I was working in the Victoria Infirmary in A&E and I went for a thought I quite like this living on the south side of Glasgow. I'm going to see if I can get a job here. So I applied for a job doing orthopedics in the Victoria Infirmary and the consultant whose name I'm afraid I can't remember said come up to my office. So I went up to his office. He didn't ask me to sit down. He looked at my CV and he said, you're an Edinburgh boy, what on earth are you doing over here? So needless to say I didn't get the job. Anyway, so yes, I'm a GP now in Edinburgh, three weeks out of four. I'm working mostly in a practice, an area called Wester Hills, which is an area in the west of Edinburgh with quite a high degree of deprivation. Before I work in Sutherland, covering the area between Thurzel and Durness. So I've got a swing now between inner city and remote and rural practice. When I'm in Wester Hills, I work in a very densely populated area with people from all over the world and when I'm working in Sutherland, I cover about 1000 square miles with 1500 people. And I love that contrast of moving between two very different extremes of general practice in this country, but actually both populations, the remote populations in Sutherland and the people of Wester Hills, there's a great amount of unmet need, actually. And so I hope over the course of the next 45 minutes or so to talk to you about some of the challenges I see the NHS facing in both those kinds of contexts. And so I'd like first of all for you to cast your mind back. If you possibly can bear it to March of 2020. It's a time that many of us like to recall and certainly nobody recalls that time with any pleasure. Remember it was quite a frightening time there was news of this pandemic coming to us all the time through the television through the radio and the newspapers. We could see what China was doing building hospitals overnight to deal with the casualties. We could see them digging mass graves in Iran which saw this sort of terrifying things coming out of Italy. The pandemic hadn't reached here yet. And I had had maybe one patient that I thought might have had COVID but we didn't have access to testing. And something quite odd and unusual happened. In the middle of March, I got an email. And the email had an attachment from the General Medical Council and all the four chief medical officers of the UK. So the most senior civil servants in the United Kingdom charged with informing government and managing our health service and public health, really. And that attachment said, essentially, and I'm going to, I'm going to have to summarize, but it said a pandemic is coming. It's going to be really difficult. The NHS is going to be stretched to its absolute limit. You're all going to be asked to go above and beyond what you were trained to do. And trust in your professionalism. We want you to rely on the fact that we have your back, because we know it's going to be hard for you. So please rest assured when you're asked to do things that you've not been adequately trained to do that as your regulator and as your most senior line managers, we're aware of the huge pressures that you're under. The letter was about a page and a half long. And I was quite startled, but I was also quite reassured. I thought, well, that's quite good of them, actually, to say, we're aware that you're all going to be put in a situation that you're not adequately resourced for. We understand that you're going to be frightened, but we are going to trust you and we're going to support you. So I was very grateful for that letter. And now, in November 2022, when the pandemic was starting to recede, I got another email from the General Medical Council. And it was also signed by the four chief medical officers of the United Kingdom. And it said, and I'm going to summarize again. You're all going to be pushed beyond what you're adequately resourced for. You're going to be asked to step up and fulfill roles that you haven't perhaps been adequately trained for. You're not going to have the resources that you were trained to expect. But don't worry. We trust in your professionalism. We've got your back. If you're referred to your regulator for a complaint, we will take into account the pressures that you're under and the fact that the system you're working within is inadequately resourced. And so a letter that in March of 2020, I found greatly reassuring. And I don't know, I was just, I was kind of heartened and proud of being part of that profession. Had in November 2022, 2022 become something far more chilling, actually, desperately chilling. And I went on the BBC website. I looked at the newspapers over the next couple of days. I thought, why is this not first front page news? The most senior civil servants in our country and the GMC believe that the NHS is now incapable of offering basic standards of care because of the tilt of the planet away from the sun. So it wasn't a death weeping pandemic that caused us to drop our medical standards. It was winter. You know, it made me really alarmed. It made me quite scared. Also made me quite angry. I mean, if you think about it, think about what that letter actually meant. It meant that the most senior decision makers in our country about clinical standards, understand that we now have a two tier service. We have a service for the summertime when the NHS is adequately resourced and we expect one set of standards from our doctors. And we've got a set of standards for the winter when we know everybody's overwhelmed, there's not enough beds, corridors are lined up down the trolleys are lined up down the corridors. And we're not able to deliver the care that we want to be able to deliver. So let's think about that analogy a little bit more broadly. Imagine if you got in a plumber, and you said, I need a new boiler. I want a new boiler. This old one is not doing the job anymore. And the plumber said to you, I've got a great boiler for you. It'll work really well between April and September. Do you know, October to March, you might get a bit cold, but it's really cheap. I would say I don't want that plumber thanks, although for a different one, but that's exactly the situation we've allowed to evolve in this country and we've allowed to develop within our national health service where we're expecting the service to be overwhelmed every winter. We resource it for the quietest days of summer. How has that come about. So I was so alarmed about this, I was, I wrote a very angry piece for the economist about how I felt that we now we're here with a two tier service with a two tier NHS between winter and summer, rather than a two tier between who can pay and who can't pay. So listen to some of these statistics about how under resourced the NHS has become this. These are figures from 2019. So before the pandemic. The NHS England said in 2019 that it had 43,000 nurses vacant and 43,000 nurses that believed it needed to fulfill the rotas on its hospital words across England, but those jobs are vacant they couldn't find those nurses. They were two and a half thousand midwives short. Overall, the NHS England as a whole had 110,000 vacancies. The UK employs 1.4 million people, it's huge, absolutely massive. And so you might say 110,000 vacancies isn't very much compared to 1.4 million or 1.2 million as NHS England employs. But to me that's absolutely staggering how can any organization continue to function with that degree of absence, that degree of holes in the rotas. And just since the pandemic are worse, those figures are worse. Now we have a third of junior doctors as soon as they qualify are leaving the UK, they're going to work in places where their skills are more appreciated where they'll get better paid where they'll get nicer rotas, where they will feel less exhausted overwhelmed and pushed, people don't drag themselves through six years of medical school to give up medicine. At the end of that, just because their lightweights or their snowflakes or they're just lacking a bit of moral fiber, they want to be doctors if they've dragged themselves through six years of medical school. So let's think about what it would take to make a third of those people decide this isn't for me I'm going to move to the other side of the planet in order to find work that is more rewarding and where I will be more appreciated. And there is now been good economic analysis of the pay rates of doctors and nurses over the last 13 years since the change the Westminster government in 2010. And the drop in pay for doctors and for nurses is about 20% in real terms in such fact for doctors is slightly more than that. I know if in Edinburgh, awards that have lost their clinical support workers because the coffee chain on the ground floor was offering better pay. So, if bringing a market into healthcare and capitalism as a society as a whole is supposed to find better value or supposed to place value on what we think is most important what we prioritize is quite clear that we now prioritize having a skinny latte more than having somebody be able to be well nursed well cared for in bed, you get paid better for making skinny lattes than you do for caring for people on a hospital ward. Now, cast our mind back a little bit further. Beyond 2010 to many of you will remember the mid staffer chair scandal, the mid staffs scandal. The mid staff scandal was the product of a new labor initiative to place a kind of hierarchy in hospitals and you could get a different status as a hospital if you met certain targets. Now the new labor government as we know flooded the NHS with lots of money but they were kind of obsessive about how that money be spent quite rightly it was public money. They wanted to make sure that money was spent very very well and they put huge pressure on hospital managers to get results. And when the Francis report into the mid staff scandal came back, it showed what the results of that pressure was. There was so much pressure on that the staff in that hospital that nurses in any were told that if a patient breach the four hour waiting target, they would be sacked. So they doctored the paperwork to show that the patient hadn't reached the four hour waiting target, and then that was discovered and they got sacked anyway. So that's an example of what happened because of that kind of pressure was put on those hospitals now as a result of the mid staff scandal and national whistleblowing service was set up, whereby any staff member who had concerns about standards of care could phone an independent whistleblower to register their observation of what happened and have independently investigated. Now, the NHS is now so under resourced and so many services have such long waiting lists that these kinds of terrible failures of care are now routine. And after one such failure of care that occurred on my one of my patients when I referred a patient urgently to be seen, I was told that they couldn't be seen because there was no resources for them to be seen. And I said, well, I thought I should do which was for these whistleblowers. I said, look, I've got this patient. All clinic all clinical standards say that this patient should be seen urgently I've tried to refer them to be seen urgently and I've been told that they can't be seen because there's no resource for them to be seen. There's no staff available. This surely is a prime example of what the whistleblowing service was set up for. I was told by that was the blowing service that a, they're quite right there aren't any resources to do better. Be that if I made my report anonymously, it wouldn't be investigated. So I had to put my name to it and see I had it confirmed by them that actually as a GP I was unusually free to be able to speak about these things that if I was a hospital consultant. I may be able to speak publicly about these problems because it would be in my contract that all contact had to go through the hospital press team. So, in summary of this this is my introduction preamble to what I'm going to explain to you this evening, you know, essentially, I hope it's becoming clear I don't really want to be rising about politics. Graham made reference to some of my other books that are about various other kinds of things to do with travel and to do with medicine. And I want to be writing about those I want to be writing about the synergies and the harmonies between medicine and literature and arts and travel. But I cannot sit by and do my job when it's getting harder and harder and harder to do it the way I was trained to do it without saying something. The autonomous piece was a real for me was an old departure, as I say because I don't normally write about politics. But when the general medical council and the chief medical officers say that they know that the NHS is so threadbare that we have to drop our standards every winter. I thought it was time for me to say something. After having read quite a lot into this as you can imagine is that really is quite simple. The NHS is still a very efficient system comparison with most other developed world economies and their health systems is just underfunded. There's a sort of tabloid refrain that actually there's too many managers in the NHS that is very wasteful that is bloated. If you look into it actually most industries, about 9% of the workforce are involved in management in some way. The NHS has 2% of the workforce are involved in management in some way. We pay less for our health care than the French than the Dutch than the Germans than the Danes. We pay less for it and the reason it's less is perhaps less obvious or it's more infuriating maybe for the politicians in charge is that the NHS is funded in quite a unique way and almost uniquely and that it's all to be from general taxation, rather than an insurance based system. If it was through an insurance based system then it's easier to point the finger of the insurance companies for failures, but because of the founding principles of the NHS that have been funded through general taxation. It does mean that we have to keep going back to government to blame them for its funding. This executive officer of the NHS in England in 2017, Simon Stevens, he said 2017 six years ago, he said the NHS is no longer funded to do what politicians or electorate expect of it. So what he was saying is what can we cut. If you're not going to give us any more money. Will you please tell us what can we stop doing. He didn't receive an answer he wasn't told that anything could be cut. So this little book that I've written it's a very short read it's 150 pages or so long. It sets out what for me constitutes really a modest contribution to what is now quite a heated national public debate about the future of the NHS. I'm going to show how bad things have got at the cold face. There's a GP, how I see them so easily that they could be better. And it really celebrates the founding principles of the NHS, because I believe that they're good for patients, I think they're good for communities, they're good for the practice of medicine my clinical colleagues are good for everybody, except private company shareholders. When I was thinking about how to write this book, I thought, you know, they've got this sort of massive different kinds of messages I'd like to get across. And I thought the best way to open it actually would just be to tell you all, and some of you I know it'll be GPS or retired GPS, let's tell you all what happens in a normal day in general practice. So opens are the day in the life of potentially the best job in the world. Because I do think the general practice is potentially the best job in the world. What you do is you take all this scientific knowledge that you learn the first six years of medical school and then five years of specialty training. You take all this scientific knowledge, and then you do something quite simple, but actually quite beautiful, which is you use it to try and make people feel better. Very rewarding, very satisfying when it works, it's great. You see people with all kinds of problems, rich and poor, young and old, black and white, all kinds of issues. And usually you can do something quite straightforward to make them better. Small proportion you have to refer on to hospital, but most people you can deal with there and then in general practice. It's very cheap as a health care system because 38 pound for the, the, the ex checker every time you go and see a GP that costs 38 pound. If you turn up at any that costs yourselves across us taxpayers 200 pound. Every time you phone an ambulance that costs 400 pound. So see a GP is a very cost effective way of delivering medical care. I wanted to show how across that day a normal day in the life, you have this sort of extraordinary and quite beautiful breath of different problems that you deal with diversities lots of satisfactions quite a few frustrations. I wanted to show as well how much of my time is taken up now with the system not working properly. How much of my time is taken up with people who when I started my career as a GP I qualified as a GP in 2005 so 18 years ago. My time is now spent actually dealing with people who would have then been seen by a specialist already but they're now stuck on interminable waiting lists. Now if I had the answer to their problem I would have done it. I wouldn't have put them on a waiting list to see the specialist I've already reached the end of my therapeutic options, but now people are stuck on waiting lists for so long waiting to see the specialists that they keep coming back to the GP who's already exhausted. I wanted to show their possibilities of what they can do. I wanted to show what happens when he is overwhelmed and when people get more or more when they come out of hospital than they are when they went in. I wanted to show what it's like when you phone for ambulances for a very sick patient on a home visit and you can't get them. The ambulance you're told by the ambulance staff, we're taking six hours now to respond to one hour blue light ambulance calls. I wanted to show how much of my time is also taken up with bureaucratic kind of failure of patients who didn't get the letter for the outpatient clinic so they've got to be re referred patients who got the letter the day after they were supposed to be in the hospital clinic, sort of sort of laughably idiotic things that should be working very easily that would be quite straightforward to make work properly. I remember exploring a day in the life I talked about what life was like before the NHS now I was born in 1975 so I can't tell you much about life before the NHS but I've got I've got plenty of patients who remember life before the NHS. I certainly did before and when I started out in general practice. Old lady I used to look after who told me about the jar of money on the mantelpiece whenever there was any spare money at home it went into the jar and the jar was for the doctor, or for the dispensary, because somebody in the family becoming ill could ruin the whole family's prospects frequently did. And so it was important to keep that that jar available. So let's think for a few minutes I want to dwell on the issues of why it was founded or why the NHS was founded with the principles that it was. As you know, a great founding architect of it was an outing Bevan, Bevan the Labour politician, most war Labour government. He said, society becomes more wholesome, more serene and spiritually healthier. If it knows that its citizens have at the back of their consciousness the knowledge that not only themselves but all their fellows have access when ill to the best that medical skill can provide, but private charity and endowment although inescapably essential at one time cannot meet the cost of all this if the job is to be done in the state must accept financial responsibility. He also said, we ought to take pride in the fact that despite our financial and economic anxieties, we are still able to do the most civilized thing in the world to put the welfare of the sick in front of every other consideration. We have extraordinary distillation and crystallization of the principles that I certainly have taken for granted throughout my whole career, but which I am now seeing undermined and are crumbling as we can see in the fact that the chief medical is in need to issue issue that letter. And this another another quote I would like to tell you is often misquoted as being from Bevan but it wasn't it was a sociologist Th Marshall said this as a summary of Bevan's philosophy. There is neither an indulgence for which people have to pay, not an offense for which they should be penalized, but a misfortune, the cost of which should be shared by the community. It seems to me quite self explanatory that if we collectivize bad luck of illness that will be fairer and cheaper as a way of delivering health care. I heard last I was a lecture. Last week with Graham for the medical aid for Palestine and heard a quote from Will Hutton, this lecture, which said, the NHS is how we share bad fortune and inheritance tax would be how we share good fortune. This is a nice way of putting it but I think the NHS is how we share bad fortune. I don't believe that illness is an indulgence for which people should have to pay. Graham had many battles with GPs when he was trying to sell the NHS but he did love them he wrote that he had a worm spot for general practitioners, which quite like you recognize that a robust primary care service would save the country a lot of money. And, and he recognized actually that the bedrock of NHS would be not just good primary care, but good primary care with GPs that knew their patients. I was anxious to ensure that the general practitioner should be able to earn a reasonable living without having to aim at a register which would be too large to admit of good doctoring. I suggested a graduated system of capitation payments which would be highest in the medium range and lower in the higher, which would have discouraged big lists. I thought that he wanted GPs to have manageable numbers of patients so they could get to know them and be good doctors. And this is something he didn't manage to get that in to the founding principles of the NHS. And so there's still absolutely no incentive whatsoever in general practice or primary care contracts to promote continuity of care. There's no incentive at all. Yet you were now getting researchers come out recently actually showing that if you have known the same GP for 15 years. You have got 25% less chance of being admitted to hospital than someone that's known their GP for a year. And you've also got between 20 and 25% lower mortality than somebody who's known their GP for a year. And if we had a drug that could lower hospital admissions by 25% or lower mortality by 20% you know our politicians would be insisting that we prescribe it but we, we have that drug we know that drug is that drug is a robust primary healthcare service where people know their GP, but we have yet no policies whatsoever to promote it. And because of the way the NHS is funded almost unique as I said, it's inextricably linked to its stewardship by government, sadly and lots of governments have hated that and been very frustrated by that but that's the way it is. You know when the government stewardship of the NHS is good it does well when the stewardship is poor it does badly and for many many years the UK has relied on the relatively efficient way the NHS delivers healthcare to justify spending less than other countries. So we do still spend less as I said in the French the Germans the Dutch. People have defended that by saying but we're much more efficient than the French and the Germans and the Dutch we don't need to spend as much money as the French the Germans and the Dutch. But that argument has worn very very thin. There was an international analysis of the NHS competing it with Canadians the Australians the French Germans Dutch various other Western developed healthcare systems, published in the BMG in 2019. And it says the NHS showed pockets of good performance including health service outcomes but spending patient safety population health were all below average to average best taken together these results suggest that if the NHS wants to achieve comparable health outcomes to the Canadians the Australians the Germans the French and at a time of growing demographic pressure, it may need to spend more to increase the supply of labour and long term care and reduce the declining trend of social spending to match these comparator countries. So that's a big economic analysis of all these other countries, just so that we just, we've got a budget service and we're now getting budget results. So to say that the UK cannot match the health care spends of France or Germany or Denmark or Canada is to say that the UK has become too poor to be a developed country. The economically we've fallen too far behind our neighbours to be able to afford comprehensive medical care for all, or perhaps that we've reached a point in our society where this might be true where wealthy people are no longer willing to subsidize the health care of poor people. Or maybe we've reached a point in our society where social mobility has seized up to such an extent that wealthy people no longer need to fear that they might one day become poor and need to rely on the service of health provision that's there for the poor. So my argument is that for the last few years, our governments have been persistently dishonest with the electorate about what good health care is going to cost. And because these other countries can just like insurance premiums when they need to improve health care in our country, we have to hike taxes. And the governments have been persistently too frightened to do that and too scared of going to the electorate and saying, if you want a better health care system, we're going to have to charge you a bit more, because the NHS is not inefficient, it's just underfunded. Now there's a chapter in this book called No Slap, the Normalization of Crisis, because it feels that's how it feels now to work in the NHS. The last time I remember things feeling this bad among colleagues was in the final years of my medical school training in the mid 90s. Now in the mid 90s, the UK's national contribution towards NHS was about 6.3% of GDP. At that time, the EU 14, so the main EU economies, they spent 8.5% of their GDP went on health. That was in the mid 90s. And then I mentioned the new Labour government came in 1997, Tony Blair famously said that he was going to match that EU average 8.5% of GDP. But by the time he got to 8.5%, the EU 14 had got to 10%. We're always playing catch up, they were always slightly behind what our European neighbours were spending on health, how much our European neighbours were prioritising health in the economy. I can still just about remember a time at the start of my career, 2005 as a GP, when you could refer a patient to a specialist clinic and they would be seen within 12 weeks. I mean 12 weeks now seems like an absolute fantasy. I can't imagine a patient that might now be seen within 12 weeks, but being referred to a specialist clinic. If you look at patient satisfaction outcomes with the health service, they track funding almost exactly. So whenever funding goes up for the NHS, patient satisfaction goes up, funding goes down, patient satisfaction goes down, which is another way of me emphasising this is not just about poor management. It's not about waste and squander. It's just about actually funding healthcare to the priority that our society wants it funded. And so the crisis as we see it now is caused by so many different things. It's not been caused solely by COVID, although that's hastened it, it's not caused solely by the seasons. I know the chief medical officers tell me now that standards drop in the winter. It's not been caused just by Brexit and the economic downturn of that. It's not just been caused by the rising costs of modern medical interventions, although that's part of it too. It's a combination of all these things and more have hastened it. There was a recent King's Fund analysis which showed that just to keep pace with our European neighbours, we now need to spend 40 billion a year more on health. That's just to match them. So how do we fix this? I mean, some of my colleagues think we have to unhitch the management of the NHS from political cycles that we need to make a cross party and boards that looks after it. I know that's the disadvantage of that, of course, which is often also being voiced is that then we would lose our ability to register our displeasure with the government of the day when the NHS is being failed. And there's, it's not easy, of course, to see any kind of solution to how we do what we do with with with the rising costs of an aging population. So we have to pay more. Now, people often shudder when I start to mention these figures because we don't like to think in terms of bald figures translating into life and death scenarios but that's what health economists and politicians are doing all the time. So somebody who is 65 costs the NHS or costs the taxpayer or draws from their own taxes they've paid on their life. Someone who's 65 costs two and a half times more than somebody who is 35. Someone who's 85 costs the NHS or the taxpayer or the exchequer five times more than someone who's 35. And that's the reason that because we have this wonderful magnificent success story of the population aging, we're now living longer than we have ever lived in the history of humanity. The lifespan of human beings doubled over the course of the 20th century. It took archaeologists tell us it took 10,000 years to double life expectancy to the figure it was in the early 20th century. It doubled life expectancy again over the course of the 20th century, quite extraordinary, but that is going to come with costs and I believe in a civilized society who looks after all of its members young and old we have to find that money somewhere. We have to find that money other countries are doing it we will have to do it too. The chapter in this book is about something alluded to earlier which is workforce and you know we're losing, we're losing a third of our junior doctors were short 43,000 nurses at least two and a half thousand midwives and I read an interview online. This was last winter, with any doctor, Dr Fiona Hunter, who was a spokesperson for the College of Emergency Medicine. And she said, we need to stop staff leaving in their droves make our staff feel valued allow them to come to work and do a caring job and leave the shift feeling as if they've made a difference. That was heard at the end of last winter when any doctors were really a nurses were struggling to look after people in corridors and people weren't even making it to the world. A consultant pediatric surgeon asked in the same interview series Amanda McCabe said of staffing. There's a huge amount of goodwill in the NHS and it's important that this isn't eroded by pressures put on healthcare workers and urgent steps need to be taken to ensure NHS staff are valued nurtured and supported. So there's a real problem in healthcare right now to make people feel valued nurtured and supported have we seen pay is only a small part of it. One of the many consultants I interviewed for this book told me the half life of satisfaction to increase pay is actually quite short and there's millions of around the world unhappy doctors who are in a successful private practice so pay is only part of it. Huge part of it is about teamwork and there's been a real diminution of fellow feeling and teamwork. I would say as the system becomes more stressed. And people are batting down the hatches trying to protect their own patch trying to look after their own patients as best as they can. And they're much more willing to refuse requests for help from outside because that dilutes the possibilities of looking after their own patients. And for most of my career it's felt like a real privilege to be part of a system that's so cherished for its principles and most people that work for the NHS are really committed to the principles of the NHS they see how the principles are good for patients they're good for clinical care they make good clinical decisions because of the way the NHS is funded. But that fellow feeling is getting so squeezed and working conditions are clearly being degraded and you wouldn't see this exodus of staff if it was a lovely place to work. And it's more than just a pay it's about the feeling and the morale and the words and then the A&E departments and the GP clinics up and down the country. Recently I was on the phone to an occupational therapist who's part of a team whose job is absolutely vital to get people out of hospital and back home safely. They're a home care team that do assessments urgently at short notice, not only to try and get people home safely but also to try and prevent people from getting admitted to hospital. And she told me that there was supposed to be four occupational therapists in our team but she worked alone. So she had a 75% absence rate in her team so she was trying to do the job of four people. Now you can imagine if somebody if you're trying to do the job of four people and someone comes along and offers you a different job with less stress than the same money. I think you'd be very tempted to take it. But we seem to have gone in the space of two years from clapping on our doorsteps for health care workers. So a kind of media narrative that often vilifies them when complains when they ask for better pay or for better resources. I asked a colleague of mine who's 10, 15 years older than me what he thought about this change in the staffing and the change in the morale. And he said something interesting that I hadn't thought of about why there's such an exodus of the junior doctors many of whom trained in England. He said well they paid fees they paid through the nose to get here. And then they feel exploited why should they have any love for the NHS. But my generation felt they had their education paid for the taxpayer paid for them, and they had an obligation to give something back they felt grateful for their job, and they felt much more valued. And that's a really interesting reflection on when you market ties and monetize higher education, and you inform a whole generation that education is an investment for your future for which you will carry a large debt that changes the whole way that you approach the world of work afterwards. Another colleague I was discussing this sort of almost almost deliberate vilification of the healthcare workers during the junior doctor strikes that we saw in England earlier this year. And he quoted back to me Bevan on the Conservative Party of the 1950s. And this is this is this is in the mid 50s. If the service could be killed they wouldn't mind but they would wish it done more stealthily and such a fashion that they would not appear to have responsibility. So that was 1955. And I believe that's a large part of what we're seeing just now. There was recently during recent junior's doctor strikes. There was quite a lot of junior doctors were posting their payslips on Twitter. And so one of these I saw one of these payslips. And it's difficult to compare because junior doctors now work about often work about 45 hours a week and then my day in the late 90s we worked a lot more. But I was really quite shocked that he was getting paid now in 2023 only 100 pound more a month than I was getting in 1999. So that's when they say that they're seeing their pay degrade over that time in real terms it's really startling to me. And when I was in 1999 I used to work about 100 hours a week but I got 1600 pound a month take home. I was after tax in my pocket. And this payslip I saw on Twitter last year so junior doctors are working a lot of hours and very responsible position he was getting 1700 pound a month take home. So, exploring other potential solutions I've got one chapter in this book explores private medicine as a possible solution and various governments have become enamored of private medicine as a potential solution particularly to long waiting lists. But my own experience that I outline in the book is that often private medicine has poor outcomes. It shouldn't really be called private medicine because it's not any more private or confidential than the NHS. I mean I would rather it was just called what it is which is commercial medicine, you know, you, you, you pay because you want a service, you want a particular service you find a vendor of that service you give them money and that service is provided to you. It shows a commercial transaction, and it should be called as such. My own experience is that standards are often put or when things go wrong, they just punt the patient back to the NHS. So I've spent a lot of my time picking up the pieces of poor standards of care in the private sector. I recently reviewed a book by a neurologist in London Andrew Lee's and he has this brilliant line about private health care in London. So in Scotland, I'm sure many of you know private health care is pretty tiny here. It's less than 5% of all the health care that's delivered in London. It's about 40% of the health care is delivered. And so Andrew Lee said in his book, private hospitals are there to generate income and all the rhetoric of quality safety and patient satisfaction is in truth no more than a public relations exercise. And my own experience of that is very true because again and again I found profit as a motive doesn't work in health care. If your partner, if your child, if your mother or father is ill, there's almost nothing you wouldn't pay to try and ease their suffering. And so the potential to exploit that in a commercial transaction is almost limitless. Health care before the NHS, the cost of health care often did ruin a family's prospects, and it still does in many parts of the world. I've got many patients that come to see me in my NHS role for their, as I told you, I just told you it costs £38 to the taxpayer to come and see me. They won't pay £300 to go to the supplier or the other private provider, hear their options and then they'll come and ask me what they should do. Because they know I don't get paid any differently depending on which course of action I recommend and that highlights something very crucial about the medical transaction that has to be about trust. And when trust evaporates, therapeutic consultations evaporate. So it's absolutely imperative that we rebuild the NHS from its current terrible state that we feel as if we can trust our doctors. I explore some things about the spiralling costs of modern medical care and that's something we're going to have to face up to as a society because modern medicine is amazing. You know there's drugs coming online now that are just absolutely transformative for all sorts of things. And as a society we're going to want access to those drugs. Right now, for you to have access to a GP costs you about £15 a month. So it's less than a phone contract. So that's the primary care budget per person is about £180 a year. But the drug budget per person for the whole country is £360 a year. So if we average it all out at the moment, we are all consuming £360 worth of drugs a year. That's because some people are consuming 30 grams worth of drugs a year, and a lot of people are consuming man at all. But new drugs are coming online now that are really expensive that cost 10, 15, 20,000 pounds a year. And they're going to help an awful lot of people but we're not all going to be able to afford them unless there's a radical hike in the funding of the NHS. And so if we don't find a way as a society to do that, we're going to see a two tier service develop and something of course that we saw many years ago happen within dentistry. So, I do think that the NHS is a magnificent success story. I do think that our incredible longevity as a society, living longer than we've ever lived in the history of humanity, is an incredible success story. But it's a success story that needs support and we're going to have to find a way of transforming the NHS soon or it's going to fall apart. We already can't fill the places, we can't recruit the staff, we can't retain the staff, and we're going to have to do that. At the moment, 9 billion pounds a year of money that was in the capital maintenance grant to keep the bricks and mortar of the NHS going is being diverted to provide frontline care. So there's a big backlog now in capital maintenance. I read a statistic recently that the private finance initiatives brought in by the last Labour government, they have now cost us as taxpayers, they have now cost us 70% more than if the government had just borrowed the money. So, for example, I think this is a great example, there's a hospital car park in Edinburgh that came in under the PFI that has changed hands five times, I heard, since it was, its contract was first signed and is now owned by a Swiss equities firm. So this is the kind of ways in which we're paying and paying and we're demanding that our children pay and our grandchildren pay for decisions that were made long, long ago. The chief medical officers have now told the workforce that are aware that we can't cope. The chief executive of NHS England has been saying for six years that the service is underfunded and can't meet demand. And my question is now to our politicians who are charged with responsibility for the NHS is if there's no more money forthcoming. What can I stop doing? Because I absolutely cannot carry on trying to provide the same level of care that I was trained to deliver without an expansion in the budget of the NHS. I've been talking for quite a long time, I will stop and I hope we'll have some interesting discussion and questions. Going forward, but I just like to read you a short but something I hope that might slightly lighten the mood or slightly give us a bit more of an optimistic feel about the future of the NHS. I was at a teaching session recently at my local medical school, and a disconsolate and anxious group of students asked me about falling standards in the NHS, dismal morale among clinicians, and whether there could be any hope for their own careers. We look at the junior doctors, one of them said and wonder what it is that we've signed up for. I told them that 30 years ago when I started out in medicine the feeling in the NHS was the same, a burned out exhausted workforce was fed up of working in a failing underfunded service. Patient dissatisfaction was at an unprecedented high when towards the end of my university training there was a change of government. The voters demonstrated that they wanted their politicians to put the NHS back to the top of their priority list and taxpayers money flooded in. Morale among doctors, nurses and allied professionals quickly began to rise in patient satisfaction too. And within a few years of that change studies were being published that put the NHS among the most effective and efficient healthcare services in the developed world. The disenchantment in the NHS now won't last forever, I said to those students, the fortunes of the NHS will improve again, they have to. And I told them that despite all the challenges of the services is today, caring for others remains the most rewarding of jobs to work in medicine or in nursing is to engage your intellect to your curiosity or humanity or compassion. And there's no other job that I would want to do. The principles that the NHS was founded upon are still widely revered, good quality healthcare for all, provided by everybody, for everybody. And whether those principles can continue to stand up against the costs of the 21st century world of gene therapy, robotic surgery, innovative biologic treatment stem cell transplants, and a population that's living longer and with more frailty than has ever done remains to be seen, but I'm optimistic that it can. The alternative is to admit to a lack of imagination and compassion and a health service free for all at the point of delivery, based on need, rather than on demand as an expression of what's best in our society and we will get the NHS we are prepared to insist on. I hope that you will agree that it's worth saving. Thank you. We've reached the end of the time for Q&A. So it's time to bring the evening to a close. Many of the lectures we have here are primarily to inform sometimes to entertain I think Gavin has had the additional purpose of trying to stimulate to move. Possibly even to enrage the implicit target of his talk, not only politicians but the passivity of the electorate.