A society can be judged by it is ability to care for its most vulnerable members, so providing a free (at point of usage) comprehensive healthcare system is a huge positive for any nation. The NHS was originally introduced in the UK in 1948, and has long been a source of pride but it has been under strain for a long time and the pressures seem set to rise. The problems are symptomatic of the current economic climate, with an increasing elderly population, stagnant economic growth, rising costs, and reduction in work force from Europe after Brexit. Healthcare is becoming ever more complex and costly everywhere and has always been a politically sensitive matter in the UK, challenging every government administration. In the last few weeks, the demand for emergency services, has far outstripped supply, with chaotic scenes witnessed across the country, with queues of ambulances waiting outside hospitals and care provision spilling into car parks and corridors. Whilst the NHS will undoubtedly require increased funding, it is perhaps surprising that the UK spent 10.4 per cent of GDP on public health in 2020, more than every other country except for Germany and USA, admittedly on the back of some prior periods of reduced spending, yet it consistently ranks lowly on many healthcare outcomes. Behind the macro politics and economics lies a highly inefficient organisation. The NHS is undergoing widespread reform with the adoption of integrated care systems, from the 2022 Health and Social Care act, which will lead to a local recombination of primary care and secondary and councils, but it remains to be seen how this will develop and whether the problems with the health service will be resolved. Private Finance Initiative (PFI) PFI was introduced by John Major’s government but really proliferated during the Blair administration. It was essentially a buy now pay later private funding agreement which brought about large public infrastructure projects, including many new hospitals, without raising National Debt. However, these deals which many hospitals are still locked into are extremely detrimental to the public purse, with private cost of borrowing at a much higher rate than government borrowing. Total PFI debt stands at over 168 billion pounds and many hospitals are locked into contracts until 2050, with one trust, Bart’s Health paying 116 million pounds in interest per year, which will lead to a total repayment of 6.8 billion from an initial outlay of 1.2 billion The trust are treated as tenants to the private landlords and are responsible for maintenance cost and many trust are locked into using specified contractors in accordance with their PFI agreement with the land owners benefiting from this arrangement. Examples of this include a police station that was charged £800 for replacing a chair, a hospital was charged £5000 for a replacement sink. Successive governments have overseen this needless squandering of the public purse in favour of a small group of finance and engineering companies. Thankfully new PFI schemes have been abandoned but the legacy of the debt will hamper NHS Trust for many years to come. Split between primary and secondary care The health service is highly fragmented, though the introduction of 42 integrated care systems in the UK looks set to change this. There has been a split between primary care which are general practices and secondary care which is hospital care. Primary and secondary care are then split into many different provides (NHS Trusts and primary care groups) which are all separate legal entities. Two thirds of the funding for patients is provided to primary care who transfer some of this funding to a secondary care provider with the patient, when they are referred to a secondary care provider for a service. The idea is that different secondary health providers will compete for the referrals on the grounds of efficiency, and eventually less efficient service provider would merge or be taken over my more efficient providers, however this is not what happened. Service costs between secondary providers are set by national tariff and the only choice that a primary care has is waiting times and distance for the patient; but waiting times are long everywhere and what ensued was a game of cost minimisation with primary care and secondary care working against each other for short term gains. For example, if a patient is found to have a second problem by the secondary care provider that isn’t part of the original referral or if the issue is more complex, then the patient will often be discharged back to primary care with the issue incompletely resolved. Primary care will not be happy dealing with a matter that is not ideally suited to and will make a referral back again to secondary care to a different or even the same secondary care service, so they receive adequate reimbursement for their activity. The system isn’t well suited for patients with more chronic problems and this bouncing back and forth is a waste of time and money. Overall, this sort of fake market is completely unnecessary, as there is no means of driving the costs down. A more efficient provider may make a profit on an aspect of its service so it could try and expand this activity to increase the profitably however Trusts have very limited ability to mobilise their workforce to increase their activity which is usually very costly and in the UK patients often don’t like to travel further to receive healthcare services and often prefer the convenience of locality above a potentially superior but further located service. Small mentality The NHS is a huge organisation, but it does not behave like one. Each NHS trust has its own policies, its own governance, individually approves its own procedures and makes its own contracts and has its own individual data to protect- from other parts of the NHS! The NHS providers regard other providers as suppliers and contractors rather than part of its own organisation. The NHS misses out on cost savings made through purchasing in bulk and issuing their own contracts which also makes it prone to corruption. There are thousands of people who have access to the public purse and unfortunately, a tiny minority cannot resist dipping their hands into it. There are many examples of managers and executives who diverted NHS funds into their own companies; one executive even though it right to fund their horse breeding company, disguising their purchase as medical supplies. But inefficiency can be more subtle such as favouring inferior contracts in favour of friends, family or business partners. This was quite prevalent during the covid pandemic when the government issued billions of pounds worth of contracts on a less than competitive tender. Companies were 10 times more likely to receive a Covid contract if they knew government officials or MPs. It is estimated that 9 billion pounds was wasted by the government on Covid PPE that was unusable. In an investigation by the BMJ and the Guardian, 437 out of 5671 primary care contracts were awarded to healthcare providers in which one or more CCG board members had declared an interest. The NHS brings together an unholy mixing of public and private financing. Those controlling the public purse have no skin in the game, in fact the opposite is true; their skin may be in a different gain. This would not occur if they were spending their own money, if they were shareholders for example, spending funds, or spending public money on public providers; it only arises from public money being spent on private providers. Lack of IT IT has been a terrible problem though it is slowly being resolved. Trusts and primary care do not have efficient ways of communicating patient information to one another securely and, have different computer systems between providers, multiple systems for different tasks and incomplete coding, which means digital information requires a lot of human extraction, and data security is more complex. Everyone has an NHS number which is 10 digits long, foresight indeed, however trusts continued to issue patients unnecessarily with their own hospital numbers (which are 7-8 digits long), presumably as they thought this would be more handy and easier to scribe in the pre-computer era, however this proved to be a colossal waste of time and money. Some patients have multiple hospital numbers generated on different encounters, if there isn’t a complete match between records, causing delay and loss of information even detrimental health consequences. Patients have different record numbers for different hospitals which impairs communication between hospitals and provides further barriers to communication beyond the data protection concerns of transferring data from one trust to another. The lack of connectivity between different part of the NHS has been exploited by some patients I.e., receiving multiple prescription or trying to cover up domestic or child abuse, or receiving follow up in multiple hospitals for the same thing. If the NHS is one organisation, why is there no unified data policy which caters for the entire organisation as a single legal entity? Clinical governance 'The New NHS: Modern, Dependable' government white paper of 1997 introduced the concept of clinical governance. Whilst there were many positive aspects such as team working, focus on quality adopting a trust ethos, a desire to improve services, and openness, there is also an idea that the trust (not the government which serves to monitor the service) is responsible for the patient outcomes, though politically this would be an impossible line for any government to toe. The clinical governance framework dictates that everybody who works in a trust is responsible for everything in their trust and only their own trust. There is the idea that regardless of how poorly designed the service is, it is up to the workers to patch up all these problems and even redesign the service as they go along, as a grass roots phenomena, rather than good top-down planning of a service in the first place. If everyone is responsible, then no one is responsible. Additionally, it is everyone’s job to keep and eye on everyone else and this promotes a culture of blame. Employees are taught to blame themselves or blame each but turn a blind eye to the service planning, the system, or government policies. This can lead to internal politics, which often is not based on any facts as there is often no clear performance information. Vulnerability is inversely proportional to power and some groups of people come of worse in these internal politics. Doctors are often publicly shamed for serious mistakes in the media. It is most convenient for the government to use staff as scapegoats for all the deficiencies in the system. Staffing The one thing that is standardised across the NHS is pay and is not performance related at all. In many ways it dissuades productivity. Consultants largely cannot carry out additional activity when it is required due to their concerns about UK pensions taxation which means that additional work may result in little or no additional pay. Whist many NHS workers carry out additional work for the benefit of patients without any thought about pay, for many, there is no incentive to be highly productive, it would just result in exposure to additional risk with no reward. When additional activity is required, providers often need to turn to locum agencies to provide much more costly alternatives to their own staff. Social Care It is estimated that 14000 people may be stuck in hospital at any one time unable to be discharged from hospital due to inadequate provision of social care and there are many hundreds thousand of elderly living in the community in unsafe conditions awaiting assessment for placements. There have been many opportunities to reform social care, but it has been afforded a low priority by successive governments, but this seems very short sighted as poor social care for the elderly leads to increased hospital admissions as well as delays in discharging patients and reduction in available bed capacity. The population is ageing but as a society we don’t seem to be planning for this. Conclusions Only time will tell if the planned reformation to the NHS structure will lead to a more efficient NHS and provide better value for the taxpayer. Already there are signs through the presence of private companies as ICS board members and reduced preferentiality to NHS providers that this may not to be the case.