Doctors’ disorders: Britain’s overwhelmed health service

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Hello and welcome to the Intelligence from the Economist in London. I'm John Fassman. Every weekday we provide a fresh perspective on the events shaping your world. Germany and Poland are neighbors, trading partners and vital strategic allies of Ukraine. But a Polish official recently accused Germany of trying to turn his country into a vassal state. The latest dust up in an increasingly fractious relationship. And the United States army is missing its recruitment targets, in part because so many potential soldiers are overweight. But a new program aims to slim them down. It's proving popular and appears pretty successful. First up though.

I've been asked to tell you just a little about this new plan for better health.

Britain's National Health Service opened its doors almost 75 years ago, which will provide.

The best medical advice and treatment for everyone, every man, woman and child in this country.

It was revolutionary, offering care that was free at point of need for all citizens, paid for by their taxes.

There'll be no charge for treatment. The National Health Service will include family doctors whom you can choose for yourself.

It's long been the pride of the country, with near universal public support. But the NHS is in crisis today. Around 20,000ambulance staff are on strike over pay and staffing. Nurses have been striking too. Right in the middle of a winter twindemic of flu and Covid. Then there's the 7 million patients waiting for operations. More than ever. The National Health Service has long missed its wait time targets, but the situation has worsened considerably in recent weeks. This includes delays in ambulance response times, treatment in hospitals and discharge to care. An association of doctors, the Royal College of Emergency Medicine, estimates that the chaos is leading to 300 to 500 additional deaths per week. It's a number the British Prime Minister Rishi Sunak disputes.

Well, I think first thing to say is when it comes to numbers like that, the NHS themselves have said that they don't recognize those Numbers and would be careful about banding them around. But look, I think what matters.

So who's right? Well, we've taken a deep dive into the figures at the Economist, and here to talk me through them is our data correspondent, James Francham. Hi, James.

Hi, John.

So, are death rates higher than average for this time of year?

Yes, they clearly are. Excess mortality in England and Wales, which is basically a measure of deaths from all causes. Compared to a baseline period, that number in the four weeks to December 30th is about 16% higher than the average of the same four weeks between 2015 and 2019. If you adjust to the demographic changes, which is basically the aging of population in that time, the number falls to about 12%, but that's still about 5,000 additional deaths for this time of year.

And is the chaos in the NHS the cause, do you think?

The data point to that. However, the question is how much it's playing a part. And the number put out by the Royal College of Emergency Medicine can be checked because the NHS provide a treasure trove of data. And what we've done is to build a statistical model using hospital level data on patient deaths and AE wait times for about 120 NHS trusts that publish data between 2018 and July 2022. We also find, like the RCEM, that hospital wait times are associated with higher mortality, as you'd probably expect, but particularly so trolley waits, which is when patients have come into AE as emergency and they're left waiting to be transferred from AE to a ward in the hospital.

So that's up to July 2022, which is before the winter crisis we're going through now. Do we know how high it may have got since?

Yeah, we can't account for mortality since then, but we can account for wait times. And so we have data for wait times through to November. They have increased since. And what our model suggests is that there are Perhaps an additional 5,500 NHS associated deaths that have occurred in that time between August and November. Compared to a scenario where wait times remained at 2019 levels, that number 5,500 is about 325 per week. And that number, 5,500, amounts to about 325 additional deaths per week and corroborates the ballpark figure from the Royal College of Emergency Medicine overall, linking that to the higher excess mortality that we're seeing now nationwide. That accounts for about one third of the excess deaths that had been observed across England over that same period.

So, James, it sounds to me like the crisis is causing more People to die. Is that a fair conclusion to draw?

Absolutely fair.

So the crisis, according to the Economist data team, looks to be causing thousands more deaths. And while the most visible signs of the problems in the NHS are the long waits at accidents in emergency departments, there are other big factors in play. Among them are pressures on General Practitioners, or GPs, local doctors with surgeries who practice in the community. These gatekeepers to the NHS are conventionally the first port of call when a person feels unwell. And if things go wrong here, it can have huge knock on effects.

So we know that gps are under incredible pressure at the moment. They're getting a lot of the demand that we're seeing on the health service.

Georgia Banjo writes about Britain for the Economist.

So I decided to go to Mountain Ash, which is a really poor town in the Welsh valleys, to try and see for myself what was going on.

Just giving you an idea of the morning. 15, 16 was a gap there. 17, 18, 19, it'll be about 20. I think in the end, possibly there may be another couple.

So there I met Dr. Camilla Hawthorne, he who's a salaried GP at the surgery, and she's also recently become the new chair of the Royal College of General Practitioners. So she was able to give me the insight of both a doctor and someone who's working on the political front as well.

But this essentially has got all our patient records on the computer.

So she started by showing me what was on her computer and that showed what a typical day for her encore colleague looked like and the appointments she had for the day.

So there's a couple of urgent extras, somebody with a bad stomach and pain, somebody with depression. Here comes one born 2013, a child, white spots in throat, high temperature. Could it be Strapp A?

And it really did seem relentless. Patients have 10 minute appointments and they were all there back to back.

So you'll see as the day progresses that this list just gets longer and longer and longer. And there have been days when she's had 57, 60 people on her list. You know, it's just unbelievably busy.

And I hung around as Camilla, placed phone calls, went out on house visits and saw lots and lots of patients.

Hello, hello, it's Dr. Horsthorne.

Hello, Doctor.

Hello. Glenconnen Surgery, good morning. So the blood tests that have come back are mostly okay.

So lots and lots of patients. What impact is this is the crowding of GPs having on the NHS?

So we know that general practice is being overwhelmed by demand from other parts of the health service. But what we are also seeing at the same time is that when they're overwhelmed, they're turning millions of people away. And this means that those people have a choice to make. Do they stay at home and try and take care of things themselves, or do they try and seek other medical help? So there's a few polls which show that around one in five people who can't see their GP are turning up at accident and emergency departments. A few of them will be calling ambulances. And what this is doing is really further overwhelming emergency departments and hospitals at a time of real, real severe need. And then for those people who stay at home, for many of them that will be okay. But for those who have more serious conditions, if they're not treated, they'll get worse and worse and eventually they're going to need more urgent treatment in the future. And what we're also seeing is that as it gets harder and harder to see your gp, satisfaction with them is falling. There's an annual survey which looks at satisfaction in the NHS, and satisfaction with GPs has plummeted from 68% in 2019 to 38% in 2021.

Are people right to be dissatisfied, do you think?

I think partly they are, because there's a few things going on here. At the start of the pandemic, most surgeries closed their doors, really, on the advice of the government. But I think a lot of GPs now would admit that was a mistake. It gave the impression that they weren't available at a time of incredible need, and I think that stuck with a lot of people. And then the other aspect is that, compared to the average Brit, GPs get paid a lot of money, on average. Unlike hospitals, general practice is a business. That means that gps, in most instances own their practices and then they're independently contracted by the NHS to provide services. So the average GP partner earns around 144,000 pounds in England, which is a lot of money. So there is still the criticism that a lot of GPs are well paid and work part time and that they haven't always been there when people need them. But I've thought about this quite a lot since I visited the surgery, and I think that's quite unfair. I think GPs have an enormous workload which is increasing at the moment, so they're facing these enormous stresses, they're still working very hard and facing these increasingly large numbers of very frustrated patients.

What sort of patient numbers are we talking about here?

So I spoke with another doctor at the Mountain Ash Surgery. His name is Dr. Ahmed, and he told me that on One afternoon in December, he had 42 appointments with patients. That's a lot higher than the British Medical Association's recommendation, which is of 25 patients per day for a safe workload.

Well, imagine on the day when we are seeing 60 patients, if you say, right, we're only going to see 25, everybody else go to A and E, then what will happen?

The sheer stress of dealing with so many people who need his help really gets to Dr. Ahmed, because you're dreading.

The number of patients you're going to be seeing and are you going to make a mistake? Are you going to miss something? Because if you have 60 patients and you give each patient 10 minutes, there's not enough time to see the number of patients, the queries, the prescriptions, the blood results. It's not enough time to do that.

So this sort of workload is not uncommon for GPs. I've heard various reports of doctors seeing 90 patients in a day, even 100, and you have to imagine that each patient needs a 10 minute slot. So, as a journalist, I can't even begin to imagine doing 90 interviews. I mean, it's really quite overwhelming.

Why are GPS facing such high workloads?

So I think partly this is because we have a big shortage of GPS here in the UK. England was missing the equivalent of 4,4200 full time GPS in 2022, and that number is projected to double by 2030 if all things stay the same. And so a lot of them are retiring, they're moving abroad to places which offer a better work life balance, like New Zealand. And the rest are just steadily reducing their hours. So what we're seeing is that a lot of GPs are deciding to quit, and this seems to be because the job is a lot different than it was before. So being a GP was always incredibly tough. You had a lot of pressures, a lot of responsibility. But now GPs are also dealing with a lot more patients with chronic conditions and they're having less contact with patients they know. So it's a very different job, it's become more impersonal, there's more bureaucracy and we know that this is affecting the kind of satisfaction doctors too are having.

With their jobs and also, as you said, contributing to this ongoing crisis in the nhs.

So we know that hospitals are struggling a lot, but Whereas there are 9% more consultants and 15% more junior doctors than there were in 2019, there are 2% fewer fully trained GPs. And this is obviously a really big problem everywhere, but it seems to be particularly an issue in poorer places, places like Mountain Ash, which have lower numbers of gps, but also a lower standard of education. So it's harder for patients to treat themselves. This was shown to me, I think, really vividly by a story that Dr. Akman told me when I was visiting them.

One example, I'd give you a really horrible example. We had a patient two, three months ago who had actually rung in with complaints that she went for a walk and part of her breast fell off. And I'm thinking, what, you know, it doesn't register. Brought her in. She had cancer at the breast. The tumour had become so fungating and dead tissue that she had let it go for years and years and not realizing and not wanting to seek help. So there's lack of education and.

So, Georgia, what's the solution?

I think, John, it's really difficult to kind of find a solution right now. I think right now the most important thing is to try and recruit and retain GPs, and Britain's trying to do that in some ways. The government's funding training for more new gps than ever, but at the same time, it seems to have dropped its commitment to have 6,000 new GPS by 2024. And that's, I think, because a lot of them are leaving. But I think it's really difficult in the long term because for the partner model to be sustainable, we need to have people willing to take on the responsibility to run practices. If not, some people are talking about switching to a different model where GPs become salaried employees of the NHS. I think that would be very difficult to do. But we need to be talking about different solutions and longer term solutions to this crisis, because at the moment, gps, overwhelmed as they are, they're incredibly overworked, they're incredibly. They're very stressed and mistakes are going to happen and people are going to be missed out and that's going to drive more people away from general practice, more people into an overwhelmed nhs. And that's not good for any of us at the moment.

Which one is acceptable to the government? Is it okay if I cut corners or do they want me to work myself to the grave? That's what we need to ask, isn't it?

All right, Georgia, thank you so much for your time today.

Thanks so much, John.

In November, when Ukraine was fending off a Russian missile strike, a stray Ukrainian defense rocket fell in neighboring Poland. Germany's leader, Olaf Scholz, was quick to offer Poland a sophisticated Patriot missile shield for its protection. At first, the Polish government welcomed the offer, but then rejected it. Only after a week long delay did Poland allow the system to be deployed. Germany and Poland are among the most important members of the pro Ukraine Western alliance. But this episode exemplifies the relationship between the two countries, which is uneasy and getting worse.

Poland and Germany should be happy neighbors.

Max Rodenbeck is our Berlin bureau chief.

The trade between them is worth more than $150 billion a year, and it's been growing very, very quickly. They have really close family ties between the two countries. They're both members of the European Union and of NATO. And crucially, right now, in the face of Russia's war, they're two of Ukraine's most vital allies. But unfortunately, there's a growing degree of ambivalence or even hostility in Poland towards Germany.

Tell us about that animosity. How does it manifest itself?

Well, for example, I mean, you know, on the 3rd of January, we had a deputy Foreign minister of Poland, Arkadyz Mularczyk, who made some extraordinarily harsh comments about Germany. He called Germany disrespectful to Poland and unfriendly and accused Germany of trying to turn Poland into a vassal state. He also called on the United nations to intervene to support Poland's claim for reparations against Germany. These are reparations that date to World War II. But the ruling party in Poland, the Law and Justice Party, puts the sum at a colossal 1.3 trillion euros, which is about 20 years of German defense expenditure. And in October, Poland formally presented this demand to Berlin. And until now, the German response has been just no, basically. But the leader of the ruling party in Poland, Jaroslaw Kaczynski, who's the kind of hard guy in the Polish regime, his rhetoric against Germany has been really harsh. He claimed that Germany's agenda is to turn the European Union into a Fourth Reich controlled by Germany. That was a statement he made more than a year ago. But even after the Russian invasion of Ukraine, when Poland and Germany have been acting as crucial war allies, Mr. Kaczynski was still suggesting, this is in August, that Berlin is colluding with Moscow in order to enslave Poland.

So there's lots of incendiary language there from Poland's leaders. But on that point about war reparations, there's clearly a dark history between these two countries, right?

Absolutely, yes. And no one disputes the monstrosity of Nazi war crimes in Poland. Poland was devastated. Six million of its citizens were killed during World War II. The country was ruined. Its capital city was razed to the ground. It's appalling. Poland says that it has never been properly compensated for any of this. And it also says that any of the deals made with Germany during the Cold War, when Poland was under the control of the Soviet Union, don't count. But from the German perspective, what the Germans say is that, look, these things happened eight decades ago. That's three generations back. And in the interim, Germany actually ceded huge territories to Poland. After the war, it signed deals with various different Polish governments to close the books. So from the German perspective, the timing of this Polish campaign really raised questions. The campaign doesn't just include the reparations. It's a kind of general hostility. So the Germans ask, well, why now? That's what they want to know.

So what do you think? Why now? If this is not about war reparations, what is it really about?

Well, really, one doesn't want to dismiss Poland's demand for reparations, but really the question for why now? It's about Poland's internal politics. Opinion polls show that there's been a slide in support for the ruling coalition, and strains have also grown inside the coalition since it won a second term in 2019. There's some micro parties on the far right in Poland that are whining that their far bigger ally, the Law and Justice Party, is failing to stand up against what they describe as bullying from the European Union. And with elections coming in Poland in the autumn, the Law and Justice Party is keen to rally its base and hold its alliance together. So it feels the need to be slightly extreme.

So in this situation, is Germany entirely the innocent victim of Polish domestic politics, do you think?

No. Germany has also attracted blame to itself, and not just because it has failed to pay Poland quite the same respect for the damage caused in World War II that Germany has shown to, for example, Israel or France. Germany has paid tens of billions in reparations, for example, to Holocaust survivors. But that's not the only reason. Despite being Europe's richest economy, Germany was very slow to react to the war in Ukraine, much slower than Poland, which was very quick to react and reacted very strongly. And Germany is now the continent's biggest contributor to the war effort. But it just took a long time. And during that interim, many people in Poland and across Eastern Europe blamed Germany for being slow to step up to the plate. And Mr. Kaczynski, the law and justice leader, is not the only leader in Eastern Europe to wag a finger at Germany and say, we told you so. You trusted Putin for too long. Germany allowed itself to become dependent on Russian energy, and its companies got deeply engaged in Russia. But many commentators now say that it's ironic that Mr. Kaczynski is flaunting this kind of moral superiority over Germany, when actually Germany has admitted that it was wrong for years over Russia. And at present, Germany and Poland are probably closer together in policy than ever before. They've really converged because of the war. And the fact is that despite its heroic response to the war in Ukraine, it's actually Poland that's making trouble for the broader Western alliance right now.

Tell us about that. What sort of trouble?

Poland. Because of its own history with Russia, Poles have been among Ukraine's most ardent supporters. So it's not a question of Polish support for Ukraine. It's a matter of sort of playing on the team, so to speak. You know, when Germany, for example, found that a lot of the weapons that it gives to Ukraine are breaking down, they get used so heavily on the war front that they need constant repair. Germany asked Poland if it could set up a sort of repair yard in Poland, and Poland was very hesitant about this. In the end, the Germans had to turn to neighboring Slovakia, which is not as convenient, but it's okay. And the Germans have set up this very important repair center there instead of Poland. And recently in November, when a Ukrainian rocket fell in Poland and killed two farmers by mistake, the Germans responded by offering Patriot air defense missiles to Poland. And the Polish government first said yes. Then Mr. Kaczynski from Law and justice intervened. He said that the Germans operating these Patriot air defense systems would be too scared to shoot at Russian aircraft. And this is certainly a kind of insult, actually. And it took a week of muddle before finally the poll said, okay, okay, we'll let this go ahead. So it's this kind of irritant behavior, rather than full fledged opposition to any German participation that is causing trouble.

And what about the Polish public? Do you think they share their government's dim view of Germany?

Well, the drumbeat of anti German stuff coming from the government and the coalition, which is echoed very sort of gleefully by state controlled broadcasters, it's definitely influenced Polish public opinion. There's an annual barometer of Polish sentiment done by a group of academic institutions that last year for the first time showed that more than half of polls say that relations with Germany are not good. 35% of them describe relations with Germany as downright bad. That's the first time in more than 20 years. But the sense that Germany owes Poland for World War II and that it has been weak on Ukraine is quite widespread in Poland. And this means that even Polish opposition parties who find it slightly cringeworthy how people like Mr. Kaczyski can be actually rude and insulting to their neighbor, still find it difficult to criticize the reparations demand. But you know, some people in the Polish government have tried to repair things. For example, in December, Andrzej Duda, who's Poland's president, that's a rather titular role and he doesn't have very many powers, and he's a former member of the ruling party who often acts as a good cop. To soften the bluntness of Mr. Kaczynski, Mr. Duda, the President of Poland, paid a cordial visit to Berlin to his German counterpart, Frank Walter Steinmeier. This was to kind of soothe things and make things look as if they're all on course. But it will take more than diplomatic niceties, which have been dismissed by Poland's Deputy Foreign Minister, Arkadyez Mularchika's fairy tales, to fix the current message.

All right, Max, thanks very much for your time today.

Thank you.

America's army is starved for recruits. One of the reasons is that millions of Americans are obese and they're just too fat to join up.

Rebecca Jackson writes about America for the Economist.

When I say star for recruits, I mean that they miss their target by a lot. In July, they kicked off this new course that was basically army fat camp.

My name is Michael and I'm 22. And when I was in high school, I became homeless. I was homeless for like a year or two. And all my life I've been told I was gonna be big and I was gonna be fat. It's cause I was big boned.

Michael Davy told me that he always wanted to be in the armed forces. He didn't really care about which branch, and he was certainly smart enough to get in, but it was his weight that precluded him. And being homeless certainly didn't make things easier.

I went and I talked to my recruiter and I said, I'm not really worried about the asvab. I'm sure I'll be fine on that. But I am really worried about my weight. I was like mid to high, 260s, 270 almost.

It turned out to be Michael's lucky day. He went into a recruitment office and found that there was a brand new program that had literally just kicked off that he was eligible for. It's called the Future Soldier Preparatory Course. And the idea is it's a two pronged scheme for kids who either couldn't make it academically into the army or were a little too overweight to make the fitness cut.

March.

You march.

This year, the army actually only recruited 75% of the number of soldiers that it aimed for. And that's kind of a problem because to begin with, only 23% of 17 to 24 year olds are eligible to serve. And you can imagine that only a fraction of those want to. But it turns out that if you're on the fitness track, which is the track that helps people lose weight, then you have to be pretty stellar academically. The prep course is pretty comprehensive. They're not just doing 6am workouts, but they're also taking courses. They take courses on nutrition so that they actually understand what they're eating. They talk about meditation. They take courses on sleep so that they can sleep better, because that's been shown to be a critical part of being healthy. The army has a system where they tape you twice in one year. And what taping means is that they literally take tape and put it around your waist and your neck to measure how many inches you are. If you're too overweight two times in one year, you can actually be permanently dismissed from the military. So the course is really incentivized to make sure these kids develop good habits and they're not just trying to get them to slim down as fast as possible. But it's not just about wellness and resilience. They're also doing plenty of push ups.

Since the program started, right? It's like floodgates, like everybody wants in.

That's Senior Drill Sergeant Tyler Brooks. He leads the recruits through workouts every morning. The drill sergeants want the recruits to lose weight for good. They really try not to fat shame them in the process.

It's like a golden ticket to them. They're here to lose weight. I haven't seen anybody, you know, walk around with their heads down. They're motivated. They keep their heads up. We're not here to destroy them, right? We're here to build them up, right? Lose that body weight and get them to basic training. So it's just when they get the tape every Thursday, when one of them doesn't tape out that day, you know, that's where you see a little bit of like, maybe dragging their feet a little bit. Like, I didn't make it this week, my battle buddy's gonna leave. You know, I have battle buddies that want to stay and help their battle buddies, you know, like, hey, can I stay in the program, help my battle buddy out and then we'll leave together. Unfortunately, it's not the way it works.

In order to actually be eligible for the course, recruits can only be up to 6% above their weight threshold. And that's a threshold determined by their age, their gender and their height. For example, to join the army, a 20 year old man who's 5 foot 10 has to weigh under 180 pounds. To continue on to basic, trainees have to shed the extra pounds within just 84 days. You might think that's really challenging. So far, 850 recruits have passed through the program and none has missed their target. While the military enlists many more middle class soldiers than it did, say half a century ago, one officer told me that the recruits on this course tend to be more destitute. Research has shown that children from poorer households tend to be heavier. And this program is kind of a glimpse into the old school American dream. Down and out teens are offered a chance at good benefits and a good career. And if they serve 20 years, they even get a lifetime pension. Michael, the recruit you heard from earlier, has good reason to join up. His father lives in a halfway house and can barely walk because he's so overweight. Michael hopes that one day he can put his father as a dependent on his military health care plan. Throughout the program, Michael would write to himself and the people he loved for motivation. He wrote these letters and he actually read one out to me.

I don't know if I'll pass the future socials program, but I will still lead a much better and happier life because of this program. When I look at myself in the mirror for one of the first times in my life, I can finally and truly feel like I love and trust the person standing in the mirror. So thank you for taking every step you can every day, no matter what, because I know you are enough. We took a fears class and that was one of my fears is that no matter what I do, I'd never be enough. But I know because of this program that I am and will be enough.

Michael did tape out. He's gonna be shipped out for basic training in mid January. Though the army is facing a recruiting crisis, the problem isn't exactly new. Americans have been fat for a long time. But in the last 60 years, the childhood obesity rate has actually quadrupled. And most states have gutted physical education in public schools. That means that many high schoolers aren't even required to take a PE class. And the pandemic where everyone kind of ended up slumping on their couch, only made things worse. The army plans to expand this course. They hope to get in more overweight recruits and whip them into shape for basic training. In fact, they kind of need to, because as more Americans become obese, the chasm between what the army needs and what Americans can supply is only widening.

That's all for this episode of the Intelligence. Let us know what you think of the show. You can get in touch@podcastseconomist.com and you can subscribe to the economist@economist.com intelligenceoffer the link is in the show Notes. We'll see you back here tomorrow.

Sa.