A Tale Of Two Forests
The NHS mono-forest culture
After a week oscillating between insomnia for the first time in years, a migraine, creative bursts of writing, and then crashing for twelve hours at a time, I needed to go back to basics to straighten myself out. Ground. Nature. It was a cool February morning, the sun was making an appearance intermittently between the fast-moving clouds, but it was dry at last! So I set off to the forests that I’ve been staring at from my office window since I moved to these mountain lands. A dark, green shadow intersecting the horizon where the rare white-tailed eagle we were lucky to have seen a few times would fly towards, after finishing her swooping, her flying and her hunting for the day.
Dark and foreboding, but I wondered what the forest held inside - a potential for Autumn mushrooms, for foraging, a home for owls and other birds? As I waded through the rain-drenched muddy fields and over the bogs and open moorland, I reached the perimeter and stepped inside. At once I could tell this was a mono-crop plantation. Barcodes of identical, fragile evergreens crowded together in long, neat rows of tall mono-crop monotony.
Dead wood.
I pushed in further along the OS maps footpath as the immediate world around me started to take on a more eerie atmosphere, sparse and devoid of daylight. The occasional stream of sunbeam would dapple and find it’s way through, painting a hauntingly beautiful, unnatural picture.
And then the path was suddenly blocked as I approached a scene of destruction in front of me. The underworld, exposed and naked to the elements, acutely visible. I wondered whether this was the aftermath of one or more of the recent winter storms passing through the forest? Perhaps Debi, Jocelyn or Isha had wreaked this havoc. The exposed roots, shallow and thin, were unable to withstand the force of the gale winds that ripped through the heart of this forest.
Tree after tree was ripped and pulled from the ground, collapsing into its neighbour, pulling them down too. A mess of tangled deadwood, leaving scars and cavities in the Earth from where they once stood tall. Now roots and soil and mycelium particulates were half suspended in the air, severed from the ground. Some trees were still half standing, bent awkwardly with the weight of what they were trying to hold up around them. Unsupported, with no other organisms around to help, nothing to provide some much needed nutrition or a lifeline. Alone. I climbed and crawled through the ever smaller gaps getting further lost into this mess of fallen trees, branches, wondering if I would be trapped here. The official footpath had long disappeared under this destruction. Eventually I approached the centre where scores upon scores of fallen trees scarred the land, leaving a crater, a chasm in the heart of the forest.
These trees could not take it anymore. The stress of trying to survive and just get on with life in an unnatural, mono-crop world - devoid of rich ecosystem diversity, devoid of fertile soil, disconnected from other plants, animals, insects and fungi had pushed them to breaking point, to collapse.
This deadwood forest reminded me of what I feel is happening within the NHS. An apt analogy and metaphor for the crisis that has taken hold, particularly for its healthcare workers. As the NHS has grown ever larger, become ever more bureaucratic and politicised, the powers that be no longer see our unique characteristics, our different personalities and our sensitivities. Our human-differences as healthcare workers are suppressed in the NHS mono-forest. The different abilities we have to problem solve, some logically, some creatively. The different ways we work with each other and our patients in a mutually beneficial, symbiotic manner. Some workers, like some trees, are stronger and more resilient - natural born leaders who thrive in a high-pressured environment, sustaining and supporting other organisms. Some are scarred and battle wounded - having been dealt an unfair hand in life, but they are still compassionate, caring and dedicated team players.
In society today, our large public sector organisations like the NHS and our education system, have been reformed and reorganised with each new government, planted and treated more and more as though we are one large mono-crop plantation. Expendable, identical, just a cog in a large and ever more soul-less machine. As healthcare professionals, we often find ourselves navigating how to work within this demanding system that overlooks the fact we are not just cogs in a big machine. Not all the same trees in the forest. We are all unique individuals, with multifaceted lives and aspirations outside the clinic walls.
We have different interests, different financial situations, different family dynamics, different relationships, different personal health conditions, different mental health struggles and differently wired brains. We all carry a tapestry and a rich history of life experience within us, and yet we often try to deal with our own challenges alone, or suppress them entirely, whilst shouldering the sometimes enormous weight of our professional responsibilities.
All of us have other lives, other creative hats, other professional hats. Other identities. Some of us are mothers, fathers, carers, daughters, sons, sisters and brothers that need to put family first sometimes. Some of us are pet parents. Some of us are writers, painters, musicians, athletes, mountaineers, yogis, traders, property developers, tech wizards and everything else in between. Some of us are wealthy, some of us are struggling financially, some of us have help from our loved ones, some of us have no-one.
It’s the human in us. We are all unique but highly connected individuals. We respond to this vocation, this job, differently. We respond to night shifts differently, we respond to stress differently, we respond to trauma differently, we respond to the workload differently, we respond to death and family illness differently, we respond to parenthood differently.
As more and more trees fall, the scars and the gaps in the forest grow ever larger. Instead of looking into nature for creative solutions, and to realise the enormous potential that comes from ecosystem thinking, the powers above invest more into this mono-crop forest. However, this time, they will plant analogous trees that grow twice as fast, but at half the cost, the knowledge, the experience and the strength. The trees look similar, plugging the ever growing gaps of the falling, and fallen ones. Scapegoated by the government, attempting to prop an ever weakening system up. The mono-crop plantation buckles heavily under the strain of many fallen trees unable to take the strain anymore - the ever more intense storms rip through causing more destruction, more burnout. The nearby machines and loggers are waiting in the wings, ready to cut it down bit by bit, selling what’s left of the wood to the highest bidders, thinking only of quick profit, shareholders and short-term economic growth.
Ultimately though, the cost is to the wider ecosystem. Around the forest - the bird life, the fungi, the insects, the plants, the soil, the planet. Around the healthcare system, the cost is to the patients and to society as a whole. These are both systems now devoid of diversity, flexibility, interconnectedness, cooperation and collaboration. An unhealthy mono-system, not a thriving society and ecosystem.
Just like this planet and all its creatures deserve better than the anthropogenic nightmare we have created, the same goes for the large public sector organisations that were created for the benefit of all in our society - healthcare, education, government and the civil service, utilities and energy, transport. Those who dedicate themselves to work in these sectors, as well as the recipients - patients, children, the elderly, and all constituents, deserve better than what has been imposed upon them without much public consultation in the post-Thatcher Neoliberal era. They deserve far better than what is currently being offered, and what is being planned. With further exploitation, greater privatisation and ever more dismantling of our public sectors, the government is complicit in widening the inequality gap.
The healthcare sector needs an overhaul before it is quietly, ruthlessly, broken up under our very eyes to usher in a new dawn in this country. A two-tier healthcare system, where the privileged few access top doctors, the newest treatments and no waiting lists under a privatised system available through a rapidly growing private health insurance industry. Meanwhile, the rest of us including our mothers, fathers, grandparents, sons, daughters, aunts, uncles, dear friends, and sadly those who have no one, are left with an NHS oscillating between ‘not fit for purpose’ and at times downright dangerous.
An NHS that is chronically understaffed thanks to an impressive haemorrhage and brain drain of talented healthcare professionals. One in three medical students now plan to leave the NHS after two years, emigrating to other countries or leaving clinical medicine entirely. An NHS where seven out of ten GP trainees are currently burnt out and less than twenty percent feel confident about their future as a GP. An NHS that has lost the equivalent of 1,830 full-time GPs since 2015. An NHS that has more than 9000 doctor vacancies, and yet nearly 13000 doctors gave up their medical licence in 2022 alone. An NHS that would need an additional 50,000 doctors in England alone, simply to put us on an equivalent standard with today’s OECD EU average of 3.7 doctors per 1,000 people. These gaps are now being plugged in by the rapid expansion in training and funding going towards ‘non doctor’ roles (physician associates, apprentice physician associates) before rigorous piloting, auditing, consultation with patients and clinicians, and feedback has taken place. An NHS that is actively recruiting and exploiting ‘cheaper’ healthcare workers from other parts of the world where they are very much needed in their own healthcare systems, and where leaders in those systems have branded this a new form of colonialism.
These are the short-sighted ‘solutions’ that are being rushed through by the government. Rather than listening to what those who work on the frontline day in and day out have to say. Rather than acknowledging the deteriorating work conditions and pay. Rather than speaking to healthcare professionals. Rather than finding out what could be done to retain the medical students who have studied so hard, amassing tens of thousands of pounds of debt in the process. Rather than finding out what could be done to retain the workforce already in the system.
From the GPs who want to provide excellent holistic care as they were trained to do, to the nurses who have worked compassionately and tirelessly for years, to the highly specialist consultants who can treat your cancer or surgically remove the blood clot from a vessel in your brain, to the registrars who run the hospitals and manage a team of junior doctors, admitting and treating complex, often very unwell patients, to so many of the other allied health professionals - dieticians, psychologists and other therapists, physiotherapists, occupational therapists, healthcare assistants, speech and language therapists, mental health liaison workers, social workers, operating department practitioners, radiographers, pharmacists, paramedics, podiatrists and many more. Not forgetting the backbone that keeps the whole system functioning – the multitude of poorly paid ancillary workers who also risked their lives during the pandemic – the porters, the caterers, the cleaners and many, many others.
All these professionals who are now voting with their feet, for their sanity, wellbeing and sometimes to save their lives. Tragically, and far too frequently in what has been recognised as a silent emergency, they are unable to leave or get help, and die by suicide instead. In 2020, seventy-two healthcare workers ended their lives, more than one every week. In 2022, more than one nurse a day attempted to end their life. Charities like Doctors In Distress and the Laura Hyde Foundation are being set up by bereaved relatives every year, following their painful losses.
WHO’s European regional director, Hans Kluge, was recently asked in an interview where he questioned the UK’s employment of PAs, what he thought the number one crisis in the health system was. He was very clear that the single biggest issue world health systems face is the health workforce. He acknowledged that ongoing wars, infectious diseases and mental health are all contributors to a current state of ‘perma-crisis’ but that “the decline of the health workforce is the single biggest issue world health systems face. There is no health without a health workforce.” If you talk to doctors, nurses and allied healthcare professionals to find out what is really going on, you might get a better insight. Clue - pay is only one small tip of a very large iceberg despite what the media will tell you.
We all trained and worked in the world’s first universal healthcare system, and the values of the NHS - healthcare for everyone, free at the point of delivery and based on clinical need, not ability - run deep within us. As sad as it is for me to now write this - I am not totally naive, and I realise that part privatisation is here to stay. With current levels of health funding, the acute demands on the system are far too great to be able to provide the high-quality care we were trained to believe we could provide, resulting in a collective moral injury and record levels of burnout.
As a nation though, we were never consulted on what this privatised model would look like. There has been no public debate as to whether we want an ‘Americanised’ healthcare system, where medical debt is the reason for two thirds of bankruptcy cases and directly causes homelessness, and where people have to raise money through charitable crowdfunding platforms to treat their cancer. This is the direction we are headed towards, as the government hands £330m worth of contracts and all our medical data to American for-profit spyware company Palantir, whose other clients include the CIA and the US Department of Defence. The Good Law Project is challenging the government about this contract given that 417 of its 586 pages were redacted, including vitally important sections relating to data protection because they were still “subject to commercial negotiation”. Centene, another American insurance giant has already sold the sixty GP practices it only just bought in 2021, citing ‘unprofitability’.
Instead, if there had been public debate, both with the public and with clinicians, perhaps we could reasonably and sensibly discuss the hybrid model that is coming and have a say in shaping what this would look like. Perhaps we could move more towards an Australian healthcare system, where I worked for nearly three years in emergency medicine. A system whereby if you earn more than $97,000 (just over £50000), you are given the choice to opt to pay for private health insurance at a reasonable and affordable annual rate, thereby reducing demand on the public system, or you can choose to pay an increased medical tax (medicare levy surcharge) ranging from 1 to 1.5% of your income, that goes directly to the health system. Funding is maintained and the system is not ‘cheapened’. The government does not favour one system over the other, and strives to maintain the quality of the healthcare system. Australia also puts a big emphasis on disease prevention and health management so that emergency departments and public hospitals don't get overrun, believing that prevention is more cost-effective in the long term. Overall, the American healthcare system costs nearly double per person of the Australian system, but life expectancy remains lower in the US.
Australia is seizing the opportunity to strengthen and secure its workforce by actively recruiting UK trained healthcare professionals who feel completely let down by our system through targeted social media campaigns and billboards outside hospitals where doctors are striking. I receive emails from Australian recruiters most months reminding me how much more I am valued as a GP down under - about six times, if we look at pay alone, but there were so many other reasons I felt more valued working as a doctor in Australia.
Is there further short sightedness by the government by not including clinicians and the general public in the private/public healthcare debate? Given my values and my belief in universal healthcare, I for one, would not work for a privatised system if it were based on the American style model, which in my opinion widens the inequality gap. It would be interesting to survey our workforce to find out how many would actually want to work in a privatised system not of our making.
As I finally found my way out of the forest to the perimeters, I breathed a sigh of relief to have found the exit, the sky, the wide open moors and mountains. Ahead of me, I could see a small island of trees at the foothill of the mountain that I made a beeline for. A heterogeneous collection of gnarled, twisted oaks and silver birches, covered in velvet emerald-green moss, with ferns growing from their branches. Bright orange velvet shanks grew out from one of the trunks contrasting with the infinite greens in this forest. Pale green bearded man’s lichen, a natural antibacterial remedy used to treat wound infections, hung from the branches, as though this woodland were adorned with decorative tinsel. I stood in this ancient and natural woodland, feeling at peace compared to the forest I had nearly been trapped in. This very small island of protected rainforest was thriving.
The NHS has one of the largest workforces in the world. Like all healthy ecosystems, we must recognise its unique diversity and respect the caring staff who have dedicated so much to this vocation. If we continue to treat it like the mono-crop plantations that are void of life, of nature, of diversity - that collapse under the weight of weak foundations and poor government leadership, this too will happen to the NHS and its workforce. We are no longer able or willing to prop up the rest of the forest.
As Albert Einstein once said, “Look deep into nature, and then you will understand everything better.”
Nature’s healthy ecosystems are a combination of all their elements and relationships - the trees, water, soil, fungi, lichen, plants, insects, animals, the weather. A community of living organisms interacting with the non-living components of their environment. Interconnected in a complex system of nutrient cycles and energy flows. You can’t solve the climate crisis by only planting trees without thinking about the rest of the ecosystem. Similarly, you can’t just treat disease by focusing on only one organ or symptom. We need a more holistic approach - the mind is connected to the body, is connected to our spirit, is connected to community, and is connected to nature.
We urgently need a holistic and ecosystems-thinking approach to attempt to reverse some of the rampant damage that has been done deliberately to our healthcare system, and to society, in the last few decades. We need to reimagine and rebuild a different kind of healthcare system. We need to focus and prioritise incentivising well-being, prevention and lifestyle medicine. We need to rebuild communities and social care. We need to make health and well-being a core part of the education system. We have an opportunity to intervene and rebel from within. If enough of us organise, demand and vocalise, perhaps we can still have hope.