Saul Miller is a GP in Belford, Northumberland


So the NHS is in crisis. Again.

Lucy Letby was convicted on 18th August of murdering multiple neonates during a short nursing career that included well-documented attempts to raise the alarm.1 The BMA announced a joint strike by both junior doctors and consultants to take place on 20th September.2 The UK closure of large numbers of schools just prior to the start of a new school year due to revelations about the risks of collapse in buildings that contain structural elements made of reinforced autoclaved aerated concrete (RAAC) has led to concerns about hospitals.3 A new variant of Covid-19 has led to a sudden push for early vaccination of a large part of the population in the Autumn campaign (4). And obviously, this is just a selection determined by my availability bias – I have not mentioned crises around waiting lists or NHS staffing, for instance, though they too exist.5,6

Humour me here: I’m going to argue there is a thread that runs through all of these. It is the thread that is labelled expediency or short-termism.

Of course, it is never one thing alone. But I am saying that though the beads may look different, they’re all on this same thread.

Of course, it is never one thing alone. But I am saying that though the beads may look different, they’re all on this same thread.

The Lucy Letby conviction has already been noted to have strong echoes of the past in it.7 Of warnings having gone unheeded. Worse still, whistleblowers made to feel as though they were the problem by managers with more pressing priorities.7,8

Junior doctors and consultants have followed others – including nurses, physiotherapists, dieticians and ambulance workers – in striking during 2023. This speaks for the selfless commitment that so many made during the Covid-19 pandemic having not been followed up by addressing the reality of their working lives afterwards. The entire national response to the pandemic was an exercise in short-term planning, necessarily so unless you read the work of those like Nassim Taleb.9 This took us through the heart of the crisis but the push for the same level of productivity to help manage the subsequent backlog of ‘usual’ care has met with extreme dissatisfaction across the NHS.

The very point of RAAC use over so many years in so many public buildings in the UK was short-termist. That the safety concerns about its limited lifespan, already mostly exceeded, have only become a central concern now also appears to be a question of expediency – ignoring them is simply no longer deferable.10

Annual target versus bigger picture – the former always wins.

And Pirola, as the new variant of Omicron is being called: how have we ended up in yet another vaccination rush over 4 years on? We were due to have an autumn booster in any case, but the deal offered to primary care was so unsympathetic as to be unworkable for many practices. And so the deal has been revised but at the same time as a requirement to conduct the campaign with urgency.11

I personally have experience of having been bullied over an issue by a senior NHS manager. It was many years ago but I have no confidence the underlying culture that drove that behaviour has altered. This culture is focussed endlessly on in-year targets. The longer term planning the NHS needs cannot be sustained, even when tried.

I trace this back to the top. To the 5 year government election cycle, to politicians’ love of reorganisation and reform as a way of being seen to make a difference, and to blame being easier than review. It drives the culture all the way down.

Annual target versus bigger picture – the former always wins.


  1. (accessed 4.9.23)
  2. (accessed 4.9.23)
  3. 4.9.23)
  4. (accessed 4.9.23)
  5. 4.9.23)
  6. (accessed 4.9.23)
  7. (accessed 4.9.23)
  8. (accessed 4.9.23)
  9. Joseph Norman, Yaneer Bar-Yam, and Nassim Nicholas Taleb, Systemic risk of pandemic via novel pathogens – Coronavirus: A note, New England Complex Systems Institute (January 26, 2020).
  10. (accessed 4.9.23)
  11. (accessed 4.9.23)

Featured photo by Jonathan Ford on Unsplash

The British Journal of General Practice and BJGP Open are bringing research to clinical practice. BJGP Life is where we add the debate and opinion to help ensure everyone benefits from that research.

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