It’s worth reading the article by Health Correspondent Nick Triggle on the BBC News website (see here.) It is indeed worrying for the service that demand is now at an all-time high, these examples being quoted by Triggle:
- Nearly 23m people visited A&E in the 12 months to March 2016 – a rise of more than 500,000 from the previous year.
- More than 2m patients visited an A&E in March, the single highest monthly figure on record
- Delays discharging patients reached record levels with nearly 170,000 days of delays experienced by patients unable to leave because of a lack of support available in the community
- Ambulances only responded to two in three of the most serious calls – Red 1 – in the target time of eight minutes, the 10th month in a row the target has been missed
- The number of patients undergoing routine operations jumped by 4% year-on-year, but by March 8.5% of patients on the waiting list had been waiting for more than 18 weeks, the worst level since record-keeping began in 2012.
All the more justification for governments and critics to cane the service, which as free marketeers would point out is asking for trouble by being free at the point of entry – yet no party would ever dare include in its manifesto compulsory charges or healthcare insurance since it is a sure vote loser. We Brits love our NHS, and it is still envy of much of the world – not least America where even the insured middle classes can easily find themselves bankrupted by a serious illness in the family.
So why are we using more expensive hospital services more than ever? Many answers, of which here are a few commonly discussed and have at least a nugget of truth:
- Failure of primary care to offer acceptable alternatives to A&E trusted by the community, and A&E’s inability to turn non-emergency cases away.
- Treatments now available for conditions that at one time would be dealt with locally or not at all.
- Increased likelihood of GPs referring patients rather than risk potential legal action if they diagnose incorrectly.
- Migrant demographic changing service utilisation (eg. increase in birth rate from Eastern European immigration.)
- We are more demanding customers, wanting the best available treatments.
There may be many more, but what seems patently obvious is that Acute Trusts are locked in a pincer movement: government has changed the priority of service so financial stability and break even outstrip patient care, which means there is less money to commission patient treatments; and growing resource shortages and unfilled posts, meaning all flexibility within the service to meet the peaks and troughs of demand have been reduced. Guess what? Mr Hunt’s insistence on 7-day shifts will ration resources even further, with no sign of additional doctors and nurses to meet that shortfall – and it looks like bringing them from other countries will soon be even more difficult.
Worse than that, hospital performance is still measured in terms of waiting times and (to a lesser degree) outcomes, yet nobody foresaw the vast increase in demand, resulting in hospital waiting lists being swamped far in excess of their ability to cope, while fines are applied by commissioners if they fail to treat patients quickly enough. Wards often lose a stack of money, and can often not be resourced, so they are closed to save money – but have to be reopened to meet bed shortages.
Yes, NHS England has provided some additional funding to reduce waiting lists, but they also demand constant flows of information to demonstrate that this is not just a subsidy into the money pit. Trust me here, it’s not easy running a hospital these days. Simon Stevens, NHS Chief Executive, put together a plan which included £22bn of “efficiency savings” to justify £8bn of extra funding, plus significant changes to provide a full range of services at primary care level, better integration with social care, ramping up mental health provision and increasing the emphasis on public health and prevention ahead of treatment – including integrated care between primary trauma services and A&E. Some A&E services are being merged, but the taboo of turning away or charging patients for emergency care has not yet been breached.
But ask voters and local MPs and they may say they agree to changes but will almost certainly oppose vigorously any reduction in care at their local hospital. Do we want our hospital services broken up and privatised? We sure as hell don’t! Not only that but the sums don’t add up. For one thing, all the low-hanging fruit has gone, and the major efficiency improvements will demand investment in equipment, pathway processes and people. Consider this: government plans to appoint 5,000 new GPs, but where are they coming from? There are not additional doctors being trained, so the more GPs you appoint the more are taken away from Acute specialties – or filched from their native countries, though the reality is that government is struggling to cope with the attrition rate of disaffected GPs retiring or leaving to work elsewhere.
The bottom line is simple enough – we have choices, not all of which are mutually exclusive. Here is a small selection, though I may expand on this list in future articles:
- Write off the deficits, return to a system where money was allocated according to need, and increase funding to the European average. In 2009 we spent 8.8% of GDP on healthcare, where EU-14 stood at 10.1%. The Kings Fund predicts that by 2020/21 the UK shortfall will be £16bn. Ask voters and they would undoubtedly support an increased proportion of spending on healthcare, linked to the cost index of healthcare services to invest in improved facilities and staff training.
- Remove governance from Westminster and eliminate the failed artificial internal market for services and support more schemes like “Devo Manc” – to provide effective management of support to each local healthcare economy (see here.)
- Break the taboo and introduce compulsory healthcare insurance to supplement the NHS – though that is the surest vote loser. Don’t consider it impossible though, bearing in mind the 2011 Health and Social Care Act was not included in any party manifesto. You could easily find the next government introducing changes you certainly did not request.
- As Stevens says, we can change our national libertarian culture and do something to address the underlying causes of many conditions. Government is dipping toes in charging for alcohol by unit, and has long campaigned against tobacco, but is treading warily around obesity for fear of provoking opposition. A tax on fizzy drinks barely scratches the surface, but tackling the food industry head on is not deemed a vote-winner.
- Take an aggressive stance to refuse non-emergency treatments, regardless of reactions.
Whatever happens, our misty-eyed view of the NHS is going to change, no matter who governs us. Watch this space…