Political intervention is usually unhelpful and cross party working is needed
Over my 47 years, reorganisations, new systems, new contracts and new targets all came in different colours. But during my life as an A&E Consultant, I have witnessed a lot of 2nd World care. If anyone believes A&E is in a sudden crisis they need to appreciate it has never been resourced adequately. Through the 1980’s until recently, I have seen people neglected in corridors. Thirty years ago I recall a woman of 41, dying on a trolley in a corridor queue while completely unsupervised. Throughout the years I witnessed inhumane stacking of elderly people waiting for beds in drafty holding areas and, more recently, people who could not leave an ambulance waiting outside A&E as there was no physical space for them in the department. Meanwhile Chief Executives came and went on salaries that defied justification.
On a background of chronic underfunding, political interference has tended to make certain problems worse not better and demand has risen over time.
Many have called for the NHS and Social Care to be taken out of the political arena, and overseen by a cross party commission, in order to avoid political point scoring, and simplistic solutions. Let me describe one such example. When A&E targets were introduced by Labour in 2004, they did not come with any new resources. The backdrop was a mix of relentless increased demand, reduced acute bed capacity and woefully inadequate elderly services. But we identified all work that could be jettisoned to focus on achieving the goal, as failure involved penalties to already squeezed budgets. That meant many rapid review clinics in A&E disappeared, and patients were merely loaded into specialist clinics thereby, in turn, reducing these clinic’s capacity to see GP referrals. Or they were admitted to a bed, contributing to the burgeoning bed-block witnessed over the preceding years. Worst of all, A&E specialist expertise was trimmed to what could be done in 4 hours, rather than what could be done to sort out a problem and get a patient safely home. And the final whammy has been that A&E attendance increased by a massive 22% over the last 10 years.
Combine this with the fact that between 1987/8 and 2016/17, the total number of NHS hospital beds fell by an eye-watering 52%, from 299,364 to 142,568. The rise in day surgery, helped by key-hole surgery, and the change in mental health policy were the main drivers, but there were others. Not surprisingly we have seen a growing shortage of beds as acute demand has increased. In 2016/17, overnight general and acute bed occupancy averaged 90.3 per cent, and regularly exceeded 95% in the winter, well above the level many consider safe.
While the system has been played with, it is not so fundamentally different to pre-1948 years. So GPs have a confused role, somewhere between gate-keepers, chronic disease managers, and (just hanging on to) being family doctors. Their numbers and their workload mean they are harder to access. Hospitals are still in a separate silo, with competing acute versus elective care. The patients who can’t access their busy GPs tend to default to the creaking A&E service. Meanwhile social care is still dislocated from secondary care, and massively unavailable.
In addition to ill judged political interference, there has been a lack of joined up thinking and working resulting in waste, lack of clarity about how the component parts work together and inefficiency. Failing parts of the system have tended to increase costs for all other areas
The crumbling care system in England has cost the NHS £669 million over the last five years with hospitals forced to care for elderly patients who could otherwise be discharged. Analysis by Age UK concluded that over these five years the NHS lost 2.4 million bed days as a result of so-called “bed-blocking” because of a lack of care and support outside hospitals. Over the course of a year more than 680,000 elderly people treated by the NHS languish on wards for weeks, even though they are well enough to be looked after in a care home or at home with social services support. At the same time, cancelled operations have rocketed by almost a third since last year as hospitals ran out of beds.
One good thing has been the standardisation of treatments by the rise in clinical governance. Perhaps the best known example is the National Institute for Health and Care Excellence (NICE) which seeks the best outcomes for the best prices. And our drug procurement process is robust. We have resisted pressure from some EU suppliers and have imported alternatives from countries such as India. This gives me confidence that the Trump medicine fear-mongering is just that:- fear-mongering.
Improved public health is crucial as ever increasing demand is not sustainable
But despite all I have written about threats to the NHS, there is more. Lifestyle factors are a major determinant of health demand and the UK has a particular problem regarding our role as consumers. We have a couple of national foibles.
The first is highlighted by a study of the 36 OECD nations which shows that the UK’s alcohol consumption is now among the highest in developed countries. The research shows that adults in Britain are now consuming an average of 9.7 litres of pure alcohol a year, the equivalent of 108 bottles of wine annually. The figure amounts to an extra nine bottles of wine, or 35 pints of beer annually.
Separate figures show the number of pensioners starting treatment for alcohol problems has doubled in the past decade. Health campaigners said baby boomers who grew up in a “hedonistic culture” in the 60s and 70s were consuming far more than younger drinkers, and turning “a blind eye” to the potential health risks.
The second is that over the last decade obesity prevalence has doubled. Some 67% of men are either overweight (40%) or obese (27%). Meanwhile, 31% of women are overweight and a further 30% are obese. Professor Stephen Powis, NHS National Medical Director, said: “Obesity is a dangerous public health threat that is already leading to 13 types of cancer, heart attacks and strokes, with these figures bringing another stark reminder of the scale of the obesity crisis”. Research shows that 13 million adults are now classed as obese. Obesity is the most significant driver for new cases of type 2 diabetes, accounting for up to 85% of risk. As a result, record numbers are being treated for type 2 diabetes. It follows reports that the numbers being treated in hospital for obesity-related conditions have risen by nearly one quarter in a year.
Simon Stevens, the NHS chief executive, has warned that the “startling” trends could cut short thousands of lives. The number of obese adults in England has risen from 6.9 million in 1997 to around 13 million in 2017. The analysis, by Diabetes UK, warns that 29% of adults and 20% of children leaving primary school are obese.
As I write, over 10% of all NHS drug spending is devoted to treating diabetes, and the overall bill for all types of medication and devices to treat diabetes has reached more than £1 billion, representing a 68% increase in 10 years.
While there is widespread concern among the general public about funding for the health service, there is perhaps a lack of awareness that reducing demand through improved public health is crucial for the sustainability of the health service in the long term.
Yet many people are reluctant to engage with the facts and the risks. Ed Southgate reported in the Telegraph this week “Parents branded a primary school “disgraceful” after it gave Slimming World leaflets to children”. He went on to report ‘A mother-of-four emptied her five-year-old son’s homework bag last Friday to discover a booklet entitled Be Slim for Life showing before and after pictures of two weight-loss journeys. The 42-year-old mother, from Staffordshire, said it was “appalling” to allow the “inappropriate” material to go out to impressionable youngsters and said her eight-year-old son had since asked about his weight. She said: “There’s so much pressure on kids at the minute already. They are meant to conform to be stick-thin insects. Then they’re having this leaflet in their face saying ‘be slim for life’. If they’re not ‘slim for life’, does that mean they’re not accepted?” Tackling obesity will obviously be an uphill climb.
Lifestyle and diet may well play a part, but how money is spent is also crucial to the impact. System changes are necessary. In fact, our ‘gatekeeping’ primary care philosophy in perhaps the single-most barrier to achieving falls in cancer mortality rates. Cancer diagnoses used to be rare in A&E and are now common-place.
In conclusion, let’s not be simplistic in blaming the left or the right of our political spectrum for the present state of our NHS. It really is a lot more complicated. Those Facebook ditties and covert insults really don’t do the subject justice. Yes, we probably need to get to 8.5% of GDP as a minimum for Government NHS funding. And we certainly would benefit massively from a cross-party commission to lead the NHS and Social Care. But we need to decide where that money comes from, and how it is spent. These are not left or right issues, but ones that need balance, wisdom and rational thinking. But I think we also need to take a lot more responsibility for our own health.