Once again, the NHS is making headlines for all the wrong reasons. You’ll have seen that non-urgent operations and clinics are being postponed to cope with what is being described as “the winter crisis”.
What is indisputable is that capacity in hospitals is at breaking point; many are operating at close to 100 per cent bed occupancy, which means that patients are being discharged sooner than they should be in order to create beds for the acutely ill who need admission, acutely ill patients are having to wait in corridors and ambulances waiting for beds to become available and medical and nursing staff are working under increasing pressure to stop the spinning plates from crashing to the floor.
The media has suggested that the some of the causes of this crisis are as follows: winter viruses, inefficiency, drunks, GP appointments being unavailable, immigrants and lazy staff to name a few. However the fact that there has been chronic underfunding over the last seven years seems not to have been addressed too widely as a cause for the current problems.
The issues can be explained by looking at things in terms of simple supply and demand. There is a finite amount of capacity in the NHS and demand is currently outstripping supply. This is not a new thing: winters have always put a strain on the service but for the last few years, winters have been fraught with increasing demand. Ways of reducing demand have been explored – for example by campaigns to encourage people to self-manage minor illness, ask pharmacists for advice or use GPs instead of going to A&E.
All of these seem to be sensible moves and a lot of effort has been put into them. However this makes the convenient assumption that the problems are all due to inappropriate use of hospital services and that by reducing demand, supply would be adequate. It is not in doubt that there are a number of inappropriate presentations to hospital but the patients who are stuck on gurneys are all patients who need to be in hospital and can’t be treated in the community.
It is also much less costly to do things to try to reduce demand than to increase supply. One obvious intervention to reduce demand on hospitals would have been to increase provision of GP services – yet what has happened in reality is that primary care services have been decimated and are struggling more than ever to accommodate the demand on their services.
What about supply? Although the Health Secretary is very proud to claim that he has increased the numbers of doctors and nurses being trained, the reality is that there are big holes in both the medical and nursing workforces. Those that can are choosing to retire early, other people are leaving to work in other countries or are leaving healthcare altogether. The removal of the nursing bursary and the after-effects of the morale-sapping junior doctors’ dispute are coming home to roost. All of this means that remaining staff in hospitals are struggling to provide safe and effective care, leading to increasing levels of sickness and absence and a greater dependence on bank and locum staff, potentially impacting on patient safety.
Because of this and the persistent drip-feeding of negative stories in the news, staff feel undervalued and as a result the goodwill and extra time and effort that has propped up the NHS for years is ebbing away.
Staffing is not the only issue though. Beds are full; there isn’t the physical room for patients to be admitted to wards. Wards have been closed over the years to help hospital trusts to stay in the black, reducing capacity while demand has increased. Provision in the community for patients who are medically fit for discharge has been lacking, leading to the situation known as “bed-blocking”.
Supply, in terms of staffing and beds, has slowly but surely decreased as demand has increased. This has not been a surprise to anyone who works in the NHS. You may remember that 55,000 junior doctors tried to make the point that there was not enough staff to provide a safe service. The new contract imposed by Jeremy Hunt has done nothing to solve the problem. Each of the last two or three winters has been similar yet little of any value has been done to deal with the structural problems that lead to this happening every winter.
As a result, emergency care in the English NHS is at breaking point and moves that compromise the care of non-acute patients so that staff can deal with the acute demand are being hastily imposed to paper over the gaping cracks in the service. These include cancelling operations and clinics (which will need to take place at some point down the line so supply is not really being increased, just reallocated temporarily) so that senior doctors and nurses can plug the gaps at the frontline caused by the issues discussed earlier.
There are also increasingly hare-brained ideas such as admitting adults onto children’s wards (I promise that this is not made up; it is being considered as a serious option in my own place of work).
How has this been allowed to happen? It is not the fault of patients, doctors, nurses, immigrants, drunks, Australian flu or hospital managers. It is entirely down to the Department of Health focusing so much on financial targets that the point of what we are trying to do is being lost. The health service is there for the patients who need it. We seem to be in a situation where the patients have become something of an expensive inconvenience who drain state resources.
I can only put this down to either incompetence or a deliberate strategy on the part of the Government to underfund the NHS to the point that it fails to provide a safe service in order to prove some kind of ideological point.
Demand needs to be managed but this will not change overnight. Supply needs urgent input to cope with current demand or else patients will suffer more and more. The public need to be aware that the main reason for the “winter crisis” is long-term under-resourcing of acute services more than anything else, and the Government need to be honest enough to admit this as well and do something about it.
Ravi Jayaram is a consultant paediatrician
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