This post was written by my regular correspondent “ARC”, who has several family members working in the NHS. – NS
I’ve been discussing the NHS A&E issue that’s been in the news of late with the medically knowledgeable and NHS-aware members of my family and thought you might be interested in their background information, so have written it up while the conversations are still fairly fresh in my mind. I summarise, then give my own thoughts at the end.
The immediate cause of the NHS A&E issue being such a story in the media at this time (other than the upcoming election, of course) is simply that at Christmas a great many staff take holidays. The resulting shortfall exposes long-term trends in an area under pressure. There is no other immediate cause, as distinct from long-term trends: these problems have been growing for 15 years and more as follows.
1) Flow-though is crucial to A&E: you must get people out the back-end of the process to maintain your rate of input to the front-end. However ever-increasing regulations mean a patient without family cannot be released until a boat-load of checks have been done. This is clogging up the back end. It may be preventing the release of a few who had better not be sent home yet (not much and not often, is the general suspicion) but it is definitely delaying hugely processing the release of all others who could be. All this admin takes time and effort – delaying release and also using up time of staff in non-health work – and costs money.
This effect needs to be understood in the context of the 15-years-older story of the destruction of many non-NHS nursing homes by galloping regulation. These homes were mostly owned and operated by senior ex-NHS nurses and provided low-grade post-operative care. The NHS relied on them as half-way houses to get patients out of NHS hospitals when they no longer needed intensive care but were not yet recovered enough to go home. These nurses did not want to spend time form-filling instead of caring for patients, and for each home there was always one of the 1000+ rules that was particularly hard for that given home to meet without vast expense or complication. So they died one by one. The ‘waiting times have increased’ story of Tony Blair’s early-2000 years – “If the NHS were a patient, she’d be on the critical list” – was caused by this and the resultant bed-blocking more than any other one cause.
A more recent context is over-regulation of local councils’ social services leading to declining throughput, unrealistic expectations for their visit times, etc., and there have also been some social services cuts by said councils. These also have an impact on a hospital’s ability to get people out of the back-end to free up beds for A&E incomers.
2) The new 111 service is sending many more patients to A&E.
2.1) The service’s advice is very risk averse. The people who set up the process were afraid of the consequences of the statistical 1-in-a-million time when anything other than mega-risk-averse advice would see some consequence that would become a major news story blaming them.
2.2) Thanks to the post-1997 reforms, GPs work less hours on-call but the doctors are not just slacking off and doing nothing. The huge growth in regulation means they are in effect putting in as many hours as before, but on form-filling and admin to provide all the info the NHS and other government demand, to ensure they tick every box, etc. The out-of-hours on-call time they used to have is now swallowed by this work. So they are not in fact working less; it is the balance of what they are working on that has changed: less on healthcare, more on admin. Thus 111 must send people to A&E, not an on-call GP (and, of course, fewer on-call GPs mean more people phone 111).
3) Regulation prevents fixing the problem as well as causing it. A Birmingham hospital (Queen Elizabeth in Edgebaston IIRC), said to be very efficient as such things go, tried to create a low-level care unit precisely to solve the problem. Because of the regulations, the attempt had to be abandoned – they just could not tick all the boxes.
4) Back in the early-80s, when my sister (a doctor) did her elective in A&E, she loved it. Now, doctors are avoiding A&E as a speciality because they know how brutal is the pressure there. So the problem is beginning to compound itself.
There is a great deal more one could say, but the above are what my informed relations see as the key immediately-relevant causes. So far my summary. Now some thoughts of my own.
What I observe has most changed in the last two decades in these either left-leaning or were-left-leaning people is firstly their belief that “No party can fix it”. (This I heard from a previously definitely-left individual who would probably still cut her hand off before it voted Tory and whose heart wavered between Labour and [Scots] Nats although her head despises Nats ideas and despairs of Labour.) There is an expectation that no likely government will do anything other than talk of reform while actually causing yet more regulation. Some of this in some of them might be a reluctance to think that the side of politics they’ve loved to hate in the past might be the place to look for an answer (I am reminded of Gore Vidal in 1979, “I feel the despair of coming to think that the Soviet Union may be as despicable as the U.S.” – quoted from memory) but it also reflects their opinion that the Tory-led coalition has failed to reverse any of the above trends, and this opinion I fear is not mere prejudice but has a basis in their experience of the last three years, just as much of the above reflects their experience of the last 15 years.
Secondly, they report a widespread belief within the health service that this time “a bit of money can’t fix it”. There is no expectation of an ocean of money (and – I sense – awareness that the NHS already consumes an ocean of money, so can hardly demand another ocean of money even as a righteous goal, however impossible to arrange).
Lastly, I know that behind all this inefficiency of regulation, there lurks a compounding problem of looming social trends. The number of patients who have no family ready to help is rising. The promise that the state will look after all has led more people to lead lives that make no other arrangements. But these long-term trends are not the reason the NHS operates much worse now than two or three decades ago.