It’s now a month since the general election, and it didn’t turn out as most people expected. But that doesn’t mean that the outcome for the NHS will be very different.
How many of the rash promises thrown like sweets at the electorate look likely to be realised? It didn’t seem worth reading the manifestos, or even the headline list of undertakings which the parties claimed they were ‘locked into’. They all had Houdini clauses to enable the parties to wriggle out of what look like cast-iron commitments. Even carving ‘An NHS with time to care’ in stone was never going to guarantee anything. A few – a very few – themes emerged from the war of words on the NHS.
- Labour promised us a world-class health service. Though beloved of managers, it’s a strange ambition, since the standard of health care world wide is nothing to aspire to. And, despite the NHS having fewer of everything (except patients), an independent assessment in 2014 of 11 western health services rated the NHS’s performance top in almost every respect.
- Jeremy Hunt promised that the Tories would “put GPs at the heart of a revolution in health care”. Turns out this means squeezing a seven-day week out of GPs who are already exhausted by five days of unachievable demands. Hunt spent the last parliament fomenting GPs’ demoralization, and the last month does not suggest he has realistic plans about rebuilding what he has done so much to damage.
- Everyone promised that patients will get an appointment today/at any time of day/night/every day of the year/NOW. It’s unrealistic. Oh, so it’s an aspiration? Just as well: it will take years to train the extra staff. Oh, and the promises are for patients who ‘need’ an appointment? Who will determine a patient’s ‘need’? In the consumer-oriented society that successive governments have fostered, that’s the consumer’s choice, isn’t it?
- Shorter waiting times for secondary care. We would all like that. But, again, where will the doctors come from, and does the budget, if one exists, include not just their salaries, but those of ancillary staff, equipment and additional buildings required?
- Money. There was a hot bidding war. It may have sounded like megabucks, but even the highest bid would barely meet the current shortfall. Eighty percent of acute trusts have overspent their budgets. Are they all inefficient and profligate? Or is it simply impossible to provide a decent standard of care with the money they have been allocated? Private providers like SERCO think so; they have opted out and left it to the public purse to take over.
- Three percent efficiency savings year on year – till the budget approaches zero? There will always be inefficiencies but the profits demanded by private providers may cost more. And some ‘inefficiencies’ provide essential flexibility. To an accountant, unoccupied beds in July is overprovision, but having too few beds in January is inefficient and costs lives.
— michael wright (@wrightdrmc) June 16, 2015
Many things important to those who work in the NHS and to patients were not addressed in the election sound bites.
- A lot was – is – said about getting patients into hospital. Little is said about getting them out again. There are bottlenecks all through the system, starting with ambulances queuing outside hospitals waiting for a bed/trolley/board to become free. But the ultimate rate-limiting step is discharge. Patients used to stay in hospital for 10 days after routine surgery. Now that stays are down to 48 hours, patients are more vulnerable. And they are likely to be older, so less likely to have someone at home who can care for them as they convalesce. Amalgamating health and social care doesn’t solve the problem if there is no money to provide home care.
- Flexibility. Yes. But only where it’s appropriate. Farming out an elderly man with epistaxis to the orthopaedic ward, or even to a gynae side ward, is monumentally inefficient. And dangerous. ENT nurses know about managing potentially lethal nosebleeds. Orthopaedic nurses don’t.
- False economies. When Monitor is on your back about your overspend, the easiest cut is salaries. But it costs, even in the short run. Experienced staff provide better value for money than younger, cheaper replacements. Slash your established workforce to dangerous levels and you have to plug the gaps. But agency staff, however able they are, don’t have local experience and the loyalties which make an effective team. They are very expensive. As the government is realizing. But it looks as if it is too late to rebuild a stable, valued, efficient workforce. The staff have left the NHS and it will take years to retrain replacements.
- How long before governments realize that care in the community doesn’t necessarily save money? Hospitals have economy of scale. Paring down community costs by not paying staff for travel time between patients is immoral.
- Technology, yes: SMS, down-the-line results. But despite huge investments in IT, too many hospital consultations are frustrated because the doctor doesn’t have the patient’s notes. Why not turn the problem around and put all the notes on a patient-help smart card? Probably fewer records would be lost than currently go missing in hospitals. And every health care professional could add their notes, every prescriber could check a patient’s history and medication and add their new drug safely to the list.
- Elastoplast is cheap but no treatment for serious problems. Politicians think short term, NHS staff have a longer view. Leave the bright ideas to them.
Underlying all the words is the assumption that money, allocating more or squeezing more out of each £, can enable the NHS to make us live forever. So we don’t die of heart disease, or cancer, or dementia. The rhetoric misses the point, that the major determinant of health is your social condition. People living in nice houses and earning decent incomes live years longer than those who live a mile away on meager benefits in dilapidated housing. It’s the survival of the richest. But that is a nettle no political party hoping to form a government will grasp. Despite the onslaughts, the NHS is kept going by enthusiastic and dedicated, if increasingly weary, staff. And they have lots of ideas. Look at the submissions for the 2015 BMJ Awards and be inspired. ●
This article first appeared in The Sessional GP magazine June 2015.