Specialist care crisis

Amidst the political posturing over the NHS, few MPs dare mention the crisis in specialist care. This has been on MD’s radar since the Eye broke the story of the Bristol heart scandal in 1992. I have argued over 23 years that highly specialised complex care such as child heart surgery needs to be reorganised into fewer, larger, more sustainable units where training and resources can be concentrated. The fact that it hasn’t happened is down to the usual toxic mixture of political and professional self-interest, and patients suffer and die as a result. It’s pointless exposing these recurring stories because nothing changes, and whistleblowers get shot.

The NHS does, however, listen to money. Specialist hospitals are in financial crisis not just because they only get paid a third of what it costs them to treat the surge in emergency department traffic, but because tariffs for specialist care are also being slashed. Indeed, they have never reflected the complexity and cost of what treating the critically ill patients demand. For patients that cost more than £100,000 to treat, specialist hospitals now lose over £80,000 per patient. If NHS specialist care was a business, it would long ago have been declared bankrupt.

There are marginal efficiency savings to be made – patients in remote locations may take two days to trek up and back to a specialist centre for an outpatient follow up that could easily be done via Skype – but without the widespread merging of specialist units, many hospitals will simply go bankrupt if they continue to provide them. Where massively expensive public and NHS consultations such as the Safe and Sustainable reviews have failed, the pressure of debt may succeed.

Highly specialist care is expensive, and if the NHS wants to do cutting edge heart surgery guided by 3D printed hearts on children who would previously have died, someone has to pay for it. NICE is likely to approve artificial hearts (VADs) for long term use (i.e. not just as a bridge to heart transplantation). These are very expensive but compare well to the cost of some cancer drugs which are politically sexy but only prolong life by a few months.

For specialist care in the NHS to continue in its present ‘multiple centre’ form would require higher taxes which many people might be prepared to pay. However, NHS England boss Simon Steven’s 5 Year Forward View that the NHS can survive with just 1.5% extra funding each year (half of Thatcher’s increase) requires merging of specialist care on a massive scale. No politicians dare talk about this prior to an election, for fear it will catalyse fears about local hospitals being downgraded.

The public need to be included in this debate. We either decide super-specialist care for the unlucky few is like deep space exploration and can’t be afforded when we have so many elderly patients missing out on basic care, never mind their specialist care. Or we accept hospital mergers to deal with the debt. We must also pay much more for the NHS, at least the equivalent of Germany and France.

In the current culture of denial, services are stretched beyond what they can safely deliver and avoidable harm flourishes. Hospitals can cut their costs (and improve their figures) by saying no to the sickest patients, but that goes against everything the NHS stands for. Alas, the last 23 years have shown there is a huge gap between the high quality, high value care that could be achieved when politicians, NHS staff and the public collaborate – and the hugely variable status quo we have when vested interests get in the way. There are currently 143 nationally defined specialised services, which account for £11.8bn of annual spending – equivalent to about 10 per cent of the overall NHS budget. They’re currently facing a £5 billion funding gap, and yet the entire NHS may only get £2 billion a year more. Specialists are now having to do the maths before they do the 3D printed hearts.

MD