Consequences

In 2009, NHS chief executive David Nicholson was set a challenge by Gordon Brown to find £20 billion in “efficiency savings” by 2015, as the NHS’ contribution to bailing out the banks and paying off the national debt. It was dubbed ‘the Nicholson Challenge’ by Brown, a tag enthusiastically embraced by the Conservatives to signal where the buck would stop if it failed. Nicholson was clear this was a one off, drastic squeeze in NHS funding that he hoped could be achieved by improving quality and productivity without affecting patient care. The fact that it was enforced as the horrors of the Mid Staffordshire scandal were unfolding, and yet were repeatedly ignored and denied by government, showed the dangers of prioritising savage savings over safe staffing of the NHS.

Nicholson’s failure to meet Mid Staffs campaigners and to act earlier on widespread concerns about appalling care contributed to his retirement, but his replacement Simon Stevens fell into exactly the same political trap. In promising to make a further £22 billion of fantasy efficiency savings by 2020 to fund his ‘Five Year Forward View’, the NHS is now facing over a decade of static funding in the face of rising demand and – coupled with massive cuts in social care budgets – parts of the service are in meltdown. The initial bail out of the banks in 2008 could have funded the NHS for eight years, but Theresa May and Philip Hammond still insist no more money can be found for the NHS, and that it has been given ‘more than the £8 billion extra over 5 years’ that Stevens asked for. The true figure is £4.6 billion, and NHS managers are once again prioritising financial savings over patient care.

The Mid Staffordshire Inquiry concluded that the NHS must introduce safe staffing levels for nurses in hospitals. Research has repeatedly highlighted the link between nurse numbers and patient safety, and the benefit of nurse to patient ratios below 1:8. The skill mix of the staff is also important. And yet the Health Service Journal has just published the culmination of a two year investigation into nurse staffing levels. It found 96% of acute hospitals in England are failing to meet their own planned level for nurse staffing during the day and at night, and that the situation is getting worse. It is not uncommon for a nurse to have to care for 16 patients on a night shift, and the HSJ found one nurse on an acute ward looking after 24 patients. 4 in 10 hospitals have declared a major alert in the last month because they were not able to safely cope with demand, and there are at least 24,000 nursing vacancies across the NHS. There has also been a 23% drop in the number of applications to study nursing at English universities in the wake of the government’s cuts to the bursary scheme. And under Jeremy Hunt’s leadership, the number of junior doctors progressing directly into specialty training has fallen from 71.6% in 2011 to 50.4% in 2016, its lowest ever level.

Despite the government’s boast to increase GP numbers by 5000, there was a reduction last year in the number of ‘whole time equivalent’ GPs, meaning any new recruits are thin on the ground and the job so stressful many are choosing not to work full time. Meanwhile, Simon Stevens has challenged Theresa May and Jeremy Hunt over their claims that the NHS has received £10 billion of new money but is still trapped into trying to enforce harsh financial controls without harming patients. The English NHS has been carved up into 44 ‘footprints’ which each devised a Sustainability and Transformation Plan in secret to balance the books by June 2016. Most have now been published and many are laughably deficient, particularly in their plans for safe staffing levels. NHS England will doubtless try to pass the buck for their failure down to local commissioners. Kent CCG has already had to ban routine operations from December 20 to April 1 to try to make £3.2 million savings.

STPs do radically increase opportunities for private companies to take over entire NHS services as well as buildings, but Theresa May was still parroting the Alan Milburn lie that ‘the NHS is not for sale’ on the same day that Care UK took over out of hours services in Gloucestershire. The business opportunities of a £120 billion NHS market will not be lost on Donald Trump, and given the desperation to achieve a trade deal with America, it seems very unlikely the UK would have the muscle to protect the NHS from an ‘America First’ policy and the might of their predatory private health corporations, one of whom (UnitedHealth) Simon Stevens worked for. But maybe that’s part of the plan. When politicians say they love the NHS, they mean they’d love it to be off the balance sheets and no longer their responsibility. Extra charges, insurance and top up fees aren’t far away.

MD is taking his health revolution on tour. Dates here

Blamestorming and Bedhunting

Politicians have always been adept at centralising praise and devolving blame, but for Theresa May and Jeremy Hunt to blame GPs for the meltdown in hospitals takes it to a new level of stupidity. True, the waiting times for routine GP appointments are rising (due to increased demand and a lack of GPs), but 86.3% of GP practices in England already provide pre-bookable appointments outside core opening hours. The limit on appointments is down to the number of GPs, and we have fewer of them per head of the population than comparable countries in Western Europe. Hence the alarmingly high levels of staff stress, unlikely to be eased by the government’s crude blamestorming.

We also have far fewer hospital beds per head (2.8 per 1000) than comparable countries, and are about to cut thousands more in an attempt to squeeze a further £22 billion of savings out of an already over-stretched NHS. Patients who go to emergency departments for a minor illness that a GP, chemist or sensible family member could have sorted out are easily treated. The reason hospitals are in crisis is because of the number of sick people turning up who need to be in hospital, and the cuts in social care preventing discharge. The lack of NHS intensive care and high dependency beds has absolutely nothing to do with GPs, and neither does the increasing cancellations – often repeated – for urgent heart and cancer surgery. The costs of standing down entire surgical teams because intensive care has no beds is considerable, not to mention the distress caused to patients and relatives. Without beds, hospitals are paralysed and highly paid and trained clinicians can spend all day on a bed hunt.

MD has been writing this column for 25 years, and although the NHS and social care system is not quite in the disastrous state it was in the nineties, when waiting times regularly exceeded 2 years and deaths in the queue were commonplace, it’s heading back that way. Our health spend is around 8% of GDP, heading for 6.6% by 2020. Civilised countries spend between 10-12%. UK NHS spend fell to 6.3% in 2000, when Tony Blair made a promise to match the EU average – but on the proviso the NHS accepted mass management consultancy, an expansion of outsourcing and private provision, diabolical PFI deals and a move towards American models of ‘integration’ and ‘accountable care.’

The Conservatives and NHS England have accelerated this corporatisation of the NHS whilst deliberately defunding the service, forcing departments to close because they cannot be safely staffed to cope with the increased patient demand and the costs of technological advances. May could take a lot of pressure off herself is she ‘did a Blair’ and agreed to fund the NHS to the Western European average. Yet despite months of terrible health deadlines and missed targets, a ComRes poll from January 11 and 13 asking ‘Who would do a better job at managing the NHS this winter?’ found 43% in favour of the government and only 31% in favour of Labour. If Labour can’t win on the NHS now, it can’t win on anything. And it leaves the government free to pursue its aggressive austerity agenda that is undoubtedly contributing to avoidable deaths, albeit of those unlikely to vote Conservative.

The social care crisis can be traced back to Margaret Thatcher’s decision to allow long term care to fall off the NHS. In the 20 years from 1979, over 100,000 long stay beds were lost from the NHS. Patients with incurable diseases were re-categorised as ‘social care’ rather than ‘medical care’, transferred to private nursing homes and obliged to pay the difference between social security benefits and the nursing home fees. In 1990, a 55 year old man was admitted to an NHS hospital with a severe stroke leaving him incontinent of urine and faeces, unable to talk, walk or feed himself. The hospital discharged him to a private nursing home in 1991, on the grounds that it had done all that was possible to cure him, and the NHS had no obligation to care for him. So much for cradle to grave.

Savage cuts in social care funding have predictably bankrupted many nursing and care homes. Jeremy Corbyn’s idea to take them back into state ownership makes good sense, but is unlikely to happen. The government urgently needs to invest in general practice and social care, not blame it, and halt further bed cuts. But with no credible opposition, it might get away with running services into the ground, with the NHS becoming a poor service for poor people. Everyone else is expected go private (as many do in NHS England, the Department of Health, the CQC, the GMC and even the BMA). The NHS is still the place to go in an emergency, but you may have to fight for a bed.

The NHS in 2017

WHETHER you agree with the Red Cross that the crisis in social care and the NHS is ‘humanitarian’, or merely ‘human’, there is no doubt that millions of people are being denied the care they need or waiting too long for it.
Christmas was particularly bad, with a third of hospitals having to take urgent action to safeguard patients and reports of staff meltdown and deaths in the corridor queues. With so many hospitals overcrowded and on red alert, now does not seem to be the time for the massive cuts in bed numbers predicted by the McKinsey-heavy NHS Sustainability and Transformation Plans.
This crisis has been a long time coming. In September 2016, 32 percent of the most urgent ambulance calls weren’t responded to in eight minutes, the worst ever performance for that month. In quarter two of 2016/17, 9.4 percent of patients (558,000) waited more than four hours from arrival to discharge, admission or transfer in all A&E departments, the highest percentage for this quarter since 2003/4. More than 107,600 patients waited more than four hours for a hospital bed, up 70 percent on last year.
At the end of September more than 348,500 patients had been waiting 18 weeks or longer to begin treatment (up 9.4 percent on the previous September). More than 1,181 of these patients had been waiting more than a year. It was the seventh month in a row the target of 8 percent had been breached – the worst performance since that target was introduced in April 2012.
In September 2016 the total reported waiting list increased to 3.7m, an increase of more than 411,470 patients compared to January 2016. Some trusts have given up reporting but even NHS England estimates the true waiting list in September 2016 was more than 3.9m patients, the highest since December 2007. The proportion of patients waiting more than six weeks for a diagnostic test has now missed its target for the past 34 months in a row.
The overall waiting times target for cancer treatment is that no more than 15 percent of patients should wait more than 62 days from an urgent referral from their GP to receiving treatment for their cancer. This standard has not been met for the past two and a half years, and is up to 17.7 percent.
At the end of September 2016, 6,775 patients were delayed in hospitals, the highest number ever published and an increase of 29 percent since September 2015. The number of total days delayed increased to more than 196,000 in September 2016, the highest ever recorded and a 33 percent annual increase.
The number of urgent operations cancelled in November alone was 446, double the previous year. This prompted Jim Mackey, chief executive of NHS Improvement, to advise hospitals to cancel routine operations over Christmas to make way for emergencies. Children’s intensive care units in particular are struggling to cope.
The crisis in general practice is clear too. According to a 2016 survey of 831 practices by Pulse magazine, the average wait for a routine GP appointment is nearly two weeks, with a prediction it will rise to 17 days in 2017. 12 percent of practices surveyed in 2016 already had waits of three to four weeks.
The reasons for this ever-declining NHS performance are well known. Rising demand, flat-line funding, cuts in social care, inadequate investment in staff and community services, waste and lack of coordination in a marketised, fragmented service. Thus Tory manifesto pledges look absurd, particularly this one: “We will offer you the safest and most compassionate care in the world.”
UK health spending is just over 8 percent of GDP. France, Sweden, Denmark and Belgium spend 10-11 percent. There is no “right” amount to spend on the NHS, but the delusion that we can have the safest, most compassionate service in the world for so little must stop. Most NHS staff will bust a gut to deliver compassionate care, but with so many staff shortages, so little community care investment and so many waits for urgent treatment, the service is far from safe in 2017. The junior doctors were right. If we keep stretching the NHS, it will surely snap.
M.D.