With hospital admissions increasing, why aren't medical staff numbers going up?

A case of "too many cooks spoil the broth".

Recent news regarding a 37 per cent increase in emergency hospital admissions comes as no surprise. There has been significant advancement in diagnostics and management intervention over the past decade and beyond and hence people are simply living longer. Many individuals suffer from chronic conditions where relapses occur and do so frequently. A patient with ischaemic heart disease may present regularly with chest pain, a patient with chronic bronchitis may present with a chest infection and someone with diabetes may be admitted with excessively high blood sugars. Therefore patients are admitted to hospital to achieve optimisation of their clinical state and appropriate care to see them through the acute phase.

Having worked in the NHS for five years I am for one proud of the care we deliver – this may be a biased opinion but it is an institution we should be proud of and continue to support whole heartedly. One of its detriments however is the simple lack of its workforce. Hospital specialty teams are typically led by a consultant, a specialist registrar, and if lucky a couple of senior house officers and house officers. Of course not all members of each team are present at any one time in view of on call commitments, leave post shift work and additional training commitments which fall under the continuing medical education (CME) umbrella. Therefore it can prove quite a challenge to serve the ever increasing patient admission rate with a not so concrete workforce.

In 2010, the government introduced the NHS 111 service with its aim to eventually replace the current NHS Direct service by 2013. Individuals are advised to call 111 if:

  • You need medical help fast but it's not a 999 emergency.
  • You think you need to go to A&E or need another NHS urgent care service.
  • You don't know who to call or you don't have a GP to call.
  • You need health information or reassurance about what to do next.

(Available from www.nhs.uk)

According to the website’s section entitled "How does it work?", the service is manned by "fully trained advisers supported by experienced nurses who will ask you questions to assess your symptoms, then give you the healthcare advice you need or direct you straightaway to the local service that can help you best."

Now I may be wrong, but if I was unwell no matter how severe I would personally choose to see a doctor in person and not talk to some random on the phone. Similarly if I chipped my tooth I would surely see a dentist and if I strained my hamstring playing football I would surely benefit by seeing a physiotherapist.

In the north west of London there are now plans to close four A & E units. The medical director for NHS North West London, Dr Mark Spencer, said: "hospitals here face considerable clinical and financial challenges." Now bearing in mind the rise in acute hospital admissions surely it doesn’t seem feasible to proceed with such plans?

Research by the Dr Foster group has shown an increase in patient mortality if admitted as an emergency over the weekend as well as higher mortality rates in hospitals with the fewest senior doctors available at the weekend. In response to these findings, the Royal College of Physicians is now working on plans to ensure consultant cover is present around the clock. We have of course all read about the apparent horrors of "Black Wednesday", the first Wednesday in August, where freshly faced junior doctors start working and have been deemed responsible for an apparent 6 per cent rise in emergency admission mortality. It begs the question therefore that if these juniors are responsible for such a killing spree why are seniors not actively training them from the moment they set foot in medical school to ensure they are fully capable and confident in dealing with acute medical and surgical problems instead of brushing them under the carpet and making them someone else’s problem.

So what is the solution? Well of course there is no easy answer but with simple deduction, if the number of patients being admitted are increasing, increase the number of doctors suitably trained to deal with the problem first hand, and of course with that follows the number of multidisciplinary staff, such as nurses, physiotherapists and occupational therapists.

I guess what we have here is a case of "too many cooks spoil the broth" or as an alternative "there are too many chiefs and not enough Indians".

Whichever you prefer.

Neel Sharma is a Medical Doctor and Honorary Clinical Lecturer at the Centre for Medical Education, Barts and the London School of Medicine and Dentistry

The A & E department at the Queen Elizabeth in Birmingham. Photograph: Getty Images
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What type of Brexit did we vote for? 150,000 Conservative members will decide

As Michael Gove launches his leadership bid, what Leave looks like will be decided by Conservative activists.

Why did 17 million people vote to the leave the European Union, and what did they want? That’s the question that will shape the direction of British politics and economics for the next half-century, perhaps longer.

Vote Leave triumphed in part because they fought a campaign that combined ruthless precision about what the European Union would do – the illusory £350m a week that could be clawed back with a Brexit vote, the imagined 75 million Turks who would rock up to Britain in the days after a Remain vote – with calculated ambiguity about what exit would look like.

Now that ambiguity will be clarified – by just 150,000 people.

 That’s part of why the initial Brexit losses on the stock market have been clawed back – there is still some expectation that we may end up with a more diluted version of a Leave vote than the version offered by Vote Leave. Within the Treasury, the expectation is that the initial “Brexit shock” has been pushed back until the last quarter of the year, when the election of a new Conservative leader will give markets an idea of what to expect.  

Michael Gove, who kicked off his surprise bid today, is running as the “full-fat” version offered by Vote Leave: exit from not just the European Union but from the single market, a cash bounty for Britain’s public services, more investment in science and education. Make Britain great again!

Although my reading of the Conservative parliamentary party is that Gove’s chances of getting to the top two are receding, with Andrea Leadsom the likely beneficiary. She, too, will offer something close to the unadulterated version of exit that Gove is running on. That is the version that is making officials in Whitehall and the Bank of England most nervous, as they expect it means exit on World Trade Organisation terms, followed by lengthy and severe recession.

Elsewhere, both Stephen Crabb and Theresa May, who supported a Remain vote, have kicked off their campaigns with a promise that “Brexit means Brexit” in the words of May, while Crabb has conceded that, in his view, the Leave vote means that Britain will have to take more control of its borders as part of any exit deal. May has made retaining Britain’s single market access a priority, Crabb has not.

On the Labour side, John McDonnell has set out his red lines in a Brexit negotiation, and again remaining in the single market is a red line, alongside access to the European Investment Bank, and the maintenance of “social Europe”. But he, too, has stated that Brexit means the “end of free movement”.

My reading – and indeed the reading within McDonnell’s circle – is that it is the loyalists who are likely to emerge victorious in Labour’s power struggle, although it could yet be under a different leader. (Serious figures in that camp are thinking about whether Clive Lewis might be the solution to the party’s woes.) Even if they don’t, the rebels’ alternate is likely either to be drawn from the party’s Brownite tendency or to have that faction acting as its guarantors, making an end to free movement a near-certainty on the Labour side.

Why does that matter? Well, the emerging consensus on Whitehall is that, provided you were willing to sacrifice the bulk of Britain’s financial services to Frankfurt and Paris, there is a deal to be struck in which Britain remains subject to only three of the four freedoms – free movement of goods, services, capital and people – but retains access to the single market. 

That means that what Brexit actually looks like remains a matter of conjecture, a subject of considerable consternation for British officials. For staff at the Bank of England,  who have to make a judgement call in their August inflation report as to what the impact of an out vote will be. The Office of Budget Responsibility expects that it will be heavily led by the Bank. Britain's short-term economic future will be driven not by elected politicians but by polls of the Conservative membership. A tense few months await. 

Stephen Bush is special correspondent at the New Statesman. He usually writes about politics.