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
Photo: Getty
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Forget planning for no deal. The government isn't really planning for Brexit at all

The British government is simply not in a position to handle life after the EU.

No deal is better than a bad deal? That phrase has essentially vanished from Theresa May’s lips since the loss of her parliamentary majority in June, but it lives on in the minds of her boosters in the commentariat and the most committed parts of the Brexit press. In fact, they have a new meme: criticising the civil service and ministers who backed a Remain vote for “not preparing” for a no deal Brexit.

Leaving without a deal would mean, among other things, dropping out of the Open Skies agreement which allows British aeroplanes to fly to the United States and European Union. It would lead very quickly to food shortages and also mean that radioactive isotopes, used among other things for cancer treatment, wouldn’t be able to cross into the UK anymore. “Planning for no deal” actually means “making a deal”.  (Where the Brexit elite may have a point is that the consequences of no deal are sufficiently disruptive on both sides that the British government shouldn’t  worry too much about the two-year time frame set out in Article 50, as both sides have too big an incentive to always agree to extra time. I don’t think this is likely for political reasons but there is a good economic case for it.)

For the most part, you can’t really plan for no deal. There are however some things the government could prepare for. They could, for instance, start hiring additional staff for customs checks and investing in a bigger IT system to be able to handle the increased volume of work that would need to take place at the British border. It would need to begin issuing compulsory purchases to build new customs posts at ports, particularly along the 300-mile stretch of the Irish border – where Northern Ireland, outside the European Union, would immediately have a hard border with the Republic of Ireland, which would remain inside the bloc. But as Newsnight’s Christopher Cook details, the government is doing none of these things.

Now, in a way, you might say that this is a good decision on the government’s part. Frankly, these measures would only be about as useful as doing your seatbelt up before driving off the Grand Canyon. Buying up land and properties along the Irish border has the potential to cause political headaches that neither the British nor Irish governments need. However, as Cook notes, much of the government’s negotiating strategy seems to be based around convincing the EU27 that the United Kingdom might actually walk away without a deal, so not making even these inadequate plans makes a mockery of their own strategy. 

But the frothing about preparing for “no deal” ignores a far bigger problem: the government isn’t really preparing for any deal, and certainly not the one envisaged in May’s Lancaster House speech, where she set out the terms of Britain’s Brexit negotiations, or in her letter to the EU27 triggering Article 50. Just to reiterate: the government’s proposal is that the United Kingdom will leave both the single market and the customs union. Its regulations will no longer be set or enforced by the European Court of Justice or related bodies.

That means that, when Britain leaves the EU, it will need, at a minimum: to beef up the number of staff, the quality of its computer systems and the amount of physical space given over to customs checks and other assorted border work. It will need to hire its own food and standards inspectors to travel the globe checking the quality of products exported to the United Kingdom. It will need to increase the size of its own regulatory bodies.

The Foreign Office is doing some good and important work on preparing Britain’s re-entry into the World Trade Organisation as a nation with its own set of tariffs. But across the government, the level of preparation is simply not where it should be.

And all that’s assuming that May gets exactly what she wants. It’s not that the government isn’t preparing for no deal, or isn’t preparing for a bad deal. It can’t even be said to be preparing for what it believes is a great deal. 

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to domestic and global politics.