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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Forget the progressive alliance - it was the voters wot won it in Richmond

The Labour candidate on how voters have acted tactically for decades.

The Richmond Park by-election is both a triumph and a setback for the concept of an anti-Tory progressive alliance. As the Labour candidate, I was bombarded with emails and tweets saying I ought to stand down to prevent Zac Goldsmith being re-elected long after it was technically impossible for me to do so even if I had wanted to. I was harangued at a meeting organised by Compass, at which I found myself the lonely voice defending Labour's decision to put up a candidate.

I was slightly taken aback by the anger of some of those proposing the idea, but I did not stand for office expecting an easy ride. I told the meeting that while I liked the concept of a progressive alliance, I did not think that should mean standing down in favour of a completely unknown and inexperienced Lib Dem candidate, who had been selected without any reference to other parties. 

The Greens, relative newbies to the political scene, had less to lose than Labour, which still wants to be a national political party. Consequently, they told people to support the Lib Dems. This all passed off smoothly for a while, but when Caroline Lucas, the co-leader of the Greens came to Richmond to actively support the Lib Dems, it was more than some of her local party members could stomach. 

They wrote to the Guardian expressing support for my campaign, pointing out that I had a far better, long-established reputation as an environmentalist than the Lib Dem candidate. While clearly that ultimately did little to boost my vote, this episode highlighted one of the key problems about creating a progressive alliance. Keeping the various wings of the Labour party together, especially given the undisciplined approach of the leader who, as a backbencher, voted 428 times during the 13 years of Labour government in the 1990s and 2000s, is hard enough. Then consider trying to unite the left of the Greens with the right of the Lib Dems. That is not to include various others in this rainbow coalition such as nationalists and ultra-left groups. Herding cats seems easy by contrast.

In the end, however, the irony was that the people decided all by themselves. They left Labour in droves to vote out Goldsmith and express their opposition to Brexit. It was very noticeable in the last few days on the doorstep that the Lib Dems' relentless campaign was paying dividends. All credit to them for playing a good hand well. But it will not be easy for them to repeat this trick in other constituencies. 

The Lib Dems, therefore, did not need the progressive alliance. Labour supporters in Richmond have been voting tactically for decades. I lost count of the number of people who said to me that their instincts and values were to support Labour, but "around here it is a wasted vote". The most revealing statistic is that in the mayoral campaign, Sadiq Khan received 24 per cent of first preferences while Caroline Pidgeon, the Lib Dem candidate got just 7 per cent. If one discounts the fact that Khan was higher profile and had some personal support, this does still suggest that Labour’s real support in the area is around 20 per cent, enough to give the party second place in a good year and certainly to get some councillors elected.

There is also a complicating factor in the election process. I campaigned strongly on opposing Brexit and attacked Goldsmith over his support for welfare cuts, the bedroom tax and his outrageous mayoral campaign. By raising those issues, I helped undermine his support. If I had not stood for election, then perhaps a few voters may have kept on supporting him. One of my concerns about the idea of a progressive alliance is that it involves treating voters with disdain. The implication is that they are not clever enough to make up their mind or to understand the restrictions of the first past the post system. They are given less choice and less information, in a way that seems patronising, and smacks of the worst aspects of old-fashioned Fabianism.

Supporters of the progressive alliance will, therefore, have to overcome all these objections - in addition to practical ones such as negotiating the agreement of all the parties - before being able to implement the concept. 

Christian Wolmar is an award winning writer and broadcaster specialising in transport. He was shortlisted as a Labour mayoral candidate in the 2016 London election, and stood as Labour's candidate in the Richmond Park by-election in December 2016.