Shortly before the end of the financial year one of the occasional meetings took place in this hospital where consultant staff meet senior management. We had come to the end of Any Other Business. The new Finance Director for the Trust piped up. His voice was querulous. He had waited until the very end of the meeting to say his piece. He explained that the Trust was going to end the year with a tiny surplus but the coming year would be one of great uncertainty. Not only were there cost pressures of inflation including the lifting of a pay freeze, but the Treasury’s requirement for continuing cost improvement would apply and the tariff, the price paid by the commissioners for each episode of activity in the hospital was being reduced. He was very worried.
This air of financial uncertainty is passed off as normal throughout the Health Service. The Royal Colleges, the NHS Confederation and even the King’s Fund take it as read that there will be less money around in the future. Nobody considers it to be their responsibility to draw attention to the immense harm this is doing to health care in the United Kingdom.
This is not new. The conduct of political control of the NHS purse strings is rarely questioned. Just occasionally someone makes the comment that everyone is thinking but no-one dares utter, like the child in Hans Christian Andersen’s story who was the only one who dared mention the king’s nakedness. A few years ago it was Lord Winston who in a New Statesman interview commented both on resources for specialist care and on the shabbiness of the under funded hospital in which his mother was a patient; this comment proved catalyst for Tony Blair’s of decade of increasing funding for the National Health Service. The Treasury exacted its price for enacting this; the NHS was required to meet targets to show the money was being well spent. Clearly the officials of the day did not understand Goodhart’s Law which tells us that when the measure becomes a target ceases to become a good measure so the meeting of targets is no way to assess what the NHS is achieving.
Indeed it causes distortions and the conflicts. Gary Walker was Chief Executive of the United Lincoln Hospitals NHS Trust when, as he informed us in February, Dame Barbara Hakin told him that his Trust was required both to care for acute emergencies and meet the waiting list targets for planned surgery without extra funding for the extra operations. This shows us how with its inadequate funding, the NHS becomes a competition between patients for resources.
It is expected that the Health Service will meet this future with much less work done in hospitals and much more “in the community.” This is why hospitals’ funding from “Payment by Results” tariffs has been reduced by £2.4bn both in 2011-12 and 2012-13 to free up resources for to develop of community services. The problem is that those services are currently in no way able to take as much load off the hospitals as this policy requires; community services will have to achieve more before the resources they need to do so are released. Components of community services are actually being reduced including out of hospital residential care such as that provided by councils which are facing their own austerity. People whose care at home is unsustainable because of the combination of health issues and the inability of their family and social support network to cope and end up in the acute general hospital as the provider or last resort. To run down its resources without reducing demands on it creates the circumstance in which the hospital fails to meet the humanitarian standards. It is all too easy to see how the dehumanisation of patients in Mid Staffordshire so clearly described in the stories quoted in the Frances Report occurred. We now have an academic study describing the relationship between understaffing and care left undone. The behaviour of Staffordshire nurses in neglecting simple aspects of patient care in favour of meeting administrative demands is fundamentally no different from that of Barbara Hakin in dealing with the Lincolnshire issue or of Sir David Nicholson in issuing his challenge to the Health Service as a whole to do more with inadequate resources. Perhaps everyone in the service is showing the same attitude by the failure to challenge the funding issue. The chairman of NHS England, Professor Malcolm Grant agrees that “…although the NHS is one of the cheapest health services in the developed world, money is desperately tight” without connecting this increasing parsimony in an already undersized service to the way problems that are being faced or the way in which they are addressed1.
There is also a lack of perception that the poorest parts of society lose out here. It is recognised that there are health inequalities in the United Kingdom and that it ought to be possible to improve the health of poorer people with education in preventative measures such dietary changes, exercise and above all reduction in smoking, not to mention raising the general educational aspirations but there are also major issues about access to health care. It is poorer people that make use of the emergency departments rather than primary health care because that is the environment where they compete most effectively against their articulate and affluent compatriots, although that having been said, the journalist Matthew Parris who is undoubtedly articulate has argued that the emergency department of his local hospital is his preferred route into health care2. For poorer people an emergency admission is a much more likely route to a diagnosis of cancer than it is for wealthier people, but health policy is based on the assumption that everyone will come through the General Practitioner. Indeed there are huge discrepancies in the timeliness of diagnosis of cancer between rich and poor and it is timeliness of diagnosis that is the principal factor in the United Kingdom’s poor performance in the International league tables of cancer survival. Britons may not have to pay a bill when they visit the doctor but that should not be taken to mean that access to health care is easy and equitable.
The National Health Service has a lot of catching up to do. To make the care of people with illnesses like cancer equitable is going to require much more resources for diagnosis, doing tests on more people who turn out not have cancer to identify sooner those who do. Timely diagnosis is only of use if the patient goes onto have appropriate treatment and resources are required for that to bring the United Kingdom up to speed with the rest of Europe. The demographic issue looms large here. Important illnesses tend to occur later in life and the ageing baby boom generation is now passing through that phase of life where health care needs are increasing and they are young enough to benefit from treatment. It will not be possible to do this without more personnel and without more contemporary technology. This will have to be paid for.
Allied to the theme of more health care being provided in the community is the proposal that specialised services should be located in a smaller number of centres. This is another policy which has not been thought through. There is a growing body of evidence that large hospitals, mainly the central Teaching Hospitals, function inefficiently but meeting the costs of that inefficiency would be justified if the increment in quality was great enough. Against this must beset the issue of access which is again linked to the issue of socio-economic deprivation. In the reconfiguration of the NHS which took place in the 1960s, three specialties were designated for centralisation: neurosurgery (which has never anything other than a centralised service), thoracic surgery and radiotherapy. 50 years on there is clear evidence that people, especially poorer people, who live some distance from the specialist centres are less likely to have treatment.
Perhaps understanding this will help the powers that be in the NHS to see why feelings are running high in Leeds where there is plan to close children’s heart surgery services. Parents are not impressed by the theoretical increment in quality from fewer, larger specialist centres, but they are profoundly concerned by the reduction in access from their area of residence to the remote location of the specialist facilities. Some services can only be provided in specialist units but the case for developing services in local general hospitals which are more efficiently sized is strong. Those hospitals are better placed to work with General Practitioners and community services to promote efficient and effective balance between community and institutional care and this must be fostered in the future.
It is currently fashionable to quote stroke services in London as the epitome of modern centralisation; it is in fact a very bad prototype for a wholesale process. It is the hyper acute service that has been successfully centralised which depends on the fact that diagnosis by recognising very clear cut symptoms (do make sure you know the FAST acronym). It does not work well when diagnosis is difficult; this is the pervasive weakness of strategies that depend on a specialised service with limited capacity as history shows. The London stroke project also relies on enhancement of services in other hospitals and in the community, the centralised hyperacute service does not replace these and Jackie Ashley’s experiences in caring for her husband, Andrew Marr, suggests that the next area of growth should be in the community but not at the expense of inpatient rehabilitation3.
The perception that the Treasury has been generous to the NHS in the first decade of this century has perhaps led to the imposition of an increasing burden upon it. One way in which the Government could ease pressure would be for the Treasury to take on the costs of its experiment with the private finance initiative so that companies who take on the construction and operation of hospitals with guarantees of decades of high levels of income do not compete with poorer patients for NHS resources. One thing is very clear. We fund the NHS from a pre-defined budget which is to treat health care in the same way that a council treats its parks department; the latter is a worthy endeavour but its finances must inevitably be restricted and no-one is killed or maimed if the mowing and weeding are not bang up to date. The truth of the matter is that this approach puts the British patient at a disadvantage compared with others in the developed world where the funding authority is charged for the work that healthcare facilities perform.
NHS England director for patients and information, Tim Kelsey, has announced his report “The NHS Belongs to Us All” with the revelation that by 2020 there will be a £30bn funding gap in the healthcare system. This cannot be addressed by organisational tweaks intended to save vast sums because on past performance this will further degrade patient care, although that is not to deny that the service has to develop and improve. To pretend that extra resources are not urgently needed now is to be as foolish as Andersen’s vain monarch.
Dr S Michael Crawford is a consultant physician in an acute general hospital
1 The Times, 1 April 2013
2 The Times, 16 June 2012
3 Guardian, 1 August 2013