7 February 2017

Why our healthcare crisis won’t be over anytime soon

The disastrous effects of “Martini health care” – any time, any place, anywhere – are made worse by a shortage of staff.

By Phil Whitaker

The Red Cross came in for some stick recently when it warned that English hospitals are in state of “humanitarian crisis”. Whatever one thinks of this description – provoked by the sight of sick patients languishing on trolleys in A&E corridors, or bedded down on chairs pushed together – it’s worth pursuing the analogy.

Take Theresa May’s pronouncement that the NHS’s ills will be solved by pressuring GP surgeries to open from eight until eight, seven days a week. This was about as insightful as asserting that the refugee crisis in Europe will be addressed by extending the working hours of border guards. We need to consider the forces driving the migration – why patients are flooding in to hospitals; how we assess asylum claims – in order to sort out who really needs hospital care.

There are two drivers of the migration. The first concerns the ever-growing number of frail, usually elderly people with chronic health problems in our communities. Many of those who live at home manage to do so only thanks to threadbare social support. Even with optimal treatment, exacerbations in their long-term health conditions happen with grinding frequency, and with sudden increases in their care needs. There simply aren’t enough resources at the moment to upgrade support to look after these patients safely at home. So, in to hospital they go – and stay, until they no longer require enhanced community care, or until it can somehow be squeezed out of an already overstretched system.

The solution to this, to return to the Red Cross analogy, is to establish high-quality camps closer to refugees’ countries of origin. We need to fund flexible and responsive community care – as well as some “hospital at home” treatments such as intravenous antibiotics and fluids – to get people through short-term exacerbations without admitting them, and to enable earlier discharge from district general hospitals if they do go in.

Increasing “cottage hospital” provision, giving lower-tech, less expensive, intermediate-level care, would also be helpful. This will take lots of investment, and lots of additional staff. Try running a refugee camp on a shoestring and you’ll soon discover how little it will do to stem the tide heading for the nearest border.

The other driver of the migration is the cultural shift to Martini-style health care – any time, any place, anywhere. We seem hell-bent as a society on cramming our lives as full as possible, so we want supermarkets open at midnight, pizzas delivered at 4am, and advice about little Johnny’s rash somewhere in between. This began decades ago, but the creation of NHS 111, which was supposed to meet the demand, has only aggravated matters. It was deemed too expensive to have sufficient clinicians available 24 hours a day to deal with the huge call volumes, so initial contacts are dealt with by non-clinicians operating a computer algorithm. The system is risk-averse, and so generates large numbers of 999 calls, or advice to attend A&E immediately, for problems that an experienced GP would resolve without getting a hospital involved at all.

It is this Martini aspect that underpins May’s prescription of longer opening hours for our surgeries. The problem is, there is a crisis in GP recruitment and retention, and the harder you flog the present workforce, the more it will vote with its feet. Remember that Tory manifesto commitment to find an extra 5,000 GPs from somewhere? No, neither do the Tories.

It’s probably impossible to reverse the Martini culture, so we must come up with a system where experienced clinicians manage the first point of contact, keeping people who don’t need to go to a hospital well away. This will take lots of investment, and lots of additional staff. Sound familiar?

The bottom line is that we’re getting the health and social care we currently pay for. The percentage of our GDP that we spend on health is among the lowest in the developed world. But higher public spending is anathema to this government. This crisis is going to run on for a while yet.