My father had a stroke and was ill for more than four years before he died. During that time, he went into hospital five or six times. He always came out worse than when he went in.
Other than initially, when he was admitted to hospital after the stroke, he probably never needed to be there at all. When he developed his final pneumonia and we wanted to stop his antibiotics, we had to fight to let him stay at home to die, because the district nurse was worried that, without a “terminal diagnosis”, we might all be accused of killing him. As his GP, who supported us, said ruefully: “Dr Shipman has a lot to answer for.”
A few months after my father died, I spent a year as the cabinet member for adult social care and health at Camden Council in London. I was dealing with millions of pounds’ worth of cuts to social care for the elderly, and, despite our best efforts, there just wasn’t enough money to provide care at home. My public health budget was cut by 6 per cent, even though I had been told that “prevention” was the new byword.
At the same time, nearby hospitals were building new units, expanding their services and running up huge debts. The deficit for University College Hospital at the end of 2016 was £32.5m.
This is happening all over the UK, not just in London. Only 9 per cent of the total health budget in England is spent on GPs and that figure is falling as GP numbers drop. Data released last year by the King’s Fund showed that district nursing numbers had fallen by 28 per cent in the past five years to just under 6,000; the think tank also found that the wider community-nurse workforce has shrunk by 8 per cent to 36,600.
Gary Porter, the Tory councillor who chairs the Local Government Association, said in February that adult social-care services face a £1.2bn funding gap by 2020.
Hospitals may complain about crowded accident and emergency departments and bed-blocking, but they still control almost the entire health budget. Their buccaneering chief executives have the ear of government and their overspending is indulged. As budgets shrink, it is more cost-effective for hospitals to absorb community services because the expertise and space for new clinics is already on site.
In my view, we have been brainwashed into thinking about the NHS almost entirely through the medium of hospitals. Television shows heroic, if exhausted, doctors and nurses in such programmes as 24 Hours in A&E, One Born Every Minute and Hospital.
I have become increasingly cross about this enormous power imbalance in the NHS, which supports hospitals but has not helped the growing population of needy and elderly patients. What if we moved significant resources and brought hospital-level care into homes for the likes of my father? What if we got rid of hospitals altogether?
I am not proposing to abolish all hospitals, of course. People need specialist inpatient care, whether it’s for heart surgery, stroke treatment, or hip replacements. But these are not needed by that many of us.
Bringing services out of hospital is not a novel idea. It is what the King’s Fund has been advocating for some time.
The new Sustainability and Transformation Plans (STPs), the government’s latest attempt at NHS reorganisation, advocate this, too. According to a recent BBC analysis, under these plans, hospital services will be scaled back across a third of England. Yet if this is to be done, it must be done well: not as a stealth cut, but as a new vision.
One problem with the current approach is that it is predicated on moving billions of pounds from the NHS. The early signs that huge sums will be transferred from hospitals to the community are not good, though there may be better integration at the community level. People could end up with worse care at home, or none whatsoever, and more overcrowded hospitals. This would be the worst of all worlds. A successful transition would require duplication of services, at least for a while. As the medical director of one STP outside London told me: “Getting funding out of acutes and into the community is difficult and may need double running.”
In such a system, you would need investment in clinics with doctors and nurses, within easy reach of everyone, open 365 days a year, 24 hours a day, to take people out of accident and emergency departments. In the Netherlands, 160 clinics have been built to do just that.
There is a growing realisation that hospitals are an impediment to getting care where we want it: in our own homes. It’s time to accept that most of them need to go.
This article appears in the 01 Mar 2017 issue of the New Statesman, The far right rises again