There is a tendency for the public to believe two things:
1. That the NHS is a monolithic organisation that works in the same way everywhere.
2. That the Beveridge report on health promised cradle-to-grave care without exception.
At primary level the NHS is not monolithic but, in effect, is reliant on a section of small businesses whose main income stream derives from payments made by the state. Hospital trusts perform at different levels of delivery and outcome. Local conditions, such as the level of local deprivation and the average age of the local population will affect how long one waits in accident and emergency (A&E), and how long one waits for elective treatment.
NHS postcode lottery
A postcode lottery is very noticeable on outcomes.
Let’s take three A&E performance indicators: time waiting to be seen and treated, elective treatment waiting times, and ambulance queue times.
A&E waiting times:
East Kent Hospitals Trust (EKHT): 28% of patients waiting longer than four hours.
UK: 27% of patients waiting longer than four hours.
Waiting for an operation or treatment:
EKHT Hospitals Trust: 51.3% waiting more than 18 weeks.
UK: 43.4% waiting more than 18 weeks.
Ambulance waits more than 30 minutes:
EKHT:12%.
Note: the two sources don’t agree, but the overall picture is similar).
There is a similar picture over health screening statistics. To summarise, some regions do better on various outcomes than others, and the media will report sensational stories such as a case in Norfolk which may be an aberration. The NHS is under great strain nationally, but there are substantial differences between regions and within regions.
The Nuffield Trust figures are not showing a substantial increase in A&E visits (subject to variable factors etc), but they do show that throughput from visit to being admitted is deteriorating. There are not enough beds and corridor treatment is becoming more common. Part of this is to do with failings in social care planning.
Social care
It has also become quite a shock to many to find that ‘social care’ is not free at the point of use and that, for those engaging with social services, it can be a costly and dispiriting experience. Many believe that it is very unfair to allocate NHS continuing healthcare for some conditions but, for others, there are local authorities like Kent that consider income and assets down to £14,250 and not the £23,250 often quoted as the lower limit as, between both figures, the person in care still partly funds their care, with the remainder coming from Kent County Council (KCC).
Move to cheaper care
The cruellest part of this scheme is where the resident is then expected to be moved to a cheaper establishment elsewhere. Not only are the assets of the person in effect sequestrated, but they also pay a higher rate than KCC as a kind of cross-subsidy to fund others, and then they are expected to be moved at will to suit the KCC budget.
This is an example of extreme budget making in the public sector, which is the state sector version of the private sector’s shareholder-value fixation, where a public body charged with arranging the care of a vulnerable person, treats them as a debit on a budget spreadsheet.
The outcomes for a patient trying to access in-patient care and continuing care are sometimes inequitable and subject to short-term budgetary considerations. Hospital care, both in-patient and out-patient, has considerable pinch points with care, A&E and elective treatment.
No spare hospital beds
There are not enough spare beds and not enough doctors and nurses to provide that care. Patients are also being kept in hospitals longer because adult social care has not delivered the care plans necessary to free up the limited number of hospital beds available.
The BMA has published NHS hospital beds data analysis which shows the UK has the lowest number of beds/population, bar Sweden. However, when you look at the health system in Sweden, you can see why the Swedes are not disadvantaged. Compared to the UK’s chronically underfunded NHS and social care system, Sweden’s system is delivered on the basis of long-term funding and not the UK’s patch and repair methodology.
GP appointments
Primary care, which is the SME part of the NHS, is also facing challenging times. The BMA has published data that suggests that GP practices are under pressure, but NHS England says millions more people are receiving GP appointments than before the pandemic. So who is right?
There are fewer GPs and there are continual complaints from patients about waiting for a GP appointment. The NHS England statement includes all visits to a GP surgery, which include vaccinations and other non-diagnostic visits, so NHS England is perhaps being disingenuous in its statement. Patients want to see a doctor for a diagnosis, but what they may receive is an online appointment, telephone appointment, or something else. That something else is an appointment with a physician associate(PA).
Physician associates
In healthcare, PAs are the new kids on the block and their appearance is causing anxiety in the medical profession. Doctors receive seven years of intensive training before they are let loose on the public, and even then they are overseen by senior doctors. After yet more training and experience a junior doctor may be appointed as a GP or as a consultant. The PA and their cousins, the anaesthetist associate (AA), will be someone who holds a qualifying degree (not a medical degree) and, after two years post-graduate training, they are appointed and receive starting pay higher than a junior doctor.
They cannot prescribe and are meant to be overseen by a GP or consultant. However, as the BBC found, there have been cases when PAs have exceeded their limited brief and the public often confuses them with doctors. Because the NHS is, in effect, sponsoring them at no cost to the GP surgery, the BBC has reported that PAs in some cases are replacing GPs, which is concerning.
The PA + AA policy originates from the period when Jeremy Hunt was health secretary, which explains a lot. It appears to be another of those partwork solutions that have featured so often in the last 15 years in order to save money. The thinking behind it is that the PAs and AAs will carry out routine tasks, leaving doctors to concentrate on the more important work. Unfortunately, what may seem routine may not turn out that way, and routine work is necessary for trainee doctors to learn and become more experienced.
As paramedics and nurse practitioners also exist, is there any need to recruit expensive PAs and AAs to do work that could be done by these health professionals? Is it not, yet again, a solution seeking a problem?
Lack of planning for new doctors
The unprecedented consultant and junior doctor strikes are the result of complacency and a lack of planning by the NHS and central government. If the government sat down with the junior doctors and negotiated a comprehensive agreement on pay, conditions of service, training, and all the obstacles that the NHS put in place that impede a worthwhile career in medicine, we would not be in the absurd position of doctors leaving the NHS to work elsewhere, while it madly recruits doctors from overseas to fill the growing chasm of demand for doctors. Why is it that GP surgeries complain that they have too few GPs, and then don’t recruit those available, because PAs are offered to them for nothing?
Lack of NHS dental services
NHS dental services: in a parliamentary health committee report there is a sense of a decaying level of dental services in some areas. This is supported by terrifying media reports of patients pulling their own teeth out due to the lack of dental services. The BBC reported that the government has responded with a dental recovery plan, but this was termed by the British Dental Association (BDA) as ‘rearranging the deckchairs’, presumably on the Titanic, but other ships are available.
Health inequalities
The litany of complaints, concerns and catastrophes with the NHS, could go on with mental health services, the scandals over midwifery and obstetrics, and so on.
I can put it no better than the findings of the Marmot Review, which found that:
- People can expect to spend more of their lives in poor health.
- Improvements to life expectancy have stalled and declined for women in the most depressed 10% of areas.
- The health gap has grown between the most wealthy and deprived areas.
- Place matters: Living in a deprived area of the North East is worse for your health than living in a deprived area of London, to the extent that life expectancy is nearly five years less.
Lowest levels of spending on the NHS
The Kings Fund analysis showed that the NHS cost around £182bn and that 94.6% was spent on staff costs and medicine. Spending over the years has see-sawed but the years since 2010 have seen the lowest level of spending and, even now, the NHS is receiving annual increases not much more than the fallow years of the 1980s and 90s. In short, if we want Scandinavian standards of healthcare, and I think that is what is expected by the public, the UK needs to deliver consistent levels of expenditure to meet that demand. The NHS can be made more efficient, but the managerialist methods of restricting access to healthcare not only fail to achieve good results, they are counter-productive and more costly for each health outcome.
