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March 25, 2014

Medicine Balls, Private Eye Issue 1362
Filed under: Private Eye — Dr. Phil @ 7:53 am

What now for the NHS?

David Nicholson’s cheery goodbye to the NHS – he resigns as chief executive of NHS England on March 31 – was a step up from Liam Byrne’s parting shot as chief secretary to the Treasury (‘’I’m afraid to tell you there’s no money left.’) Not only has Nicholson’s NHS spent all the money (£110 billion a year), but he believes the government will need to spend billions more on reform or the NHS will face ‘a managed decline in the quality of care.’

Nicholson wants the NHS to ditch its reliance on expensive hospital based services, centralise  highly specialist care on a massive scale and transfer much of what is currently done in hospitals closer to the home in much better resourced community-based care. These ideas have been around as long as Nicholson has been chief executive of the NHS, and the fact that he didn’t manage to implement them and is now pleading for them as he goes through the exit door is telling.

In all Western health systems, 20% of patients – those with multiple chronic diseases (heart disease, lung disease, diabetes, cancer, depression, dementia) – use up 80% of the resources. The most successful health services (e.g. the Montefiore health system in New York) identify these patients and offer them the best possible care in the community –hour long consultations, named doctors, specialist nurses and health trainers, continuity of care based on the best available evidence –  as well as hospital care if they need it. But by investing lots of money in community care, they’ve reduced hospital admissions by nearly half and made a fat profit.

In the NHS, 90% of patient contacts occur in general practice but it gets only 8.39% of the budget. General practice is simply unsafe – with too few GPs struggling though hugely complex patients with multiple problems on multiple medications in only 10 minutes. The care is patchy and – like in hospitals – of hugely variable quality. And far too many patients go to the emergency department (ED) because they can’t get easy access to a GP, making the hospitals unsafe too and ED’s horrible to work in.

The NHS is the only safety critical industry in the world that tolerates 12.5 hour shifts for nurses. Evidence is accumulating that patients are harmed if wards don’t have adequate numbers of qualified nurses, and the best specialist care (e.g. for heart failure, stoma care or multiple sclerosis) occurs if patients have easy access to specialist nurses. Yet 4000 senior nursing posts have been lost since 2010. And around 3000 patients die every year in the NHS from avoidable error, while thousands more are harmed by substandard care. Most harm occurs because there aren’t enough well trained, well rested staff on the front line. And staff are refusing to work in unsafe wards or departments.

None of this is new, but – thanks to the Mid Staffs Inquiry – the focus of the NHS has finally shifted to providing safe, humane care rather than just crunching the numbers, hitting the targets and burying the scandals until after the next election. Without a massive up-front investment in joined up community care (rather than Labour’s profligate dumping of walk-in centres across the country), the NHS can’t keep patients healthier in their homes and prevent them going to hospital. But there is no extra money, and efficiency savings have already taken the fat off the NHS, social care and local government and are now cutting into muscle and bone. Money could come from the mass merging of hospital specialist services but no politician has yet been brave enough to advocate this. And you need good community care to already be in place.

The NHS could cease to be a provider of universal services (as the Health Bill cunningly allows) and offer a skeleton service where patients buy insurance cover to top up. Policies are already available for future dementia care or cancer drugs that NICE deem to be too expensive for the NHS. It would be a brave government to advocate mixed funding of private insurance and tax for the NHS, and there’s no evidence this would be cheaper or fairer. But the alternatives – further tax rises or more rationing and a declining, neglectful and dangerous NHS and social care system – is no vote grabber either. Simon Stevens, the new boss of NHS England, must start by being honest about the scale of the problems, even as the election looms. And Jeremy Hunt must let him.