Crisis and Consequences

age versus beds

The notion that the NHS is under more pressure than ever before is expressed on a daily basis in the media. Headlines indicating hospitals declaring a so called ‘black alert’, the four-hour wait limit in Emergency Departments being over-run, bed blocking and concerns over social care provision have been the focus of anxiety over the past couple of months.

It feels as though our celebrated service is being overwhelmed by the demands and expectations of patients and providers alike.

It is undeniable that the changing demographic characteristics of the population increase the pressure on the health service. The proportion of elderly people, many with complex and multiple morbidities, is increasing and the NHS must adapt to this changing need. In 1974 the proportion of the UK population aged 65 or over was 13.8%. In 2014 it was 17.7%. It is expected to reach 20% by 2024The actual number of people in this age group increases in the UK by almost 279,000 annually and the proportion of the population in their ninth decade and beyond is approaching 10%. This change is reflected in hospital wards where elderly patients are often subject to prolonged stays because of limitations in local social care provision.
Over the same time period there has been a steady downward trend on the provision of inpatient beds for both acute and long term care. In England, for example, there were 190,000 available beds in 1998-99. This has significantly reduced to 129,500 beds today.

In the acute sector we have all experienced the erosion of bed numbers and this has been accommodated to some extent by a parallel reduction in length of stay. This trend cannot be sustained in the face of increased demand. The balance must necessarily be reached and various endeavours to mitigate the effects by the introduction of new patterns of care and new ways of working can help to a degree.

Judging by the diminishing sense of good will and increasingly vocal expressions of concern around the country, it does appear that the service has now reached the point of being so overstretched that something significant has to stop the downward spiral in provision.

Undeniably this is complex. So what’s the answer? In short there is no single answer, rather a menu of items that need to be addressed.

Resources
While the interrelationship between health and social care and the interdependence of the two systems calls for more than integration, uniting the administrative effort and writing down some common goals will not fully address the problem. There is a need for increased resource. The UK spends 8.5% of GDP on health, which is considerably less than virtually every other comparable country. France and Sweden, for example, each spend 11% of their GDP on health and a further 21% on social care. Our social care bill comes to only 15% of GDP. This translates into some unpleasant realities. Last year, NHS organisations in England closed out the year having to weather a deficit in the region of three times that of the previous year.

Repeated claims that substantial sums are flowing from the Exchequer to the Department of Health are difficult to dissect. Medical costs last year increased by a level some 2.5 times greater than inflation. The global average projected inflation rate was 3.6%. In the healthcare arena the value stands at 9.1%. The pressure right now is to maintain service – innovation, understandably, seems like a dream to many on the front line.

Safe staffing
Increasing the medical and nursing staff numbers might help to some extent. This however is not an easy problem to solve. It takes years to train nurses, GPs and specialist doctors, so it is self evident that we cannot expect any immediate benefit from increasing medical and nursing student numbers. Employing skilled healthcare professionals from other nations has helped to ease some of the pressure but is not a complete solution. Even this issue is complex. We struggle, particularly in Scotland, to compete with respect to recruitment and retention of high quality medical staff. Our ability to ‘sell’ our best posts, our package of contractual details and remuneration are progressively falling behind other areas within the UK and indeed other nations such as the Netherlands, Australia and the US. The result? A large proportion of both general practice and consultant posts are unfilled. So while this is a UK wide problem, the staffing issues feel particularly challenging in Scotland.

Service and training
Every year the ‘winter pressures’ come and go and life returns to normal. This year has been worse than most and we have not really experienced a harsh winter at all. In Scotland, in November, 93% of patients were seen within the four-hour A&E target; in England the figure was 89%; in Wales it was closer to 83%. There have been numerous reports of elective cases, including some urgent cases, being cancelled or re-scheduled. Not only does this significantly degrade service provision, it also has a serious knock on effect on training our future specialists. Service and training are inevitably closely linked. As a College we will keep the pressure on to address these issues. Various things can change with little financial implication. These include allowing local clinicians to redesign services to address the particular pressures they face. For trainees, while this will help there is more we can do. Adding value to simulation in training and doing this across the specialist spectrum will help. It is high time that we follow the evidence and make sure that simulated clinical training becomes mandatory across the curricula.

Responsibility
It is so unfortunate that the NHS continues to be a political football. Surely the time has come for the experts to be given the responsibility to tackle many of these issues. More conversation will not serve us well. We need commitment to resource our health and social care provision adequately and we need expert direction uncontaminated by political self interest.

In a joint letter with the Presidents of the Royal College of Physicians of Edinburgh and the Royal College of Surgeons of Edinburgh, I have written to the Prime Minister asking for urgent action to be taken to set up a working group involving the Royal Colleges, healthcare practitioners, patients, the public, and politicians. This group would be briefed to find solutions to alleviate the pressures faced across the NHS. Further details, including a copy of the letter, can be found here: Royal Colleges write to Prime Minister on challenges facing the NHS