Why the political stalemate is bad for our health
This week we analyse the impact for the Health Service and conclude that the doom mongers are not crying wolf over the effect of delayed reform.
The reasons why the health service is in crisis have been cited often, but still don’t seem to be completely understood. And even then they seem to be viewed as an argument rather than fact.
To reprise. We are living longer partly as a result of lifestyle changes and partly as a result of medical progress. This of course is good news. Yet as we age we tend to develop long term conditions: diabetes, heart disease, sight loss and other disabilities, dementia and cancers together with the general deterioration of both body and mind that comes with advancing age, let’s call this frailty.
For the frail or those whose conditions are deteriorating, there comes a time when they are unable to live independently and need institutional care of one kind or another.
So therefore the growing numbers of people with long term conditions, added to the needs of the frail mean that demands on the health service are increasing, and increasing rapidly.
We are in the middle of an enormous population boom amongst those aged 65. In 2013 there were estimated to be 279,000 people aged 65+, with 33,000 of them over 85.
In the next two decades, these figures are set to rise to 456,000 and 79,000 respectively - while the demographic shift for 2015-2023 will be equal to the shift in the preceding 40 years.
Our current system cannot cope with the demand. Health expenditure already accounts for 50% of our entire budget. Health spending gets ring-fenced from cuts, and occasionally extra funds are found to patch up specific pressure points. However the reality is that it is not and cannot keep up with the inevitable demand if we are able to maintain treatment free at the point of delivery. In real terms, therefore, whatever politicians might say, as every year passes the system becomes more and more underfunded.
It is now beginning to implode. There are staff shortages everywhere, of doctors, and even more worryingly and acutely, of nurses. A&E departments are almost at breaking point. Acute hospitals are filled to bursting, often because people who are fit to go home are unable to do so because the care packages they need to be looked after at home are unavailable.
We have known about this for many years. The Transforming Your Care policy which set out the need for reform was published six years ago and yet no discernible progress has been made. Bengoa has come and gone. The Health Minister’s response was positive and a team set up to devise an implementation plan. The current political impasse. has put all that on ice. As every day goes by the situation continues to deteriorate and yet without effective government nothing will be done.
Yet there is a solution and it was spelled out in Transforming Your Care. We may need to spend more, but salvation comes from allocating it to different activities, which will ensure that it becomes affordable and sustainable.
The health service is essentially an “illness” service, it needs to be a “wellness” service. This means much more investment in preventing people developing conditions in the first place. Many conditions both in physical and mental health are either caused or exacerbated by poor lifestyle choices: alcohol and drug abuse, poor diets, lack of exercise. Delaying their onset or preventing them happening in the first place would be of huge benefit not just to the individuals themselves and wider society, but also reduce pressures on services and make significant savings. Spending on public health programmes is an investment which saves money, not a cost.
Secondly when people are ill the emphasis should be on them being treated at home. This would involve beefing up health centres so that they can offer as much support as possible to allow people to live dignified independent lives whilst suffering from long term conditions. For many of them, and also for the frail, bolstering that with domiciliary care to help with basic needs, is essential. And on top of that there is end of life and palliative care. How much better to spend your last hours at home in peace and dignity, rather than on a trolley in a crowded hospital ward. Again this provides savings over much more expensive hospital care.
Finally it involves a reconfiguration of our hospitals. There are too many of them. It is unsafe for people to stay in understaffed hospitals that may lack the appropriate medical expertise that they need and inefficient to duplicate services best provided in centres of excellence.
It is simple and obvious when you think it through. The problem is that we tend to think of hospitals as the be all and end all of the health service. We have become obsessed with the buildings rather than the needs both of patients and broader society.
This is the root of the problem. Even when we had a functioning government hospital reform proved to be too difficult for politicians. Every party signed up to the reform agenda yet individuals from all parties cried foul at the merest whiff of changes to the hospitals in their areas. This was partly a result of public and media pressure, there are no votes in reconfiguring or closing a hospital in your constituency. It was also partly a failure of communication. The general public did not, and still do not understand the necessity of change, nor do people seem to realise that patient recovery and safety and having a hospital down the street are increasingly incompatible aspirations.
This same mindset, coupled with the lack of progress on reconfiguration has forced Trusts into trying to bail out a sinking ship rather than manning the lifeboats.
So instead of investing in training more nurses over an appropriate period agencies are being deployed to fill the gap, at a very high cost, home care services have been ramped down and the required changes to community-based services are not happening. Indeed many rural GP practices are in imminent danger of closure.
This is compounding the crisis not just because reform is not happening, but also because of the cost. Earlier this month the Independent Health Care Providers, the representative body for private, voluntary, charitable and church-affiliated providers of health and social care published an analysis of official HSC figures for beds last August. It showed that, over a four-week period, there was a total cost of £1,475,000 related to 4338 “bed days” lost, at an average cost of £340 per bed per day.
This is just one part of the overall picture but it perfectly encapsulates how the present system is trapped in a death spiral. Home care is reduced to save money in order to protect hospitals, but the very act of doing so itself costs the system more money (around £17 million per annum) better spent elsewhere. In the meantime home care services are diminishing because they become unsustainable. At the other end of the system A&E gets clogged up because there are not enough beds. Patients end up on trollies in corridors. In extreme circumstances departments may even have to close their doors to new admissions.
This also impacts on staff. There are already shortages. Those on duty are stretched to breaking point. Stress and sickness is inevitable, compounding the shortages.
What this points to is not so much a system in crisis but one which is beginning to collapse.
It cannot go on for any longer. Change is long overdue and the consequences of not acting are potentially incalculable and will affect every citizen. Surely that, on its own, is sufficient reason for politicians to find a way to form a government, to take the brave actions required to enact the former Health Minister’s report: Health and Wellbeing 2026: Delivering Together It may already be too late.
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