I’m at a loss to understand how the NHS is going to meet rising demand.
Despite all the talk of efficiency and productivity, it’s going to be a tall order - and practically impossible if we want it to stick to its founding principles.
Several recent stories convince me of this. Hard evidence on demand comes in the form of a recent study by the Nuffield Trust which points to a “unsustainable” rise in emergency hospital admissions. There’s been an almost 12% rise in admissions over the last five years, costing the NHS an additional £330 million per year.
The government’s announcement that it’s disbanding NHS Direct, the 24-hour advice line, isn’t going to help. I’m no expert on primary care, but it appeared a useful service that helped take the heat off A&E and GPs.
If you believe the Save NHS Direct Campaign (with it being led by John Prescott, maybe you won’t) then the phone line fields 27,000 calls a day, or 9.5m a year. It’s staffed by 1,400 nurses, provides evidence-based information on its website and scores well on customer satisfaction.
Replacing it with a cheaper service, with fewer health professionals involved, is unlikely to help with demand.
Department of Health figures released this week suggest that GP referrals to secondary care are accelerating once more. Data on outpatient referrals and attendances show the number of GP referrals made from April to June this year increased by 169,000 to 3 million.
Referrals can be clamped down upon temporarily during times of financial crisis, but not when facing inexorable pressure.
It strikes me that there are parallels with global warming (largely because I’ve just ploughed through a weighty tome on the subject to assuage my guilt over reading Stieg Larsson on holiday).
There are loads of things we could do to help with the long-term sustainability of our health system. We should improve our approach to public health, deliver more preventative services, and so on. But, much like reducing our carbon emissions, it’s going to take too long. The NHS is going to be bankrupt long before then.
We have to do something now to deter the ‘time wasters’ from entering the system, and the only way to do this is to put a value on an NHS appointment. We need a simple system of charging for appointments. The usual groups would be exempted from charges and treatment would still be free (I’d even scrap the anomalous prescription charges system).
Jumping back to my rather spurious comparison with global warming, it’s the equivalent of investing in a quick technological fix rather than obsessing about the long game. My personal favourite is to mimic a volcano and pump some sulphur dioxide into the stratosphere to enact some global cooling.
It’s not something you want to do - and there’s always a risk of unintended consequences - but a dramatic approach like this is increasingly necessary, even if it compromises a few principles.
Tags: Admissions, Charges, Referrals
When the NHS was launched by the minister of health, Aneurin Bevan, on July 5 1948, it was based on three core principles: that it meet the needs of everyone; that it be free at the point of delivery; and that it be based on clinical need, not ability to pay.
If you start charging then, along with the re-introduction of the internal market, you will soon no longer have a National Health Service. The answers lie in efficiency and rationalisation, not charging or privatisation.
Agree completely with the above, one only needs to spend a few hours in a receiving ward, A&E or an outpatient clinic to witness the incredible waste of resources that occurs on a daily basis in the NHS simply because people have nothing invested on a personal level in the services they receive. The principle of being free at the point of delivery is an ideal, but perhaps it was better suited to a time when the public could be trusted not to abuse the system incessantly. A small, means tested charge would eliminate a significant proportion of this problem.
Sit on a Monday morning and report the x-rays taken in A&E over the weekend and you will soon realise the extent of the problem. Hundreds of banged fingers, sore toes, bumped knees all seem to end up with a trip to the hospital where, inevitably, an x-ray is both expected, if not demanded by the patient/parent. The vast majority are completely normal, and indeed are taken to “exclude” bone injury.
The problem is that if a service is perceived as “free” it will be abused as a “right”.
(Some weeks ago my own Trust was in the dodo having missed the 4 hour target on a Monday. During that day there were about 500 attendances! That is impossible to manage)
Dunno the answer!
Good points above but we should ask ourselves who it is that orders and authorises these inappropriate investigations, referrals and admissions. I am afraid to say that it is not the patients themselves despite the undoubted truth regarding increasing demands and expectations, but doctors who are ultmately responsible. The reason for this trend is the fear of complaints and litigation which results in a failure to take responsibility and make rational clinical decisions based on history and examination. Advances could surely be made by looking and revising the complaints procedures and providing more support for doctors who have made sound clinical decisions even if subsequently pathology is found. For example if the mechanism of injury and clinical examination do not support the need for an x-ray then don’t order one. Education of patients in their expectations of clinical medicine would likely reduce unrealistic expectations and improved education and support for doctors may well improve their confidence in their clinical decision making and encourage the taking of personal responsibility.
In answer to Robert S, the NHS no longer meets the needs of the people, and there are already charges in the system (dental, eyes,prescriptions, orthotics etc) and charges will certainly address his concerns about efficiency as paying sharpens the determination to keep appointments or deters timewaster. I broadly agree with Mike Broad (no pun intended), but there are many further area of inefficiency that could be addressed in the hospital setting eg how many meetings in clinical time are poorly agendaed, poorly attended and achieve nothing? In my experience the majority, and using electronic communication properly could obviate the need for meetings to be called, usually by managers, anything like as often.
A GP who was around on the first day of the NHS once described the sorry procession of people - mostly women - who appeared with horrible conditions, having spent their money previously on their sick children and their bread winning husbands. Charging doesn’t deter the inappropriate, but the poor.
There is a lot we could do as a profession, both in primary and secondary care. Tired of seeing for example X ray requests that say ‘patient wants an X ray’. Since when was that an indication? There are many guidelines eg re lumbar spine and ankle films which are rarely followed. Clinical acumen has sadly disappeared to be replaced by fear of litigation.
Agree also that we waste a huge amount of time on ‘meetings’ of one sort and another, spurious management activities etc. A dermatologist friend once visited a colleague in the US and was amazed at the efficient management support he had. The US doc explained that managers understood that only doctors can do doctors work and they cost a lot of money. Best to let them get on with it, not spend their time doing clerical and management stuff that less expensive staff can do, A recognition that good management should be about supporting the essential work of hospitals ie professionals seeing patients, would go a long way
Charging for health care is one of those things which tends to only be suggested by people who can afford to pay. You only have to look at dental treatment,now a preserve of the well off, if my patients’ teeth are anything to go by. Also prescription charges, which many people struggle to pay particularly if they need multiple medications. Rather than penalising the poor and elderly, the greatest users of healthcare, we should target the causes of public ill health such as obesity and alcohol, which cost the NHS billions. This takes more political courage as both are supported by powerful industries with effective lobbyists.