Insight: Chronic or acute? The NHS crisis

unscheduled admissions have soared, up to 55,000 non-urgent operations have been cancelled. Picture: Getty
unscheduled admissions have soared, up to 55,000 non-urgent operations have been cancelled. Picture: Getty
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Following a harrowing festive period for national health service patients and staff, Dani Garavelli asks those on the front line what’s gone wrong.

It was 8.30am on Wednesday, 27 December, when we phoned our surgery about our teenage son; he had been ill for the best part of a month and was not responding to antibiotics. Now, his glands were huge and his throat like a razor. Fortunately, we were given an 11am appointment and by mid-afternoon he had been admitted to his own room in the ENT department of the Queen Elizabeth Hospital in Glasgow where he was put on a drip and diagnosed with glandular fever and an inflamed liver and spleen.

Between Christmas and New Year's Eve, 16,900 patients were forced to wait in the back of ambulances (4,700 of them for more than an hour) before being admitted to A&E. Picture: Greg Macvean

Between Christmas and New Year's Eve, 16,900 patients were forced to wait in the back of ambulances (4,700 of them for more than an hour) before being admitted to A&E. Picture: Greg Macvean

Admittedly, the day before had been somewhat more chaotic: a 40-minute wait on the NHS 24 hotline, followed by a trip to a heaving out-of-hours clinic where he was eventually seen and sent away with nothing. But the staff at the surgery and the hospital were fantastic: caring and patient, despite the enormous strain they were under. When he was discharged 24 hours later – rehydrated and with orders to do nothing but rest – we returned home with an enormous gratitude for the treatment he had received, and for the existence of the NHS.

However, being grateful for the NHS does not necessarily mean glossing over its problems. Indeed, closing our eyes to the winter health crisis does frontline workers a disservice, as it fails to acknowledge the enormous pressures they are operating under, particularly in GP practices, A&E departments and intensive care wards, as demand threatens to outstrip capacity.

In England, the scale of the crisis has been impossible to ignore; as unscheduled admissions have soared, up to 55,000 non-urgent operations have been cancelled, and in one 24-hour period, at least 17 hospital trusts – or one in ten – have declared a “major incident”.

Professor Keith Willett, NHS England’s director for acute care, has said the situation is the worst he has ever seen. Some ambulance services have urged 999 callers with less serious conditions to make their own way to hospital, desperately ill patients have been left stranded in corridors, and last week Dr Richard Fawcett, an A&E consultant at University Hospitals of North Midlands NHS Trust, tweeted an apology for what he described as “third world conditions”.

Theresa May and Health Secretary Jeremy Hunt issued their own half-hearted apologies. Picture: Getty

Theresa May and Health Secretary Jeremy Hunt issued their own half-hearted apologies. Picture: Getty

Between Christmas and New Year’s Eve, 16,900 patients were forced to wait in the back of ambulances (4,700 of them for more than an hour) before being admitted to A&E and 12 hospital trusts were operating at 100 per cent capacity.

Theresa May and Health Secretary Jeremy Hunt issued their own half-hearted apologies, while insisting an extra £437m had been pumped into the NHS in the run-up to the festive season and that “it was better prepared than ever”.

But many staff hit back with claims of underfunding. In a Facebook post, A&E consultant Rob Galloway, who is based at the Royal Sussex County Hospital, said the blame did not lie with patients, staff, managers, GPs or the ‘system’ of the NHS,” but with the government. “Years of failed austerity depriving the NHS and council of vital monies and investment is taking its toll,” he wrote.

It is clear – both statistically and anecdotally – that the crisis is not, currently, as extreme in Scotland. Flu rates have doubled since last year and A&E admissions are up by 20 per cent, with some people waiting longer than four hours for treatment, but though non-urgent operations have been postponed in some areas, there has been no blanket cancellation.

Even so, there is no room for complacency. Many hospitals up here are also struggling to cope; in Lanarkshire, office workers were assigned to cleaning duties after Hairmyres, Wishaw and Monklands hospitals were “inundated” and the Deputy Chief Medical Officer, Dr Gregor Smith, warned patients to stay away from A&E unless they had had an accident or were experiencing significant difficulties such as trouble breathing or severe bleeding.

Last week, I talked to two frontline workers, an intensive care consultant in NHS Lothian (who liaises constantly with A&E) and a locum GP who does most of her work in an Edinburgh practice. Speaking on condition of anonymity, they described an NHS straining at the seams.

“I have not witnessed people actually lying in corridors,” says Richard*, the intensive care consultant. “But there are certainly patients who are having to be in A&E for far longer than we would like and who are on emergency department trolleys rather than hospital beds.

“Patients are within sight of medical staff, but they are having to be moved into common areas around the nursing stations rather than being given a cubicle of their own until a bed can be found.”

Richard says there have also been delays in patients being handed over to A&E from ambulance crews. “A&E can’t take them until a trolley is available,” he explains. This delay has a knock-on effect because it puts some of the ambulances out of action. Between 7pm on Hogmanay and 7am on New Year’s Day, the Scottish Ambulance Service received 2,565 calls – a 38.4 per cent increase on last year.

According to Richard, this year’s winter surge has had two principal causes; the flu epidemic, which could, he says, have been forecast by looking at the rising number of cases in Australia six months ago. Less predictably, his department is seeing a mutation in Respiratory Syncytial Virus. Normally, RSV only causes serious problems in children, but this year it appears to be affecting adults with underlying respiratory conditions and the elderly.

All this comes at a time when there is already pressure on beds. In order to function efficiently, hospitals ought to be at 85 per cent capacity or below; this allows for patients to be moved on as appropriate, from A&E to intensive care or from intensive care to a normal ward. But Richard says a reduction in the number of acute beds means that in busy periods hospitals struggle to accommodate patients who arrive at the front door. In addition, despite the integration of health and social care, which is supposed to shift the focus away from hospitals, there are still delays when it comes to discharging patients into the community with appropriate support. At some points of the year, Richard says, 10 to 20 per cent of acute beds will be taken up by people who are fit to leave, but awaiting social care packages.

“What you are seeing all around the UK just now is hospitals operating at 95 to 100 per cent capacity. When you get to that point, you really are waiting for one patient to be discharged – or, if they are predicted not to survive, to die – so that you can get their bed cleaned and another patient can be admitted.”

In some Scottish hospitals, extra overnight beds are being created in day surgery wards, but this brings its own issues as often those areas may not be equipped or staffed to deal with the very sick. Given all this, Richard believes some Scottish hospitals could soon follow their English counterparts in declaring “major incidents”.

“I don’t think it’s that far off if things continue as they are,” he says. “We already have seen chief executives from health boards in emergency departments at 2am or 3am. I don’t think senior management is unaware of the trials and tribulations of frontline staff.”

According to the locum GP, Rachel*, GP practices are also under huge pressure. “In the couple of days since I have been back, it has become apparent this is not going to be a good year for flu. Yesterday we had a huge number of contacts from patients with flu-like symptoms,” she says.

Though the practice she works in is coping with the increased numbers, she says the system as a whole is foundering because of a shortage of GPs and nurses. Last year, the Royal College of GPs in Scotland predicted a shortfall of 856 GPs in Scotland by 2021 and a recent Audit Scotland report raised concerns over a lack of staff.

“There are not enough GPs being trained, posts are not being filled, people are choosing to retire early or go overseas if they can,” she says. Such shortages mean there is no buffer when the service is stretched. Last week her practice was operating without triage because the nurse who would normally perform that role was off sick.

Rachel accepts there is a degree of wastage in the system; she says free prescriptions mean some patients come to GPs looking for paracetamol and moisturiser, and that others hoard medicines such as inhalers, but she is angry with the Westminster government for creating a narrative in which “feckless” individuals or eastern European immigrants are forced to shoulder the blame for austerity.

“It’s chronic under-funding that’s at fault,” Rachel says. “It strikes me as sad that people who are now in their 80s, who remember when the NHS was set up and the reasons why… these are the people who now need the NHS and it is failing them, though they have paid into it their whole lives.

“These are the people who apologise for being a bother, and you tell them: ‘Believe me, I wish I had more time to spend with you. I wish you had better continuity of care. I wish the system was not letting you down.’”

The current crisis comes as the NHS prepares to mark the 70th anniversary of its founding in July. And, of course, there is still much to celebrate. You only have to look across the Atlantic, where President Trump is trying to dismantle Obamacare, to recognise how fortunate we are to have such a comprehensive and accessible service.

However, when Aneurin Bevan set out a vision of a service that would be “universal, equitable, comprehensive, high quality and free at the point of delivery,” he could not have predicted the ways in which the world would change.

To an extent, the NHS is a victim of its own success: better healthcare means people are living longer, while scientific advances have increased the number of drugs and treatments available to them. Meanwhile, other societal shifts have led to extended families fragmenting and the development of a 24/7 culture which has fostered an expectation that healthcare – like fast food – should be accessible at any hour of the day or night.

As a result, the pressures on the NHS have increased exponentially. In its first year, the new service dispensed 15 million prescriptions in Scotland; today the figure is more than 103 million.

With demand potentially infinite, it is no wonder the NHS sometimes seems like a bottomless pit. In England, the service is increasingly under threat from privatisation with some futurists predicting cheap online appointments with private GPs will bring about the extinction of NHS ones. But few in Scotland want to lose the service: so what can be done to make sure it functions more efficiently?

Greater investment in frontline services is clearly key; more GPs, hospital doctors and nurses are needed, but, as Richard points out, you can’t just magic them up from nowhere. “Jeremy Hunt [or Shona Robison] can say ‘we will recruit this many GPs and this many nurses’, but they don’t just appear, particularly at the level of qualifications and skills we want,” says Richard. “Even once they have managed to qualify, they still need to gain experience on the job.” Both he and Rachel fear existing shortages will be exacerbated by Brexit with tighter restrictions on medical staff coming in from abroad.

Another bone of contention is the fixation with targets. In recent weeks, between 81 and 89 per cent of patients in A&E departments have been seen within four hours – well short of the 95 per cent target set by the Scottish government and health boards.

But Peter Bennie, chairman of the British Medical Association’s Scottish Council claims such targets are creating a culture of blame and leading to poor decision-making. And Rachel – who has worked on an A&E ward – agrees. “The four-hour target means nurses frantically rushing around after the doctors trying to make sure they have managed to click a patient outcome on their system before the deadline,” she says. “It has nothing to do with the patient as a human being, their family, their symptoms, the doctor who probably hasn’t had a break to pee. It’s ridiculous, arbitrary and it doesn’t improve healthcare.”

The long-term strategy is to keep people out of hospitals: to prevent unnecessary admissions and to speed up discharges back into the community. This is why health and social care have been integrated. Though it is early days and funding continues to be an issue, some initiatives are already making a difference. In NHS Lothian, for example, the community respiratory team takes on patients with Chronic Obstructive Pulmonary Disease (COPD) and helps keep their condition under control.

As Artificial Intelligence technology advances, it could also prove a vital tool in supporting self-management. Scientists have already developed an artificial pancreas device which could help people with diabetes. The system has a sensor that monitors the patient’s glucose levels and a pump that automatically delivers the correct amount of insulin into their system. Other potential developments include toilets that analyse a patient’s urine to check if they have taken their tablets and issue a stern reminder if not.

Mhairi Hunter, vice- chair of Glasgow City Council’s Integration Joint Board, says progress is also being made in the provision of intermediate care – a kind of bridge between hospital and home, or hospital and residential care. You can keep on throwing money at the acute sector, without actually changing anything,” says Hunter.

“We need to shift resources into primary and community care. The more you keep people out of hospital, the greater the capacity for dealing with elective treatment.”

There is no dodging the fact that people also need to take more responsibility for their own actions; they need to cut out their bad habits, stop missing appointments, remember to take the medicine they have been prescribed and use services appropriately. With this in mind, there has been investment in information campaigns that seek to educate the public not to seek antibiotics for colds and not to misuse out-of-hours services.

As a society, we also have to face up to the fact that resources are finite and that difficult decisions have to be taken about spending priorities. Most of all, however, the NHS needs to be valued by politicians and punters alike.

“It needs to be better funded and better appreciated and not taken for granted,” says Rachel. “And staff working on the frontline need to have their morale boosted. We need to stop hearing about how terribly we are doing, how awful A&E departments are. Because we are doing our best. Of that, I can assure you.

*Name has been changed