In the second of a series of blogs by members of Council at the Royal College of Physicians (RCP), Dr Roby Rakhit outlines what can be done now and in the future to improve the delivery of care by the NHS through addressing issues in service capacity, workforce levels and financial sustainability.
Develop flexible systems
The first and most important factor that is affecting clinicians’ current ability to offer NHS patients safe, timely and effective care is obvious: the disconnect between demand and capacity in the NHS. We have insufficient capacity in the system to provide a safe, effective and responsive world-class service.
Allied to that, we work to arbitrary and non-evidence-based timelines like the 18-week referral to treatment or the 4-hour A&E target. We should instead engage directly and honestly with patients, to gain a consensus about what are felt to be acceptable waits for treatment and to identify the resources that are required to deliver this.
Targets have been distracting and artificial, and they move the focus away from high-quality care. They have also led to an unnecessarily negative perception of the UK health system from the outside world. For example, in Switzerland (where I worked for a year) average bed occupancy was 65–70% and in France it’s 70–80%, whereas over the last few months some NHS hospitals have been running at 95% bed occupancy. It’s impossible to provide a responsive, safe and effective service under these circumstances.
Another flaw is the inter-relationship between elective and emergency care. By definition, unscheduled emergency care requires flex in a system, including in relation to bed base, intensive treatment unit (ITU) and theatre capacity. Running NHS hospitals to maximum capacity immediately removes flex in the system and it directly impacts on providing high-quality elective care. We need for hospitals to disconnect their elective and emergency functions and to develop more flexible, dynamic systems that would help with bed flow and getting patients out of hospital.
Invest in training
The second factor is human resource: both medical and nursing. We have one of the lowest numbers of doctors per head of population in western Europe. For example, in Italy there are five times more cardiologists per capita. We have a huge issue with underdoctoring and attracting nursing staff into the profession and keeping them. We therefore need to seriously invest in training, recruitment and retention of nursing and allied medical staff. We also need to raise nursing pay in line with the rest of Europe, and to be sensitive to the true cost of living, particularly in areas like the south-east of England.
With respect to junior medical staffing, we rely far too heavily on trainees to run services. We need to look at provision of services differently and to take a different approach by asking: ‘What is the core staffing needed for a service to be delivered and what number of additional trainees could be accommodated in a supernumerary role?’. Relying on trainees to support rotas and to fill rota gaps primarily for providing the service leads to conflict between trainees’ expectations of training and service delivery.
We need to train more doctors and to acknowledge that medical staffing is a global market, in order to attract the very best talent from around the world.
To run safe, effective services, we need more permanent non-trainee doctors working with consultants in the delivery of clinical services. We need to train more doctors and to acknowledge that medical staffing is a global market, in order to attract the very best talent from around the world.
We currently have many rota gaps at multiple levels. My trust has experienced up to 40% gaps for acute medicine, such that services are increasingly reliant on locums. The European Working Time Directive (EWTD) has been very restrictive on allowing us to fully staff rotas. Existing EU rules have meant that our recruitment and immigration systems actively discriminate against doctors from non-EU countries. The uncertainties around Brexit have compounded this issue such that the previous flow of EU doctors wishing to work in the UK has taken a hit in addition to EU applications to UK medical schools. Our inability to attract from around the globe is a big flaw. We need to change the narrative and let the world know we are fully open for work.
Talk about financial sustainability
The third factor is financial. Issues about the NHS’s financial sustainability are not going away: we therefore need cross-party political engagement in a debate about how best to fund the NHS in the long term. Ensuring that healthcare remains free at the point of delivery is a tremendous principle and it is not replicated anywhere in the world. However, with rising costs of medical intervention and drugs, and with an ageing population, our current financial template needs to be addressed. But we’re stuck because no political party is willing to start that debate.
There’s a disconnect between what front-line clinicians, non-governmental organisations (NGOs), royal colleges and institutions like the King’s Fund are seeing and saying and the government’s response.
The quality of the public debate about NHS resourcing and demand pressures is driven by political agendas and spin. There’s a disconnect between what front-line clinicians, non-governmental organisations (NGOs), royal colleges and institutions like the King’s Fund are seeing and saying and the government’s response. There is a political smokescreen that is clouding the true issues and a culture of denial, which risks harming patients.
To improve the debate, there has to be better engagement between the government and organisations like the royal colleges and other professional groups / NGOs that are interested in healthcare outcomes, rather than reacting from the hip and soundbites that appear to aim to deflect attention from the real agenda. We need an honest appraisal of the data, leading to a proper debate with the public. We should ask:
- ‘What kind of NHS do the public want?’
- ‘Rather than setting arbitrary targets, do you want to wait 4 hours / 18 weeks?’
- ‘If not, how long is it reasonable to wait for treatments?’.
The debate needs to happen first, then the decisions about the metrics, funding and resources that are needed should follow on from the debate.
In England and Wales we have developed mechanisms to keep patients away from secondary care (ie walk-in centres, minor injury units and NHS 111). However, these models have made little real impact on the flow of patients who are accessing A&E departments. This is because the interactions that patients experience are inconsistent and, in the case of NHS 111, they don’t meet patients’ expectations when they want to see healthcare professionals. The ‘virtual consultation’ that is offered to patients is inadequate and patients vote with their feet by utilising A&Es systematically and often inappropriately, in order to have a meaningful face-to-face consultation with a healthcare professional. To work properly, the use of these services needs to be allied to a major health education campaign, so that patients have a better understanding of health and wellbeing in order to better self-manage their minor problems and so that they gain greater insight into when it is appropriate for them to access medical care.
What we can do now
Two things could improve the situation in the immediate short term (ie within weeks):
- Increase bed capacity for urgent care to match ‘European’ bed occupancy levels, in order to allow hospitals to flex and be more responsive to winter or unscheduled pressures. Achieving this will require a much more realistic bed base for emergency and unscheduled care, and a zero tolerance for 95% bed occupancy levels. Effectively, we need to run an acute service within acute settings, rather than running social care in hospitals. We could try 95% bed occupancy levels for elective care, but for non-elective we need tolerance and flexibility. But that will require cash for non-elective care, and we also need to staff those beds appropriately.
- There should be a major investment in social care and primary care across the country. National funding for local government took a big financial hit. Although plans are afoot to mitigate this, the corresponding infrastructure needs to be rebuilt. Allied to this is the current meltdown in primary care because general practice is in crisis. The key to keeping patients out of hospitals is effective primary care, so urgent recruitment and retention of GPs is an urgent priority.
What we can do next
In the intermediate short term (ie within months), I agree with a whole-system approach to healthcare delivery, which is a key part of the sustainability and transformation plans (STP) programme. We need to stop the internal competition within the healthcare market that has plagued the delivery of truly integrated care. Hospitals need to interact more closely and effectively with primary care – the high percentage of recurrent patient attendances to urban A&E departments is a symptom of the failure of systems in primary care to manage patients out of a hospital setting. We need to increase access for patients to specialists by challenging the paradigm that specialists can only be accessed in hospital settings. This can occur by redefining care pathways: for example, by increasing the presence of specialists in the community settings and learning from similar models that exist in Europe.
Investment must take account of demographics – old age, frailty, disease complexity and disease prevention – and use dynamic, strong health prevention campaigns.
In the longer term (ie within 18 months or longer), we need sustained investment to allow adequate capacity to truly reflect demand and the complexity of the healthcare population. Investment must take account of demographics – old age, frailty, disease complexity and disease prevention – and use dynamic, strong health prevention campaigns. With respect to cancer prevention, we can do more to educate people on lifestyle, diet, exercise, smoking cessation and industrial pollution. It’s all about sustainable funding, and being flexible to meet the need of our changing population: our current care template is static and reactive. We need to plan for changing demographics (such as the rise in the older population that we have witnessed over the past 10 years) so that we can then predict the population’s need prospectively.
I don’t expect NHS performance to improve under our current political leadership: we have no evidence that there’s going to be the significant further investment that is needed to catch up with the lack of investment since the 2012 Health and Social Care Act. Funding for the NHS has not kept up with inflation, the rising costs of drugs and technology and our ageing population.
If anyone doesn’t believe that a targeted injection of funding makes a difference, let’s reflect back to the National service framework for coronary heart disease, which was implemented when the NHS was considered to be the ‘sick man of Europe’. Health secretary Dr John Reid put £93 million into new cardiac centres, cardiologists and cardiac surgeons, and as a result waiting lists tumbled and our outcomes are now among the best in the world as a result of that focused investment. In my field, waiting lists have meandered upwards in these last few years because investment has just not kept pace with demand for cardiac care.
Dr Roby Rakhit, elected member of Council at the Royal College of Physicians (RCP)
Dr Rakhit's views are his own and not necessarily representative of the RCP as a whole.