The series of articles by members of Council at the Royal College of Physicians (RCP) continues with Dr Tanzeem Raza, a consultant physician at the Royal Bournemouth Hospital, explaining how a lack of social care provisions and ongoing recruitment difficulties are affecting the NHS.
The immediate mismatch between demand and supply is the main factor that is currently affecting clinicians’ ability to offer NHS patients safe, timely and effective care. Patients’ expectations and needs far exceed clinicians’ and hospitals’ ability to meet them. This situation is complicated by persistent hospital bed and ward closures. Some of this, to be fair, reflects changes in clinical practice and shorter lengths of stay. However, some managers have an unhelpful perception that we can somehow make the system more efficient by generating pressure to move patients through the system faster.
The second factor is related to social care: too many people in hospital today are medically fit for discharge, but they have nowhere safe to go. As a result, they linger in an acute setting for longer than they need, and this delay obstructs proper flow throughout the system.
There are a few factors behind the recruitment difficulties: one is that every UK doctor is usually now in a training programme, so we’ve lost a pool of potential applicants to fill short-term gaps for maternity leave or out-of-programme training etc.
The third factor is the ongoing difficulty in recruitment, especially at middle grade and junior levels. Locally, we’ve advertised some posts three or four times but had no good-quality applicants. There are a few factors behind the recruitment difficulties: one is that every UK doctor is usually now in a training programme, so we’ve lost a pool of potential applicants to fill short-term gaps for maternity leave or out-of-programme training etc. Also, changes to immigration laws have made the rules about hiring non-EU doctors much stricter, which means that another big pool of potential candidates is no longer available to fill gaps or non-training posts. And with Brexit, we’ve slammed another door shut for our EU colleagues. We’re not training enough doctors and we have massive rota gaps. Jeremy Hunt talks about creating 1,500 more training places, but that will take 10 years to deliver.
So there are multi-factorial problems. At the forefront is the lack of social care provisions, especially where I work in Bournemouth, which has a significantly older population. If we can get patients out of acute settings and into safe community care places, we can improve the system to a reasonable degree and close the gaps. For example, today we have two to three wards' worth of medical patients who are on non-medical wards and on non-older patient wards, and that causes further problems. Today, in the Royal Bournemouth, we have 54 patients in non-medical wards. And about 30–40 patients are medically fit for discharge but there’s no safe place for them to go to.
If we want to improve the quality of public debate about NHS resourcing and demand pressures, we should start by acknowledging that, generally speaking, most patients receive a high-quality service in acute care – doctors and nurses do a great job in very pressured environments. However the pressures are relentless and the resources are limited. So we mainly need to highlight this in the lay press, in order to ensure that people know about the problems that the NHS is facing, and we need to make sure that this remains a high-profile issue. The same pressure is certainly also present in primary care, where people struggle to make appointments, which leads to increasing use of acute care and emergency departments as a first port of call.
When I was a junior doctor, it would be very rare for patients to go to A&E unless they were seriously ill, but now if they face waiting for days for a GP appointment, they go where the lights are on: the hospital. The new 2004 GP contract has its own issues, but changes in primary care have significantly increased the pressure on acute providers.
Access arrangements (ie to walk-in centres, minor injury units and NHS 111) have become confusing to patients and unhelpful to clinicians. A few years ago, an effort was made using Darzi centres to take patients who need routine primary care away from acute care. But patients didn’t use these services, so they ended up in acute care regardless. There’s also been a culture change, in terms of patients no longer having a personal relationship with a specific GP who knows them and their family. Since sadly that relationship has broken down (and is not restorable), we have seen a significant increase in demand at hospitals.
Without a magic wand, there’s no one thing that can help the NHS in the immediate short term (ie within weeks): we need a whole-system change. I still feel that the NHS does a great job in providing care to patients who need it. But society needs to invest in social care provision. Health and social care need to be more integrated. Also, the artificial division between primary and secondary care, and the false internal market, have caused further confusion and problems. Commissioners ultimately use money from one big NHS funding pot, so the internal market is an artificial divide that creates more problems than it solves.
In the intermediate short term (ie within months), we need far more joint working and collaboration between primary and secondary care. Secondary care needs to support primary care more, in order to blur the divide between these sectors like they do (I believe) in Scotland. Removing that barrier will not solve all the current issues, but it will lead to better communication and will possibly improve patient services. In addition, the NHS needs more investment because healthcare is becoming more expensive. However, that won’t happen while we are negotiating Brexit. Investment, if any, has to be in social care and its integration with primary care. Those areas could make the system more efficient than it currently is.
Having come here from Pakistan, immigration is obviously close to my heart. But people should realise that immigration enhances the UK’s reputation internationally, when medical professionals who trained here go back to the country of their birth.
To improve matters in the longer term (ie within 18 months or more) we again need to remove barriers between sectors. The UK needs to review its immigration policy carefully. The public need to learn that if they want the NHS to function as they expect it to, we need to let talented clinicians into the NHS more easily, in order to enrich healthcare provision. Having come here from Pakistan, immigration is obviously close to my heart. But people should realise that immigration enhances the UK’s reputation internationally, when medical professionals who trained here go back to the country of their birth. With UKIP breathing down the government’s neck, and with president Trump’s election in the USA, a relaxation of immigration policy might be unlikely, but that is what I’d like to see: a pragmatic and accommodating policy. Unfortunately, we’re currently very inward-looking.
I don’t see NHS performance improving in the immediately foreseeable future. If we can even maintain what we’re achieving now, that’ll be great. But I worry about disintegration and stealth privatisation leading to a greater erosion of the more lucrative services: that’s a real potential threat to the NHS. I’m worried about that more than about saying ‘let’s get the NHS to be an all-singing, all-dancing service with bells and whistles’. I worry for the future of the NHS – it’s crucial to this country.
Dr Tanzeem Raza, elected member of Council at the Royal College of Physicians (RCP)
Dr Raza's views are his own and not necessarily representative of the RCP as a whole.