Beginning a series of blogs by members of Council at the Royal College of Physicians (RCP), Professor Simon Taylor-Robinson explains what he believes to be the biggest issues surrounding the delivery of care by the NHS, and offers some solutions to current problems affecting doctors, patients and families.
The main factor that is affecting clinicians’ current ability to offer safe, timely and effective NHS care is the fact that hospitals are underfunded, underdoctored and overstretched, as the RCP has been saying repeatedly.
Underfunding can take the form of hospital bed cuts, which means that we can’t get people into hospital due to a lack of beds. Underfunding of social care also means that we can’t get people out of hospital. So we get crazy situations where ambulances are being stacked up like at Heathrow air traffic control because they can’t get in to the hospitals to unload patients.
Recently, we had to open our endoscopy department to people who were waiting to be admitted to A&E: that meant that we couldn’t do endoscopies, as all the trolleys were taken by those who should have been in A&E. This situation prevents throughput; it silts up the NHS’s coronary arteries and creates a sort of organisational heart attack. The single biggest consequence of this is the impact on throughput into hospital beds (which have been cut in many places), or the social care-related inability to get people out of hospital safely.
In my own discipline, liver medicine, many drugs cost an awful lot of money, and we’re somewhat rationed in terms of what we can prescribe. For example, the new hepatitis C drugs cost £35,000 for curative treatment. The new budget pressures are stretching the NHS: people want to receive these excellent curative treatments but, as a result, spending has to be cut in other places because the financial pot is finite.
In the past, we didn’t think about this cost; we just prescribed medication in the patient’s best interest. There are now big restrictions on what we can and can’t prescribe, due to finite budgets. So there is healthcare rationing, and not just in acute settings – the same is true for specialties that are treating people with chronic, long-term conditions. We’re seeing rationing over and above that of National Institute for Health and Care Excellence (NICE) approval, in my experience.
NHS England says that, for hepatitis C, we have to treat patients in the order of how sick they are. But with ever more patients, we now have a numerical limit on how many patients we’re allowed to treat: we are only allowed to treat 30 patients per month in our region. As a result, the waiting lists are long. There are very few patients who offer to self-pay for these drugs: hepatitis C chiefly tends to affect people who are not on high incomes.
The biggest factor for the NHS is the simple lack of resources, while a lack of coordination with social care is the single biggest problem amongst this.
The biggest factor for the NHS is the simple lack of resources, while a lack of coordination with social care is the single biggest problem amongst this. We can’t get people out of hospital properly. I work at St Mary’s Hospital in London, where the BBC2 documentary Hospital was filmed. That documentary showed the pressures that hospitals face, and it was fairly true to life. But that programme was recorded last year; the pressures are now even higher.
Improving the quality of the public debate about NHS resourcing and demand pressures will involve making people understand the issues and problems in the first place. Such understanding is really not out there: newspapers like middle England’s Daily Mail are rarely getting out into the NHS to really understand the issues. So a documentary like Hospital can be helpful to present the daily issues clearly to the public.
We need to do more at the RCP, to help to inform public opinion. Getting the message over to the popular press requires us to ‘drip-drip-drip’ feed information (eg to talkRADIO and others). Radio can be a very useful medium because people listen to it while they’re commuting or doing other things.
Access arrangements (eg to walk-in centres, minor injury units and NHS 111) have become confusing to patients and unhelpful to clinicians. Because of all the bad press that it’s had, NHS 111 has left people unsure and unhappy about getting the wrong advice. If they go to A&E, at least patients will get to see an actual doctor. The algorithmic diagnostic pattern of questions that NHS 111 uses may elicit the wrong answers from people who have poor health literacy, whereas seeing the patient in the flesh gives you all sorts of diagnostic shortcuts. But that also means that people may use A&E inappropriately. Although GPs have received a lot of stick from the government about access and weekend working, there’s no substitute for encouraging and involving GPs in redesigning access arrangements, rather than accusing them and making them feel demotivated. GPs have to be the first line of access so that the right patients go to A&E.
One change that could help the system in the immediate short term (ie within weeks) would be to educate the public about when it’s appropriate to use A&E. A&Es get flooded with people who just shouldn’t be there. The public needs to be reminded that they should consult GPs first, because a GP’s views of which patients need to attend A&E will be well-informed.
To help matters in the intermediate short term (ie within months), I’m aware that the sustainability and transformation plans (STPs) are coming up with some good national and regional ideas to try to align social care and acute providers in 43 individual footprints (ie local(ish) and manageable health economies rather than one big national picture). Empowering the STPs could be a good thing: they could deal with problems at a local hospital and help to get the problems locally owned. There are some reasonable ideas in some of the STPs, and in the medium term it would be helpful to see some of these ideas through to implementation.
It’s harder to suggest things that may help in the longer term (ie within 18 months or more). The government is opposed to pouring more money in willy-nilly, so more resources would depend on political will. More money in certain directions could help, especially with social care, although a recent National Audit Office report was very sceptical about the Better Care Fund. It’s not clear that any easy answer will present itself soon. But in the longer term, we must educate the public about when it’s appropriate to go to hospital.
We need to build and promote joined-up teams. Acute medicine has become perceived as unglamorous: people believe the bad news, which results in people choosing other specialties.
Also, we must have more recruitment into acute medicine, in order to make it a more attractive career. Acute medicine has become unattractive partly due to general professional negativity. RCP president Professor Jane Dacre’s campaign #MedicineIsBrilliant is spot on. I speak to junior doctors every day who say that they wouldn’t do my job because it’s tough, hard, unrewarding and stressful. The RCP could do much more on ‘Medicine Is Brilliant’, in order to clarify that in the cut and thrust of delivering healthcare, being an acute physician is a great thing to be. That message could attract young people, rather than us harping on about issues such as rota gaps and locums. We need to build and promote joined-up teams. Acute medicine has become perceived as unglamorous: people believe the bad news, which results in people choosing other specialties.
I interviewed applicants for medical school yesterday, and the number of applications has fallen. Even among the lay public, you find that people think they don’t want to practise medicine because the job is really tough. If we as a profession and a medical college send out the wrong signals all the time, we’ll get a self-fulfilling prophecy. It’s very well for Mr Hunt to say that we can try to train doctors in less time, but there are still fewer people applying to study medicine. For example, Imperial College London, which is one of the world’s best universities, took part in clearing last year.
We are not encouraging or inspiring people enough. Medicine is brilliant – so we need to agree on this and to avoid sending out the wrong messages. That feels like it is an unpopular thing to say, and it shouldn’t be: despite all the resource and demand pressures that we face, we do really good things for patients.
Professor Simon Taylor-Robinson, elected member of Council at the Royal College of Physicians (RCP)
Professor Taylor-Robinson's views are his own and not necessarily representative of the RCP as a whole.