Health care crisis

P.S., a sister in a south London paediatric accident and emergency (A&E) department, has worked for the National Health Service (NHS) for the past three decades, and though she loves her job, she has on occasion contemplated a shift to the private sector. While she knows she will probably remain with the NHS for the rest of her working life, her willingness to consider alternatives is a testament to the times.

While pressure is always high on those working in A&E departments, it has increased over the years, and this winter has been particularly difficult. Young children have had to wait several hours to be seen, and P.S. and her colleagues have faced immensely difficult decisions about whom to prioritise. “You constantly worry whether you are missing something, and a child could die as a consequence of your decision,” she says. The situation has been even tougher in the hospital’s adult A&E ward. At times this winter, people have had to queue to get in, ambulances have been unable to offload patients, and many patients have waited for hours at a stretch, often exceeding the government stipulation that patients have to be seen at A&E departments within four hours. The hospital’s experience is far from isolated, or the worst this winter, as two patients died while waiting on trolleys to be seen at an A&E in central England, and several hospitals declared “black alerts”, meaning they were unable to provide life-saving care. The Red Cross warned of a “humanitarian crisis” in the hospital and ambulance services of the country. That description of the situation in the NHS, while quickly rejected by Prime Minister Theresa May, has continued to haunt the country, sparking a new debate on the future of the public health service revered by many across the world.

“We’ve always seen pressures when winter comes, but now they are much worse and the problems continue through the year…. We are in a perpetual winter crisis,” says Dr Kailash Chand, deputy chair of the British Medical Association (BMA), who has been an outspoken campaigner for the NHS for over three decades. “Our NHS is in crisis, but our Prime Minister is in denial,” declared Labour leader Jeremy Corbyn at a recent Prime Minister’s Question Time.

Like most crises, the causes of the NHS’ current plight are complex and interwoven. Funding is certainly at the centre of it. Spending has failed to keep pace with the needs of the system as an expanding and aging population and advances in medical technology raise what is expected of it. While the government has attempted to paint a picture of a health system being given more and more money, senior figures within the NHS have fought back. At a parliamentary select committee hearing earlier this year on the financial sustainability of the NHS, Simon Stevens, the head of NHS England, was particularly frank. He said that it would be “stretching it” to say that the NHS had got more than it had asked for as the government claimed and that compared with other Western nations such as France, Germany, the Netherlands and Sweden the country spent “substantially less” on a per capita basis, with spending per person for England actually set to fall in the year 2018-19. In its contribution to the committee inquiry, the NHS Confederation estimated that while increased demand required spending to increase by 3 to 6 per cent a year in real terms, funding had in actual fact increased by less than 1 per cent a year over the past six years. In a report late last year, Britain’s National Audit Office warned that with over two-thirds of NHS trusts in deficit for the year 2015 to 2016, financial problems for the NHS were “endemic”, impacting access to services and the quality of care. “This is not sustainable,” the auditor warned.

NHS funding came into the spotlight last year as the pro-Brexit camp put funding at the heart of its campaign, pledging an additional £350 million a year for the NHS should Britain leave the European Union (E.U.). Less than three months after the vote, the Change Britain campaign removed the pledge from its website, and Cabinet Ministers who campaigned for Brexit have distanced themselves from that pledge to much public anger.

Cut in the social care budget

Critics of government policy have also increasingly pointed to the spending cuts outside the NHS that are having a severe impact, in particular the cut in the social care budget. With Britain’s elderly population far more dependent on state or institutional support than on family unlike in countries such as India, social care provision matters immensely. The government has cut social welfare spending as part of the austerity regime many European nations brought in in the wake of the eurozone crisis, and this has had a knock-on effect on the health care system. Hospitals are loathe to discharge patients who would have little support at home. “The cuts to the social welfare budget have been to the tune of £5 billion over the past five years,” says Chand.

“The end result [of a lack of investment in care services for adults] is people stuck in hospital beds that are needed for new patients or they are discharged without support,” the Red Cross warned earlier this year. “No one chooses to stay in hospital unless they have to, but we see first hand what happens when people are sent home without appropriate and adequate care… if people don’t receive the care they need and deserve, they will simply end up returning to A&E and the cycle begins again.” A similar situation is plaguing paediatric A&E, says Sister P.S. Under the British system, much of the health care for young children is delivered by “health visitors” rather than paediatricians, and with their numbers in decline as a result of cuts to local government public health care budgets, parents often use A&E as their first point of reference. There have also been questions around the NHS’ advice line: a lack of medically trained staff to advise people means that cases that general practice can easily deal with are referred to A&E, and in other instances severe illnesses have been missed, with devastating consequences.

Financial pressures have also meant that there is little focus on community health. “Fifty to 70 per cent of cases coming to the G.P. [general practitioner] or hospital are essentially diet related, yet just 2.5 per cent of NHS money is spent on public health. It’s meant to be a national health service but we are a disease service. We need to move to a preventative model. People may call it the nanny state, but they said that about the introduction of seat belts and the ban on smoking [in public places],” says Chand. The struggles of the NHS have haunted past governments, including Labour governments, but Chand believes there is a fundamental problem with this administration’s approach: “The trouble is that this government is not ideologically committed to publicly delivered health care,” he says pointing to a publication, Direct Democracy: An Agenda for a New Model Party , that a group of senior Conservatives, including current Health Secretary Jeremy Hunt, brought out in 2005. It advocates a shift to an insurance system. “The problem with the NHS is not one of resources. Rather, it is that the system remains a centrally run, state monopoly, designed over half a century ago. We should fund patients either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means would have their contributions supplemented or paid for by the state,” reads the chapter on the NHS.

24-hour seven-day-a-week service

This fundamental ideological opposition to the NHS has driven a number of government initiatives on health care, including its focus on providing a 24-hour seven-day-a-week service, which has put it at odds with medical unions, says Chand. The NHS already provides 24-hour emergency care, but questions have been asked about the provision of health care and the availability of medical staff, doctors particularly, on weekends. “When the system can’t cope with a five-day-a-week service and we have seven-day cover already, when you don’t have the manpower and resources, it’s a hugely irresponsible move,” says Chand. “Ultimately, they want to give the impression that the NHS can’t deal with things, and the only way to improve the situation is to bring in the private sector.”

While privatisation of the NHS had commenced under Labour, it has accelerated under the Conservative government through the Health and Social Care Act, 2012, which enables NHS hospitals to make up to 49 per cent of their money from private patients. “The Health and Social Care Act, 2012, did not begin the involvement of the private sector providers in the NHS; both the [Tony] Blair and the [Gordon] Brown Labour governments used private providers to increase patient choice and competition as part of their reform programme. However, the 2012 Act did extend a market-based approach to the NHS, emphasising a diverse provider market, competition and patient choice as ways of improving health care,” explains a report by the health care charity the King’s Fund in 2015. There has been a steady stream of privatisation since, including the part privatisation of NHS Professionals, one of the government’s main NHS recruitment agencies, late last year. Parliamentarians over the years have raised their concerns to little avail.

“The 2012 Act forces NHS contracts out to competitive tender in the marketplace, allowing private companies to cherry-pick NHS services from which they can make money. Since 2012, we have seen the effect of NHS contracts going to private companies; it undermines NHS services and the pay and conditions of staff and fragments the service. The sums of money involved are eye-watering,” said Labour MP Margaret Greenwood last year as she attempted (unsuccessfully) to bring a Private Member’s Bill to reverse the changes.

“They say that private is better than public, but the truth is that private companies look after shareholders first and foremost. There has been a lot of unnecessary contract tendering, which is not right for the health care sector. Administration costs have gone up tremendously: in the early 1980s, when privatisation wasn’t so ingrained, the administration cost was around 6 to 7 per cent, but that has gone up to 14 to 15 per cent thanks to bureaucracy, unnecessary tendering,” says Chand. “We have to take the marketisation out of health care. It’s a huge, huge usage of taxpayers’ money.”

The problems have been compounded by toughening the immigration rules governing doctors, in particular since 2007, when the government introduced rules requiring that preference be given in training programmes to medics from the E.U. The British Association of Physicians of Indian Origin (BAPIO) blocked in the courts an attempt to introduce it retrospectively, but the overall approach has meant a sharp decline in the number of non-E.U. doctors. It has had a particularly dramatic impact on the number of Indian medics. Indian doctors have been able to work in the United Kingdom since the 19th century, and their numbers accelerated in the 1960s following an aggressive recruitment drive thanks to shortages of skilled personnel in the U.K.

It is not just the rules that have made it harder for doctors to work in the U.K. A hostile environment has made it less attractive to do so. The domestic media constantly question the value and skills of foreign doctors and a number of studies have identified the difficulties that non-white medical staff have had in climbing to the top of the NHS and in key examinations and disciplinary procedures. In a 2014 court case the BAPIO brought alleging racial discrimination in a crucial G.P. skills test, the judge did not uphold the charges but said the BAPIO had scored a “moral victory” and called for the Royal College of General Practitioners to revamp its assessment procedures.

“The modernising medical initiative in 2007 came out when there was the perception that we are now generating enough doctors to increase uptake—there were anecdotal press reports about local doctors not getting jobs and that led to a review of the recruitment process,” explains Dr Govindan Raghuraman, divisional director of emergency care at the Heart of England Foundation Trust. It has proved a disastrous strategy: what the system and in particular the A&E services lacked was generalists able to deal with an aging population often presenting with a host of problems, including multiple organ failure, rather than the specialists being churned out by the British system, he says.

“There is a need for holistic generalist doctors to see this group of patients, but the training system is not geared for this. We produced a lot of specialists and increasingly microspecialisms arose, but if we are going to use that model of health care, we need much larger volumes of doctors.” The loss of middle-grade and senior house doctors to India amid the tightening of rules, therefore, hit the services that hospitals were able to provide hard. “Some of the doctors who remained in the system were under so much pressure they couldn’t cope; they moved to agencies and worked as locums, covering the gaps wherever they rose at high rates of pay,” he says. He adds that the use of temporary staff has had a significant impact on the quality of health care that hospitals have been able to deliver because the kind of overall career development and supervision systems that permanent employees have are lacking.

Over the past few years, the news has hit the headlines that some health trusts are recruiting doctors from India temporarily, particularly for A&E and G.P. services, but such recruitment has little appeal, given that it entails limited support systems and visas that restrict the ability to work for the longer term.

The BAPIO launched a scheme last year to help recruit Indian doctors for A&E, making it more attractive for them to come by offering them support, training and recognition from examination boards back in India. It will also offer support services for Indian nurses already in the U.K. The scheme will broaden to cover doctors in other shortage areas such as psychiatry, paediatrics and internal medicine, says BAPIO founder Dr Ramesh Mehta, and hopes to include several hundred in the longer term. “We want to ensure these doctors are not used simply as a pair of hands for times of shortage and should gain training while they are here which they can take back with them. We feel this will be very beneficial to both countries as emergency medicine in India is still in its nascent stage.”

Still the future of such schemes will depend on government policy and any changes made as Britain begins the long process of extracting itself from the E.U., which —with the government’s stated aim of ending free movement—is likely to result in a reduction of E.U. personnel within the health service. The government has given little sign of wanting to change its overall approach, though. “There will be staff here from overseas in that interim period—until the further number of British doctors are able to be trained and come on board in terms of being able to work in our hospitals,” Prime Minster Theresa May told the BBC last year, a position that the BMA has warned puts the NHS at risk. “Self-reliance should be the way to develop a strong and sustainable health care system, but do you have the right system to achieve it?” asks Raghuraman. “Do you appoint, do you train, can you get and keep the right kind of people?” With the relentless pressures on the system and even deeply committed people like Sister P.S. considering their future, however briefly, it is an increasingly pertinent question.