Thursday, 1 January 2015

NHS emergency care on wobbly legs

Britons’ life expectancy is lengthening, but A&E, GPs and ambulance services are struggling to respond to growing burden of illness
Ambulance crew bring a new patient to an NHS A&E ward. Hospital A&E units have now missed the 95% target every week for well over a year. Photograph: Mike Goldwater/Alamy

If the NHS’s recent performance underwent one of the service’s own health checks, the readings would have the doctor concerned prescribing urgent medical intervention. Almost every day brings new evidence of an increasingly worrying situation that looks ominously as if it is building slowly and relentlessly into a full-blown crisis.
The three legs of the stool that is NHS emergency care – A&E, GPs and ambulance services – are all wobbling dangerously. Emergency departments’ ability to treat the required 95% of patients within four hours has declined sharply in recent weeks, with just 84.7% treated within that time – its worst ever level. Hospital-based A&E units have now missed the 95% target every week for well over a year while patients are spending more time on trolleys in corridors than they should or being shuffled from one A&E to another.
GP surgeries are wilting under the strain of increasing demand and too few family doctors. The line of people pictured on the front page of the Daily Mail recently as they queued from 6.30am to get an appointment at their local surgery was a microcosm of a widespread problem.
Ambulance services are also wobbling. Three of England’s 10 regional ambulance services are, or very recently have been, on a state of “critical” alert. Like their colleagues elsewhere in the NHS, their capacity to respond quickly enough to genuine medical need is fraying at the edges. In March, London ambulance service reached the target 75% of critically ill patients facing a life or death emergency within the maximum eight-minute response time in all 32 boroughs. By June, it did not manage that in any of them. In some boroughs crews reached just 48% of such patients on time.
Surveying the NHS’s decline, one minister said privately: “One of the slightly scary things is that no one, including the best brains in the health system, really knows what’s going on. It’s a complex picture and there’s no one factor.”
But one last statistic – that admissions to hospital via A&E have also hit a record high – is the most telling of all. In all 159,054 patients were admitted in the first two weeks of December. That underlines a simple fact: that more people are more unwell than ever before.
Paradoxically, while Britain’s healthy life expectancy – the time people live free of disease or disability – is lengthening, it has also never seen more illness. The NHS is visibly struggling to respond to a growing burden of illness, especially given that its ringfenced budget has disguised the fall in health’s overall share of GDP under the coalition, just when rising need made that ill-advised. The ageing population is the main reason. More older people mean more broken bones, more dementia, more infections, more failing hearts and lungs, and much else besides. That trend will only continue. And the problem is compounded in the depths of winter, with colds and vomiting outbreaks common.
There are other drivers too, none of which involves an easy remedy. Obesity, drinking and smoking are producing an ever-larger toll of lifestyle-related diseases such as cancer, diabetes and drink-related liver damage.
Internal faults developing in the NHS are exacerbating the problem. A heavy price is being paid for the lack of health services outside hospitals to keep people healthier for longer at home – billions of pounds of NHS money have gone into this, with little return. Meanwhile heavy cuts to social care services have followed austerity’s deep cuts to local council budgets. Older and frail people not properly supported at home are more likely to come to grief, end up in hospital and probably need to stay there. When they get to hospital it becomes harder to discharge them without social care to look after them at home.
People suffering mental health problems are also adding to the pressures on GPs and A&E units because support is not available in the community, as we report.
Meanwhile there is a recruitment crisis in the NHS. Older GPs are retiring early to avoid burnout and too few newly qualified doctors are opting to join general practice. The result is long waits for appointments – meaning patients increasingly use A&E as their first, rather than last, port of call. More and more hospitals are pleading with patients to seek help elsewhere for less serious problems, but to no avail. Attendances keep rising. London ambulance service also says a shortage of paramedics is one reason why it is so stretched.
So there is more demand, which means more pressure on increasingly stretched resources and the NHS is in trouble as a result. While we can identify the factors at play no one definitively knows what lies behind the relentless demand for care – or the best way to fix it. Both practically, for patients and NHS staff, and politically in the runup to the general election, this could not be more pressing. As things stand, 2015 will be a very bumpy ride for the country’s most cherished institution.

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