By Laurie McMahon and Andrew Holden
HOW WELL IS THE NHS
Having both worked in and around the NHS for ages, we are lost in admiration for the people who provide its services – especially after all they have been through in coping with the pandemic.
Even so, there seems to be growing evidence that suggests that though the NHS may not be terminally ill, it is pretty poorly!
We hear some wonderful personal accounts about how well the NHS has looked after people but almost daily we see ‘bad news’ stories about how it has failed. The headlines are usually about:
the lengthening waiting lists and times for routine clinical procedures
our difficulty in getting GP appointments and the (related) shortage of clinical staff in practices
the unavailability of NHS dental care – particularly for pensioners
ambulances forced to wait for hours outside hospitals waiting to transfer patients into A&E departments
acute hospitals being half-full of patients that could be much better cared for at home or in the community
the lack of services for some care groups – particularly those people with mental health issues.
There can be very few of us who have not been affected by these and similar failings.
WHAT IS GOING WRONG?
The politicians’ knee-jerk response to all this has been to blame Covid. This was (and may well be again) hugely disruptive but the inference is that if it were not for the pandemic, everything in the NHS would be all right. However, most people suspect that there are a raft of longer standing and perhaps more significant issues.
Most often identified as the cause of the NHS’ problems is money – or the lack of it. The NHS has been subject to the strictures of austerity since 2010 and although international comparisons are difficult to make, it certainly looks as if we have been lagging behind our European counterparts in health investment and health outcomes for some time. Although there have been some increases in funding, an ageing population and expensive new drugs and technologies will continue to drive up health costs. If the NHS is not to fail us it will need
more and not – as has been hinted at by successive health ministers - less funding.
IS IT THE WAY WE DO IT?
Less often reported is a much more significant efficiency question. That is whether the way our health care services are currently provided give us the best possible value for money. To improve patient outcomes and make services more efficient, experts have long been clear about the kind of changes that are required. These include:
bringing together specialised clinical services to consolidate expertise and improve quality and outcomes
providing more diagnostic and outpatient services into local settings
fully integrating social care with the NHS to prevent unnecessary hospital admissions and to make sure patients can be discharged back home in a timely way
properly funding public health and then using all the levers available to health and local authorities to help people stay healthy
ensuring that the NHS fully exploits developments in clinical and information technology to make the service easier for patients to access and improve the quality of care.
There can be little doubt that the NHS is in desperate need of an intensive makeover to reshape and modernise its services – and quickly - especially as the parlous state of public finances will almost inevitably push the Government to seek ‘efficiencies’. However, successive Ministers have seemed unwilling to contemplate this, perhaps because whenever the NHS tries to modernise its services, it faces strong local resistance. We can be aggressively over-protective of what we already have! In the future we will have to learn to campaign for the type of efficiencies that deliver more and better for less if we are not to fall victim to mindless cuts.
WHAT ABOUT THE WORKFORCE?
Another frequently cited problem for the NHS is significant staff shortages, particularly of GPs, other doctors and nurses. The Independent reported that since Brexit, the NHS has lost over 20,000 EU employees and this has prompted heroic efforts to recruit from other overseas countries even though there are ethical issues about us poaching clinicians from poorer countries who desperately need them. There have also been attempts to boost the number of places in our medical and nursing schools. However, the lead time to produce qualified clinicians ranges from three years for nurses and at least twice that for doctors. So, it looks as if demand for staff – particularly clinical staff - will increasingly outstrip supply.
Recruiting enough staff is tricky but retaining them is equally, if not more, problematic. Because nearly 20% of the NHS workforce is over 55 years old, retirement rates are soaring. This is compounded by staff not feeling sufficiently rewarded for their contribution. The latest data shows that 35,000 NHS workers resigned voluntarily in the first quarter of this year (almost twice the number for 2020) citing work life balance and poor rewards as the reasons. So, it looks as if the people we clapped for at the start of the first lockdown are now feeling pretty clapped out! It is not surprising that those trying to provide services are highly critical of successive Secretaries of State for Health and Social Care (and there have been four since last summer) for not publishing a full workforce plan for the NHS.
HAVE YOU HEARD ABOUT THE LATEST NHS REORGANISATION?
That takes us to an issue that is just beginning to emerge into the public domain. With the passing of the Health and Social Care Act 2022 the NHS is undergoing one of the biggest shake-ups since 1948. Below, we have tried to describe the new structures as clearly as possible – this was not an easy task and you might have to be patient as you work your way through the acronym soup!
The changes have been in the pipeline for a decade or more and the Department of Health and Social Care and the NHS Executive have devoted considerable effort and energy to agree how best the structure of the NHS should be reformed. They have now created 42 Integrated Care Systems (ICSs) across England as the new legal entities responsible for planning and organising our health services. It is worth noting that because these are big organisations - each responsible for between one and three million people – there are many who fear that their creation will enable progressive government centralisation of the NHS.
Below ICSs there are to be a number of ICPs (Integrated Care Partnerships) - groupings of hospital and community care providers, serving around half a million people. The Government’s original thinking was that ICPs would ‘generate an integrated care strategy to improve health and care outcomes and experiences for their populations, for which all partners will be accountable’ but the governance and accountability arrangements to enable all this have remained a little hazy.
Further down the new organisational charts can be found a number of ill-defined elements
like ‘place’ and ‘community’ and ‘neighbourhood’. However ‘Primary Care Networks’ (PCNs) are better described as being ‘to bring GP practices, community, mental health, pharmacy, hospital, social services and voluntary services together at a local level’. Although intensive effort is being made in every ICSs to sort out how all these local agencies can collaborate – it is still very complicated ‘work-in progress’.
HOW HAS THIS ALL WORKED OUT FOR OUR PART OF KENT?
The eight NHS commissioning organisations (CCGs) we used to have in Kent were merged into one and then abolished. For Faversham, it is the somewhat remote Kent and Medway Integrated Care System (ICS) that is now responsible for planning how our health and care needs. Advising them there is an Integrated Care Board with wider representation – especially of local government - and so the acronym ‘ICB’ is being used more frequently now to describe this regional entity.
Beneath the ICS/ICB are four Health and Care Partnerships (HCPs). We are in the East Kent HCP which covers Faversham, Ashford, Dungeness, Folkestone, Dover and Margate. In it 720,000 people are cared for by thirteen separate care provider organisations each with their own management arrangements and budgets. Not what you would call ‘local’. As for the Primary Care Networks, our two GP practices were initially going to form one for Faversham. This would have provided a useful local focus but as it would have been one of the smallest PCNs in the country, it is not surprising that the GPs have now chosen to be part of a much larger mid-Kent grouping. Again, not really local.
So, although the K&M ICS people are working really hard to set up the new structures, in amongst all the acronyms, there is no bit of the system marked ‘Faversham’.
WHAT DOES ALL THIS MEAN FOR US?
This lack of a local focus creates a particular problem for Faversham since the new housing estates that are starting to spring up around the town will have a major impact on the demand for healthcare services. Although there will be a well-developed Neighbourhood Plan for Faversham that clearly identifies the new ‘infrastructure’ required as the town develops, it is not easy to use the same plan for healthcare. New houses, schools, roads, public transport, cycle paths, water treatment, green spaces and the like all have an obvious physical presence, but effective health care relies on a complex network of highly skilled clinical staff from different providers, using sophisticated technology, working together with lots of local agencies. Just popping a space marked ‘Health Centre’ or onto the plan of a new housing development does not help much!
So, to support our Neighbourhood Plan the town urgently needs a way of assessing future healthcare needs and being clear about ‘who needs to invest in what’ to ensure they are met. But as yet - and despite the best efforts of the K&M ICS - there is no fully functioning local agency to help us do it. We are stuck!
A WAY FORWARD?
But things may be about to change. The Patient Participation Group (PPG) of the Newton Place Practice invited colleagues from Faversham Medical Practice PPG to talk about the effect of the town’s expected growth on the demand for healthcare services. They wanted to find a way of getting people together to understand what Faversham’s future needs might be and then to support – even push – the authorities to make plans to meet them. The ‘Faversham Healthy Futures’ group was created as a first step but it soon realised that it would need access to a great deal of quantitative data and to expert health care analysts.
They talked to a unit at the University of Kent’s Centre for Health Service Studies whose research mission is focussed on involving local people in healthcare planning. Their response to what was being contemplated in Faversham was extremely positive. They are now working with the Health Futures Group on the design of a project that will help a representative group of local people understand the dynamics of health system and make decisive and informed contributions to the planning process. Recently the Healthy Futures Group met with the Community Committee of Faversham Town Council and they were enthusiastic about supporting the project.
So maybe - just maybe – Faversham could find a way of involving a small community like ours in delivering to the PCN, the planners at Kent and Medway ICS and the policy makers at Kent County and Swale Borough Councils, a clear and unambiguous guide to the development of services that will meet the future healthcare needs of the town. If that happens, we might have gone some way to answering the ‘what can we do about it?’ question we posed in the title!
Faversham Medical Practice, Faversham Health Centre, Bank Street, Faversham.