Health policy issues in Enfield
The local situation regarding health service provision can only be really understood against the national background and some comprehension of developments in medical practices. These notes summarise the important elements.
The National scene – where have we come from?
The salvation of the NHS does not depend on cash alone; outcomes are the top indicator of efficiency and medical skill, and UK lags behind many other countries in this regard. The NHS is over 70 years established and is sclerotic in process, bedevilled by countless restrictions owing to the need for “accountability” to Parliament and numerous other bodies. There are as many solutions floating around as self-interested bodies to promulgate them. And a number of high profile political initiatives have been wrecks from day one.
Expenditure on health service provision through the NHS has actually risen markedly over the last 15 years, and is projected to consume 20% of the entire government budget within 5 years. This spend rate has not been accompanied by parallel improvements in efficiencies and outcomes, a lot of the additional resources have been “absorbed” within this enormous enterprise, employing over 1,300,000 people directly, with far too many in management grades.
Demand continues to rise inexorably across the service, under the influence of an aging and growing population, and an enhanced ability to deliver health benefits to patients where in earlier years matters were often allowed to take their natural course. Treatment of almost all conditions to a high standard is now considered a right, but projections of current cost trends will bankrupt the system if service delivery is not reorganised more efficiently.
Trends in health thinking and provision
- Health experts now place a lot more weight on individuals taking more care of their health and avoiding harmful life styles. Questions are being asked as to how those who abuse health advice can expect the rest of the community to pick up the tab when health eventually collapses. Smoking and over-eating are obvious cases. Type two diabetes and its serious complications now affects nearly 10% of the population, is just one growing infirmity that illustrates the dilemma in public policy making.
- The NHS is facing an enormous charge to maintain an estate that it cannot afford. It needs to operate from fewer hospitals. Attempts to get surplus county hospitals closed or restructured into polyclinics or service centres have been fiercely resisted by the public in the belief, it seems, that a nearby bed will offer the optimum prospect for health and survival. But the reality is that medical skills are less effective if spread over numerous units – better that patients go to the doctors than the opposite. Slowly, services are being moved into fewer larger units and patients will have to make the longer journey for a higher standard of treatment.
- As a result of these trends the NHS which inherited over 2000 hospitals across the country when set up in 1948 found itself over-invested in real estate. Medical practice has moved on in the last 50 years and dwell time in hospital has been cut for many acute conditions. Beds have been reduced by 2/3ds since 1947 – fewer beds and wards are needed despite over 9 million hospital treatments now being conducted each year, the so-called â€śconsultant episodes.â€ť
- Higher levels of medical care can be delivered where doctors can specialise and develop their skills and deliver enhanced outcomes. Advances in medical practice can be delivered through specialisation; the benefits of this approach are proven beyond doubt.Â Indeed there is a general concern amongst professionals that a consultant led service can only be offered this way, day and night every day, by concentrating resources.
- Consultants are the gate minders to medical practice; they control what is on offer. In practice, junior doctors who often man local units and who have restricted license to intervene, either call for a consultantâ€™s permission before action, or ship the patient off to a larger consultant-lead unit. At weekends this arrangement is under particular strain when the availability of consultants is most restricted. So having local beds may comfort the public but the service that accompanies the beds will be restricted – a feature that too many patients either do not understand, or wish to ignore. The level of medical expertise available within small units is and will remain constrained. The NHS cannot afford to have consultancy lead services 24/7 in every unit.
- The NHS has always been about rationing medical care to benefit the greatest number of patients, especially those with life-threatening conditions. It has never been an intensive care system for all conditions under any circumstances. Rationing is not obvious – in past years, patients have either been scheduled for delayed treatment where the condition was not life-threatening or, the condition has been monitored but not actively treated. Expensive new drugs have been denied because the money could be applied to other patients to better effect. Treatments have expanded far beyond the original emergency health service but the way the NHS performs its function now is a sub-optimal response to votersâ€™ expectations.
Redefining the service
- Today the professions recognise that medical conditions, the ones that threaten morbidity and foreshorten life, eg hypertension, obesity, diabetes etc are better treated early, before they become very costly loads on the service. Pre-emptive diagnosis and treatment was no feature of the early NHS; now it is given more weight and current planning requires this part of the service to be delivered in the community, outside of hospitals. This is one of the prime movers behind the current service reorganisation that is devolving services into the community, bringing GPâ€™s more into the frame, so deterring more cases from reaching hospital. However, implementation is rather variable and services into deprived urban areas can be as good as nil.
- At some point, services will have to be more openly restricted â€“ a default on the â€śfree at the point of deliveryâ€ť maxim, and / or taxes will have to rise, because health service demand is insatiable. Restricting the service will play a growing part -treatments that are regarded as â€śinessentialâ€ť (eg fertility treatment) or non-life threatening will be limited, but this stance has clear political implications, which Clinical Commissioning Groups in every borough are having to work through.
- Protected from the current spending cuts, and faced with public hostility, service adjustments have proceeded slowly. Hospitals are closing gradually, surplus capacity is being eliminated and costs have been reduced. However, acute hospitals are burdened with thousands of older patients due for release but unable to proceed home safely for want of care in the community. Capacity for new patients is being throttled.
- To clear acute beds, an old idea is being resurrected, that of the intermediate recovery facility, a unit for patients able to be released but not fully discharged. There is a capital cost for this and a hiatus in government over finding funds for this logical development. Critics will also remark that patients could find themselves in such units for weeks, just as they are now in acute units because the problem of care in the home shows no sign of early relief.
- Mental health is now looming as the next great absorber of medical and social spending. Patients retained in expensive acute hospitals dilute the service for more immediate cases, but care in the community is hard to deliver to any quality, and residential accommodation is expensive.
- The NHS is now edging its way forward to accommodating the load posed by an aging population that lives longer, especially as acute conditions are better diagnosed and treated.
The NHS reorganisation and Enfield
Current developments seek to address these issues and pressures.
- Hospital services will cluster into fewer acute units offering more advanced medicine and superior outcomes; GPâ€™s will lead the way in the community to deal with ill-health pre-emptively and offer front line triage, the portal to the hospital service except for emergency cases which go direct.
- In simplified terms, a great deal more pre-emptive diagnosis and early treatment will be conducted in the community, led by GPâ€™s â€“ mostly in their own surgeries, taking blood samples, performing minor surgery etc. This will take quite a weight off the hospitals, but is only in its infancy at this time. Western Enfield is fairly well served for this service, having a good compliment of GP’s, but the same is not true of the eastern wards where GP vacancies (over 60) are reported.
- GPâ€™s who have their fingers on the pulse of local health needs have been encouraged by the government to form groupings to organise and contract for medical services â€“ known as GP Consortia (Clinical Commissioning Groups). From April 1st 2013 they took control of a huge budget – ÂŁ80 billion nationally â€“ to contract these services. They replace the 150 or so Primary Care Trusts who hitherto controlled NHS resources behind the scenes allocating health budgets; they were the gateway to services for us all â€“ GPâ€™s could recommend treatment but the PCTâ€™s disposed. All that bureaucratic rationing, so important to all residents but invisible to them, has gone, but rationing has not. GPâ€™s will assess and process patients for the most suitable treatment, either as in or out-patients, and within locally agreed treatment profiles. This task requires managerial skills, and already a few GP consortia elsewhere have overspent and need bailing out; they will adapt.
- Major local hospital units (N Mids and Barnet) will intensify their specialisations and offer extended acute services: this is evolving but the benefits to patients in terms of superior outcomes are without doubt. Operating within the Royal Free Hospital Group, patients can be allocated to whichever centre offers the best treatment â€“ a distinct improvement for all.
- This is the bottom line for people who need acute treatment, surpassing all the other political arguments that bedevil the NHS over state vs private ownership and control, greater public accountability, political supervision, consultative processes – all the state accountability apparatus that costs a fortune to maintain, adds nothing to outcomes, and which the public has no awareness of.
Accident and Emergency, and maternity
- A & E and maternity generate many hundreds of thousands of cases a year. Much A & E work can be handled by nurses, junior doctors or GPs even in the community, but the serious cases will be beyond their skills and equipment. Deciding quickly when the patient first presents how serious is the condition, is central to achieving a good outcome.
- Paramedics and ambulance staff are very often the first contact in these categories. Taking all patients to a local hospital or clinic, waiting for triage (checking the seriousness of the condition) costs time, resources and possibly even the patientâ€™s life. Paramedics are now trained to make the first assessment and direct the ambulance and patient to a suitable unit. In the case of difficult conditions such as stroke, the specialist unit may be some miles away, but it is in the patientâ€™s best interests to be handled this way.
- Maternity cases resolve into straightforward births, well within the capabilities of a midwife or junior doctor, and those where the mother or child is threatened by complications â€“ which may appear only very late in the pregnancy. Transferring the mother / child to a specialist unit late in the delivery adds risk to a successful outcome. Many complications cannot be predicted but some classes of mother have a raised chance of difficulties and should accept advice to book into a unit with intensive care facilities. If the best chance of a successful outcome is the goal, mothers might reconsider a choice of unit based on medical facilities rather than local convenience or the insubstantial gains from a â€śnaturalâ€ť birth, however defined.
All these developments militate against many smaller hospital units from whom the case work is draining away. What is their future? They will either be closed or modified to provide other services, perhaps related to long term infirmity needs, ie to meet the requirements of an ageing population.
The Enfield Scene
- The Borough is dependent on two large acute hospitals, Barnet and North Middlesex, both newly upgraded, and lie outside the borough. From November 2013 Chase Farm Hospital has been reassigned and majors now on elective (planned) surgery plus diagnostics and a daytime minor injury service, having closed its full scale emergency A & E and maternity facilities. The two main hospitals have assumed core services, maternity and complex A & E working within the Royal Free Grouping.
- Chase Farm as a unit had been in decline for over 15 years and would never have attracted sufficient funds to make up for lost time. Several senior politicians promised funds but those promises were always whittled away by the dominant needs of the two acute hospitals.
- Chase Farm has some more recent surgical facilities and was capable of supporting serious elective (ie planned) surgery but not cutting edge procedures â€“ such work is more safely carried out at other units, all outside the Borough.
- Emergency cover at Chase Farm is adequate for more minor cases, but serious conditions require the staff only found at a larger hospital. So ambulance staff are now trained to determine at the point of pickup whether the patient needs taking directly to a major unit. It is life-threatening for such cases to be taken first to Chase Farm, only to be waved on because the patientâ€™s needs are too complex; stroke is a good example.
- Likewise maternity services, led by midwives and junior staff, can only deal with normal cases. A fair number of mothers or babies, averaging 20% of total, with complications had to be moved to a major unit quickly. This exposes staff and patients to risks that are reduced if maternity is concentrated where more intensive and experienced skill sets are immediately available. It may feel cosy to deliver a child close to home where friends and family can walk to visit the patient, but if there are problems, the place to be is in a more capable unit where specialist surgery etc is available for mother or baby. The medical profession and political representatives have not gone all out to persuade the public of these truths, perhaps fearful of a backlash and, as a result, confusion and mistrust have abounded. But the UK statistics on safe birthing are no cause for celebration.
- FERAAÂ has studied the various plans issued in recent years to meet the needs of a fast growing borough, with a diverse population, and observed a litany of half truths, deceitful misrepresentations, and promises that could not be kept, all seemingly to put off the day when it becomes necessary to level with the public. Health is a very emotive subject and not all our elected representatives want to face a hall full of worried constituents and patiently take them through the realities. This is changing.
- Our contact with those responsible for aligning health resources for the Borough confirms that the trends visible throughout the NHS are no less applicable here. Concentration of resources does hold out the promise of better treatment and outcomes; FERAA maintains a close scrutiny to ensure that the promise of the current round of changes does indeed deliver. FERAA cannot just guess what number of beds or ambulances are required to deliver the service, that must be left in the hands of the clinical management, but recovery rates, safe births, etc indicate how outcomes are improving. That “our” hospitals are now working with the Royal Free Hospital Foundation Trust is proving a positive move, amalgamating skills and resources of the several units for the public good.
- Chase Farm Hospital has been the focus of much debate and pressure to turn an under-resourced local hospital into a major acute unit. Neither the resources nor the demand were ever there in quantity to make this a viable proposition. Even if built, there would not have been sufficient consultant doctors to maintain a full slew of treatments, just to retain a unit within our borough. Such funds would have been at the expense of a higher service delivery through the two neighbouring hospitals, and definitely not be in the interests of Enfield residents; asserting to the contrary has no factual foundation.
- But FERAA is acutely aware of the shortcomings in primary care across the Borough, especially the east, where health services and outcomes are notably weaker. FERAA urges resources to rectify this injustice, and knows that the GP Commissioning group has it at the top of its priorities list. We will watch closely for results.
- Enfield is not immune to the demands generated by the rising number of older residents; in health terms it is the elephant in the room. FERAA has noted how the authorities are paying more attention to this sector and considering longer term plans to meet the need, especially for those with mental conditions. But the reality is that progress to date is a hand to mouth affair.
- Enfield set up Healthwatch in 2013, a supervisory organisation to pull together and oversee the provision of all aspects of health services across the Borough. It answers to a national Healthwatch body. Enfield Healthwatch also answers and consults with the Healthwatch Reference Group, a body of volunteer groupings representative of the community: FERAA occupies one of the seats and has an overview of how supply is being managed against demand. This is a first, and represents a level of oversight not afforded the public in earlier years where health provision was seen as far beyond the comprehension of the public! FERAA will report back through its representative residents associations on what it discovers.