Behind the headlines: Understanding the complex challenges facing the NHS
Professor Tim Orchard, director of division of medicine and integrated health, features in episode one of BBC Two’s documentary series Hospital. Here, he argues that it’s really important for us all to understand the complexity of the NHS’s challenges in order to determine the best responses.
Inviting half a dozen camera crews into our hospitals as we gear up for winter may not seem the most rational of decisions. Yet, we felt it was exactly the right time to invite patients and the public to take a look behind the scenes – at the astonishing skill and care but also at the significant challenges and dilemmas.
I’ve been a doctor for 25 years and this Christmas was one of the busiest I can remember. Our two A&E departments continue to be very stretched and our beds are rarely empty. It seems to be a similar story elsewhere.
In our biggest hospital, St Mary’s, we had 500 more acute medical admissions in 2016 compared with the previous year. On top of that, we carried out more planned operations and investigations.
But demand keeps rising, and continuing advances in medicine and technology allow us to constantly push the boundaries of what’s possible. This leads to pressure on resources which, in turn, can create some very difficult decisions about whose treatment should be prioritised.
In the documentary, we see an operation postponed for a patient who is due to have a tumour removed because another patient urgently needs specialist surgery for a rupture in the major artery to her heart, and there is only one intensive care bed available. We were able to carry out the major operation to remove the tumour the next day but these situations are extremely stressful for all concerned.
You could conclude that we simply need more hospital beds. And, right now, that would certainly help. But additional beds require additional staff and expansion space. And without other changes, they will rapidly fill up again and we’re back to square one.
The full picture is more complex – reflecting big shifts in who we see and why.
We’re caring for many more people now with conditions relating to obesity and to alcohol and drug use, and mental health problems play a bigger role.
We’ve also seen attitudes to healthcare change – our lives are busier and we have different expectations. Some patients who come to our A&E departments do so in order to get same-day attention for conditions that are not, technically, an emergency.
But the most striking change for me has been the increase in patients who are frail and elderly, often with multiple health problems, especially dementia. It’s not a straight forward case of treat and discharge for these patients. Their health conditions require on-going management to prevent them worsening again to crisis point, and they often need additional social care support to be able to leave hospital safely.
We estimate that around a third of patients in our beds, at any given time, could be better cared for outside of our hospitals, at home or in rehabilitation units or nursing homes.
Our immediate priority has to be ensuring we continue to provide safe, high quality care whatever the circumstances – and NHS staff work incredibly hard to achieve that. Like all NHS hospitals, we have a system in place to manage surges in demand – you can see it in action in the documentary. We do things like re-prioritise the work of clinical teams to focus on specialist A&E consultations or discharging patients, open temporary beds and postpone planned operations.
You’ll also see me leading a meeting with other clinicians and managers where we’re looking at how we would cope in the event of something like a flu epidemic or norovirus outbreak. We can’t go back to the days when it was common place to have patients waiting on trolleys for 48 hours. So, we do have to plan for the worst and know how we could create extra capacity quickly and safely.
In terms of a more lasting response, we have a programme of initiatives under way, many in partnership with other NHS organisations as well as with social services and charities. It’s a whole system problem and so it requires whole system solutions.
Some improvements are focusing on the ‘front door’ of the hospital – making sure patients are assessed by the right specialists as quickly as possible. We’ve had success with a clinic for at-risk older patients whose health appears to be deteriorating. They come for the day to be assessed and receive treatment from a specialist clinical team who also link up with social care and community services to make sure their care is properly joined up. Many hospitals, including ours, are also expanding ‘ambulatory emergency care’ – essentially urgent outpatient care for patients who need investigations and treatment quickly but who are well enough to be at home in between consultations.
Other improvements look to make it easier for us to ensure a safe and speedy discharge once hospital treatment is completed.
These sorts of developments are all making a difference – and, importantly, offer a better experience for patients. But even if we make our current services as streamlined and co-ordinated as possible, it’s unlikely to be enough to respond fully to changing needs and advances in care and treatment.
There’s a growing consensus that the only sustainable solution is to move towards a more integrated health and social care system. We have to make the shift from care being reactive and crisis-driven to actively working to keep people as healthy as possible. Regardless of which bit of the ‘system’ they’re in, patients have to feel in control of their own care – and it needs to be joined-up and consistent.
If we collaborate and look at the whole care needs of our patients and local residents, we can better target the resources we currently use as separate organisations. And we can organise services so that when someone does begin to become unwell or has an acute health problem, they get fast access to whatever sort of care will help them most, where they need it.
It’s everybody’s NHS, and as the documentary shows it does some amazing things despite the pressures. But change on this scale is not easy, and the only way we can ensure we maintain and build on the very best of the NHS is by everybody working together.