At the dawn of the new NHS; urgent care is in crisis

Posted: 29/05/13

This April, the largest re-organisation of the NHS since its creation came into effect. GPs are now responsible for planning and purchasing health care for their local communities, via the Clinical Commissioning Groups which replace the old Primary Care Trusts. Meanwhile, the proposed closure of Accident and Emergency units at Charing Cross, Hammersmith and Central Middlesex hospitals is under way, and the NHS Direct phone service has been abolished in favour of the new problematic 111 line. And whilst the NHS has been protected from the worst cuts in public spending, which have been applied to local government, policing and elsewhere, cash pressures are building up nonetheless. Is it a coincidence that, this spring, the NHS has been convulsed by the worse emergency services crisis since the late 1980s?

Government Ministers would have us believe that the problem lies almost exclusively with GPs, whose new contracts, which came into effect in 2004, led to a collapse in out-of-hours services. This in turn has led to increased pressure on Accident and Emergency units. It is certainly true that A+ E attendances have been rising over the long term, but in fact the data shows that the largest rise in percentage terms happened before, rather than after, the new contract came into effect! Subsequently, while some GPs did change their working arrangements, with some buying out-of-hours services from private companies (with very mixed results), in other areas, including ours, many entered into new co-operative arrangements to spread out-of-hours cover between them.

Meanwhile, many other things have been changing too: the population has risen- especially in London, and our population is ageing fast (the two facts are, of course, connected). Older people, understandably, are much bigger consumers of health care. And the squeeze on local government has led to big cut backs in social care, which in turn makes hospitals less able to discharge patients into the community, and leads to a backing up of pressure throughout the hospital. Westminster Council is not alone in having cut social care for the majority of elderly and disabled users. The result is a classic case of savings in one place leading to extra spending in another.

What can be done? Firstly, we must not blunder into making the position worse. In the longer term there is a strong case for improving community services and concentrating emergency care in fewer, more specialist hospitals, but closures before alternatives are in place cannot be accepted. Second, given how fast patterns of demand and need are changing, and the long lead-in time for planning and delivering changes in care, we need to know that our information is completely accurate and up to date. Third, we need a new approach to social care, which includes piloting approaches that integrate social and health care more fully. Social care has been the poor relation for too long and this can't continue. Lastly, we have now learnt that this NHS re-organisation has been expensive, ineptly managed and a distraction from the real issues facing health care in this country. We can't turn back the clock, but we do need to learn some lessons fast- and one of them is: don't heap blame on the people who work in the NHS for what has gone wrong this spring. The quality of the workforce is our most important asset and in what should be an endless drive to raise standards, doctors, nurses and other health and care workers must be partners.