Will the NHS survive another winter?

Mark Boothroyd, co-ordinator of the Four-to-One campaign which is calling for the introduction of nurse-to-patient ratios in the NHS, discusses the crisis in the NHS and what might result without a campaign against cuts and demoralisation. This article was originally published on OpenDemocracy.

Junior doctors

Over fifteen thousands of doctors marched down Whitehall last weekend, in protest at the imposition of a new contract. The contract sets a dangerous norm which could be applied to other NHS staff. It permits longer working hours, including til 10pm on Saturday as ‘normal’, and slower pay progression for part-time workers, who are disproportionately women.

These signs of opposition from doctors are much needed. Staff morale is being crushed. Workloads are spiralling as a further £22 billion budget cut by 2020 is imposed. A quarter of staff report management bullying as pressure is piled on to meet targets. Running short of staff, management turn to expensive private agency firms, who have increased their costs to the NHS from £1.8 billion in to £3.3 billion in just three years.

Unable to do the best for their patients, doctors and other health workers are voting with their feet. Six in ten GPs are considering retiring early. Many junior doctors are changing careers altogether, or considering emigration. NHS staff who remain, finding themselves on shifts working alongside agency staff earning two to three times their salary, may question why they continue in NHS jobs with permanently frozen pay, the constant threat of job cuts and management deaf and dumb to their complaints. They may be tempted by agency work with its flexibility, improved pay and freedom to move away from the wards and departments with the worst conditions.

The logical government response would be to increase pay and invest in more permanent staff to improve working conditions and hold on to existing NHS employees.

Instead, the Department of Health’s crude solution is simply to cap agency spending, saying they want it reduced from current levels (as high as 8% of some Trust’s budgets) to 3%.

And if – when – hospitals hit their capped spending limit and find they now have dangerous levels of unfilled shifts?

Well, the government’s NHS regulators have also written to hospital bosses effectively granting them permission to reduce nursing numbers on wards. The letter states that the 1:8 [nurse:patient] ratio developed by NICE is “a guide not a requirement“ and that it “should not be unthinkingly adhered to”.

Yet copious evidence shows harm begins to occur if nurses are made to look after more than seven patients at once. Over 40% of NHS nurses are caring for more than eight patients per shift.

Of course, patients will only be exposed to this if they’re lucky enough to get into hospital. The number of overnight stay NHS beds has fallen from 144,455 in 2010 to 131,820 in 2015. Hospitals often end up discharging patients inappropriately early to free up beds for the sickest. The NHS own guidance states any hospital with more than 85% bed occupancy is liable to face problems with emergency and elective admissions. In the last quarter of 2014/5 bed occupancy was 90.7%. Patients wait for hours on trolleys in A&E, or in the back of ambulances, as hospitals struggle to find beds to admit them.

Ambulance services themselves are under strain too. At least one in ten ambulance posts are vacant in the UK. A third of paramedics have taken time off for stress, and over 80% have thought of leaving the job. The number of staff leaving the London Ambulance Service tripled between 2011 and 2014. Ambulance bosses are frantically recruiting from as far afield as Australia to attempt to fill vacancies. Response times have soared; every borough of London has failed to meet their target for Category A life threatening calls.

In the same time period, spending on private ambulance services grew by a staggering 1,000%.

As hospitals struggle under the pressure, no relief is found in primary care. GP funding has been squeezed from 10.33% of the NHS budget in 2004/5 to 8.39% in 2012/13. 500 GP practices have closed in the last five years, forcing thousands of patients to compete for places in dwindling numbers of surgeries. The number of doctors applying to be GPs has fallen 6%, and in Scotland one in three GP posts is vacant. Unable to get GP appointments, every minor ailment drives patients to seek treatment in A&E, putting more pressure on the system.

The privatisation of NHS Direct and its replacement with the 111 service does nothing to help. Untrained and inexperienced staff often refer in error, giving bad advice or sending patients to A&E unnecessarily, and some staff admit to having recommended decisions which lead to patient harm and even death.

Reduced funding leaves management with few choices. Those willing to stand up and oppose decisions detrimental to patient care risk being sacked. Many have been cowed into silence or converted to the NHS make-do-and-mend culture. The latest brainwave from NHS execs is for an army of volunteers to rescue the NHS. Indeed this already happened last winter, with the Red Cross and other organisations sending volunteers to help overstretched A&E departments.

This winter could be the breaking point. Everything is set for a perfect storm of insufficient capacity, overstretched budgets, critical under-staffing, rock bottom morale and inflexible government.

Is permanent crisis being normalised? It was May of this year before most hospitals were hitting their A&E targets again following the last winter crisis, and many staff reported no slackening of the workload, even during the warmer and quieter summer months. The government doesn’t appear to have published its winter plans for this year yet.

As the crisis becomes permanent, the voices clamouring to end free NHS care for all become louder. They seize on every crisis as further proof that the NHS cannot work, and push for more privatisation and payments from patients to fill the funding gap.

Meanwhile the public, having already endured 5 years of worsening NHS failures, may begin to run out of loyalty and support for the NHS.

It is only a matter of weeks until the winter influx of patients begins. To fail to act will put the lives of thousands of patients at risk through a completely avoidable crisis.

 

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