GPs are exhausted, A&E is overrun and hospitals are broke. What went wrong?
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Version 0 of 1. When Stephanie de Giorgio, a Kent GP, sat down at a medical conference last year in Liverpool to hear the health secretary, Jeremy Hunt, she expected to be annoyed. A partner in a busy practice by the sea in Deal, Kent, she had almost given up on medicine because of the stress of dealing with shrinking budgets while the pressure built up to do more. However, her irritation soon became hostility as the Tory politician pitched for doctors’ votes by saying he had always supported GPs. In the question-and-answer session, she asked what Hunt “was going to do (about) … the elephant in the room. The ever increasing inappropriate demand from patients. Instead of addressing this, you … make it worse by continually denigrating general practice and encouraging patients to be ever more demanding. We are exhausted, drowning and, quite frankly, furious with you.” The applause was thunderous but fell flat when Hunt responded with a plea for GPs to realise that if “something goes wrong on a Saturday morning patients don’t want to wait until Monday morning. They want to get it sorted out straight away.” Since then De Giorgio has become a leading light in Resilient GP, an association of about 1,000 doctors who regard the past few years as an assault on the medical profession. She said: “The [Health and Social Care Act 2012] is a big part of it. People being ditched in favour of targets. We are seeing our GP budgets cut. The competition from private interests. I am not against innovation but it has to be for the benefit of patients. This isn’t.” Spending a day with De Giorgio involves a whirlwind of activity. In the morning there are a dozen patients, about 25 prescriptions and a blizzard of phone calls. Lunch is a sandwich between home visits and the afternoon involves another dozen calls with patients, 45 more prescription requests to go through, 25 more lab results and 26 letters. “Two home visits today. Both were unnecessary. One had a cough, the other a cold,” said De Giorgio “That means time taken away from people who did need to see me.” She believes the changes in recent years are undermining the spirit of general practice, with experiments such as 111, the non-emergency healthcare telephone helpline, doing “exactly what we are told not to. So here we had a case recently of a man who had cut his finger. Because there was blood and he rang 111, what happened? They sent an ambulance. And what did they do? Put a plaster on him.” The coalition’s health shakeup, spearheaded by the then health secretary, Andrew Lansley, was the biggest change since the founding of the NHS. For De Giorgio, and many others in the medical profession, they were, as she put it, a “big waste of time”. With the NHS among the three top concerns for voters in the lead-up to the general election, such sentiments are bad news for the governing parties. Since the beginning of the campaign, Labour has put the NHS at the centre of its election strategy – in essence offering to repeal much the coalition’s reforms with £2.5bn of extra funding for the NHS. In response David Cameron and Nick Clegg have backed the “Stevens plan” – named after the health service boss – which involves the government injecting £8bn cash into the NHS while recouping £22bn from efficiency savings. The extra cash has not translated into extra votes. A poll of 2,000 voters this week by Health Service Journal showed they believed by a margin of more than 11% that Labour is the party most likely to give the NHS the money it needs over the next five years, even though the Conservatives have promised more cash for the service in the next parliament. Underlying the coalition parties’ difficulties is that the 2012 health act marked a leap into the unknown for the English NHS. The government’s changes increased competition, abolished tiers of management and forced local doctors to form groups to purchase healthcare on behalf of their patients. Related: Immigration: in Enoch Powell's former seat jobs and the economy matter more It was a market-based system: there were new regulators, watchdogs with an emphasis on financial rectitude, and the patient was viewed as a consumer of healthcare. The Tories’ defence is that the reforms “cleared out bureaucracy, generating savings which we have invested in care for patients. Instead of chasing managerial targets, we have focused on outcomes and performance.” The changes were so big, joked the last head of the NHS, Sir David Nicholson, that they could be seen from space. But size is not everything. While the act painted the NHS with a lick of Thatcherite free-market blue, critics say it failed to soup up the engine with the Cameronian zeal for redistributing power away from the government. Consider what happened with hospitals. The government’s ambition was that all NHS trusts would become foundation trusts, to be completely free from Whitehall control once they had proved themselves able to manage their finances without impinging on patient care. They were supposed to experiment with new mutual models such as worker control and ownership. Yet there are now just 149 foundation trusts – only 20 more since 2010. There are no examples of “employee-led” foundation trusts as envisaged in the coalition’s 2010 white paper. There is evidence that things are getting worse. NHS hospitals and other providers finished 2014-15 with hidden deficits approaching £1.6bn and face a further £2.3bn black hole this financial year. Just as the campaign began Nicholson dryly pointed out that this was a “substantial financial problem” that might need “emergency action” after the election. The failure to change the acute sector is perhaps symbolised best by the decision of the first private company to pull out of a contract to run an NHS hospital, amid rows with the regulator that patient care was inadequate. For Bill Morgan, a former aide to Lansley who now runs the consultancy firm Incisive Health, the biggest failure was relaxing the target of forcing hospital trusts to become foundation trusts by 2014. “The idea was that the ones that didn’t make it would have been taken over by successful trusts. But by dropping that target we sent a signal out to hospitals that they would be bailed out year after year,” said Morgan. The claim that GPs were in charge of patient budgets, providing a key link between hospital and local needs, also proved hollow. While the 211 new clinical commissioning groups were largely chaired by local doctors, research released this year showed that just a quarter of the “accountable officers” in the groups were GPs and hence local doctors were not shouldering responsibility for decisions made on local healthcare spending and rationing. Experts say the failure of the changes was due to the medical profession rejecting Lansley’s central idea: to pit doctor against doctor in a competition to provide patient care. Ruth Thorlby, of the Nuffield Trust, a health thinktank, said medics did not want to be motivated by “self-interest” and to protect their budgets by arguing that the cash for other medics should be slashed. “We’d interview doctors and you could see GPs at first getting very excited about the idea of reshaping, for example, dermatology services,” she said. “They would get very animated about what they might be able to fund instead. But then they would stop and ask: how would this affect other doctors in the local hospital?They don’t want to take decisions with potentially very high visible impact. It’s a very connected world, medicine. Doctors all know each other.” That doctors did not want the responsibility thrust upon them seems logical when you consider that there was no money around. An analysis by the London School of Economics showed the average annual growth in English health expenditure per capita from 2010 to 2014 was just 0.1%. For the UK as a whole there has been a small decline in public expenditure on health as a percentage of GDP – from 8.2% to 7.9%. So much was done so fast in an unprecedented squeeze The financial squeeze is having real implications on patient care. As the election kicked off, NHS in England admitted one in nine patients waited longer than four-hours in A&E – missing the government’s target and making it the service’s worst performance in a decade. Chris Ham, chief executive of the King’s Fund health thinktank, said the combination of a huge upheaval in the NHS at a time of unprecedented financial restraint meant the success of the changes was always going to be difficult to guarantee. “Lansley’s plans were always going to be tough because so much was done so fast in an unprecedented squeeze. On balance, I think there have been more negatives than positives. For me, the government has placed too much faith in regulation, which has grown over the parliament, especially with Jeremy Hunt placing faith in them to avoid patient-safety scandals. It’s a mistake, I think, because you need to consider leadership and culture in the NHS.” The parties’ policies on health Conservatives A pledge to give the NHS the “at least an additional £8bn by 2020” demanded by the NHS England boss, Simon Stevens, is a key plank of Tory policy and, when it was announced, wrongfooted Labour, which has promised less cash. However, exactly how this will be paid for remains unanswered. There are ambitious targets to deliver seven-day-a-week access to a GP between 8am and 8pm and, especially, to make England the first country in the world to provide the “truly seven-day NHS”. However, experts point out that with the current shortages of doctors and nurses it is impossible to see how such promises would be kept. Labour The NHS is Ed Miliband’s hot topic – and the party devoted a week on the issue – hoping for a breakthrough with a poster reworking the Conservatives’ “Labour isn’t working” image of 1979 by depicting a huge queue outside a waiting room with the title: “The doctor can’t see you now.” The party says it will put in £2.5bn – and hire 8,000 new GPs and 20,000 more nurses. There’s also a new right to see a GP within 48 hours and to a test for cancer inside a week. The party’s rhetoric revolves around repealing the Health and Social Care Act 2012 and integrating parts of the healthcare system. Perhaps most striking is that Labour has not backed Stevens’ five-year plan, signalling that the party will reassert control over the NHS. Related: Schools' hidden funding crisis: teachers take drastic action as cuts hit hard Liberal Democrats The party has matched the Tory pledge to give the NHS the minimum £8bn a year extra by 2020, with some details on funding but not enough to say how the whole amount would be paid for. Lib Dems have also sought to expand the health service’s focus, with their proposals for mental health to be placed on par with physical health. Perhaps the most important call is for “a non-partisan fundamental review of NHS and social care funding” – a replay perhaps of past debates but also a recognition the coalition failed to solve this problem. SNP The NHS is perhaps the most vivid expression of the West Lothian question – the anomaly which allows Scottish, Northern Irish and Welsh MPs to vote on laws affecting England while English MPs have little power over Scotland, Northern Ireland and Wales. The SNP calls for an increase across the UK of £24bn by the end of the parliament, an eye-watering £9.4bn above-inflation rise and the largest spending promise yet. The move would deliver a £2bn rise to NHS Scotland. The money, it says, will come from scrapping Trident. The Green party The Greens would set aside £5bn to exit PFI deals and offering free social care at a cost of £8bn. The party says it would increase the total NHS budget by £12bn a year, with investment in mental health care and in providing free dentistry, chiropody and prescriptions in England. Thereafter, the Greens would increase the overall NHS budget annually in real terms by 1.2%. Taken together, this radical plan would raise NHS budgets by £20bn by 2020. Ukip Ukip says visitors to the UK – and migrants until they have paid national insurance for five years – will have to have NHS-approved private health insurance as a condition of entry. The party says this would save £2bn, which would help fund the additional £3bn it says it wants put into the NHS. Nigel Farage’s party also wants to train 8,000 more GPs, 20,000 more nurses and 3,000 more midwives. |