My 85-year-old mother collapsed unconscious in church on New Year’s Day. The category two ambulance, which should have got to her within 18 minutes, took more than two hours to arrive. At A&E, 11 other ambulances were waiting to transfer their patients just as soon as the hospital had capacity. Once inside the department, it took five hours for my mother to see a doctor, and another two for a decision to be made to admit her. The hospital had no beds, so she joined seven other patients being billeted along a noisy, strip-lit corridor.
Each trolley station had its own call button hastily mounted on the wall, but the few nurses on duty were run ragged. The son of the woman on the next trolley – she was suffering from liver cancer – helped by going to summon assistance when my mother started vomiting, and both of us fetched water for other patients who had no relatives of their own.
These scenes are being repeated across the country every day. Where I work as a GP in south-west England, colleagues have resorted to driving critically ill patients to A&E because there are frequently no available ambulances. Our local hospital has set up a “red phone” for us to alert it when we are bringing someone in, otherwise patients may become stuck in queues typically eight hours long.
The Royal College of Emergency Medicine (RCEM) estimates that 500 patients are dying weekly because of extreme service delays. The RCEM has joined with the Society for Acute Medicine and the royal colleges of physicians, general practitioners and psychiatrists to demand that the government takes emergency action to address the crisis, a call echoed by the British Medical Association.
I had a lot of time during a sleepless night to contemplate what such action would need to achieve. The casualty officer, explaining why my mother couldn’t be admitted to a ward, told me that a third of the hospital’s acute beds were occupied by patients who were medically fit, but who couldn’t be discharged because of a lack of social care in the community. This is the so-called back-door problem being discussed in the media, which is creating pressure throughout the system.
Hospital emergency departments become filled with admissions that have nowhere to go. Ambulances become stranded outside, unable to offload their patients. Paramedic crews are not available to attend new cases in homes, streets or churches – wherever it is that people have been taken acutely unwell.
Less well understood is the “front door” problem – the forces that are driving so many patients into the ambulance service and emergency departments in the first place. The government is pinning the blame squarely on the pandemic – on the numbers of Covid cases in the latest wave, other respiratory pathogens such as influenza, RSV and Strep A that have rebounded following two years of mitigation measures, and the backlog of non-infectious diseases that has built up since Covid first struck in early 2020. While these are relevant, and constitute a politically expedient narrative, it is far from the whole truth.
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During the time I spent in A&E with my mother, I listened with a GP’s ear to the stories of a dozen of her fellow patients. Two certainly needed to be there: an elderly man on blood-thinning medication who had fallen and sustained a head injury, and a diabetic woman with a dangerous complication called ketoacidosis. As for the rest, all were people whose illness could have been managed without recourse to acute hospital attendance.
Invariably they’d phoned NHS 111 – the 24-hour helpline for advice on urgent problems not requiring a 999 call – only to be told either that an ambulance was being dispatched or that they should attend A&E without delay. Even my mother’s trolley neighbour, the woman with liver cancer, could have had her symptoms addressed by palliative care at home and a prompt follow-up as an oncology outpatient. A significant amount of the workload in A&E departments and on the ambulance service shouldn’t be there.
How did our emergency services arrive here, inundated with front-door demand and unable to admit sick patients because of a jammed back door? The short answer is funding cuts by successive Conservative-led administrations since 2010, though the long answer is more nuanced and dates back even further.
Successive governments have failed to grasp the social care problem and transform a low-paid, low-status profession into a viable career. Our ageing population, with increasing levels of frailty and multi-morbidity, has caused the demand for care to increase. At the same time, capacity has been shrinking. Social care is the responsibility of local authorities, which have been subject to severe cuts throughout the austerity decade.
According to Age UK, £8bn was stripped from adult social care budgets between 2010 and 2019. Staff are quitting the sector: factors contributing to the exodus include the effects of Brexit on European workers, conditions during the pandemic, and higher wages in alternative jobs. The charity Skills for Care reported a drop of 50,000 in the number of social care employees in 2021-22, the first time its annual survey has recorded a fall. The back-door problem has become acute.
The causes of the front-door problem are more insidious, arising from the failure of politicians and executives to understand the crucial part the GP plays in the cost-efficient functioning of the NHS. Since 2010, the number of hospital doctors in England has increased by 30 per cent, from 95,000 in 2010 to 127,000 in 2022. This has paralleled the rise in the number of over-65s, the demographic with the highest need for healthcare. Over the same period, GP numbers have been falling. What we see in the NHS today is exactly what a persuasive body of evidence says will happen to a health service that has been gutted of its expert medical-generalist layer.
Extrapolating from the government’s own figures, we are now short of at least 8,000 doctors in general practice in England, with a total of 27,000. This has had low, some would say zero, political priority because of a belief that the role of GPs can be diced up among other, less expensive professionals – or even, since Matt Hancock was seduced by deceptively beguiling AI symptom checker apps during his time as health secretary – by machines. The loss of GPs has degraded many aspects of quality of care and the patient experience. Most pertinent to the front-door problem, though, is the health service’s reliance on NHS 111 to assess acute illness – initially in the out-of-hours setting, but increasingly in daytime practice too as GP numbers have shrunk to unsustainable levels.
On the face of it, NHS 111 is attractively money-saving. According to figures from the King’s Fund, a health think tank, each 111 telephone consultation costs approximately £11, whereas a GP dealing with the same patient would cost around £39. But it’s a disastrously false economy. NHS 111 employs non-clinical call-handlers using software called NHS Pathways to reach its triage decisions. Pathways cannot make diagnoses, so to minimise risk it funnels around 25 per cent of all cases into the ambulance service or A&E. When call volumes rise to the levels we’re seeing during the winter maelstrom of respiratory illnesses, this results in upwards of 12,000 patients being referred straight into the emergency services every day, most of whom could be managed by GPs in primary care.
The emergency measures being called for by the RCEM and other medical groups are directed towards solving the crises affecting both the back and front doors of our hospitals. Number one on the list is urgent investment in community services. The situation in the UK is as serious as it was during the first waves of the pandemic. Just as it did with the Covid vaccination campaign, the government should convene a task force to devise urgent solutions.
The top priority is an expansion of social care capacity to facilitate discharges from hospitals. On 9 January the Health Secretary Steve Barclay announced an additional £200m to fund “thousands” more places in social care. According to the New Economics Foundation, the money will translate to a mere 2,000 extra community beds, whereas by the government’s own admission some 13,000 are required. The measure seems more about reducing political heat than solving the crisis. What is needed instead are improved conditions for all care workers – to attract back trained staff and enhance worker retention.
There is a similar, but unappreciated, urgent need for clinician capacity to mitigate the impact of NHS 111 on the front door. Research done recently by my local out-of-hours service gives some idea of what would be gained. By amassing sufficient clinicians over the course of a trial week, it showed it can divert 95 per cent of NHS 111 category-three and 75 per cent of the more severe category-two ambulance call-outs to management in primary care. A&E attendances were also diverted more than 50 per cent of the time, and my own experience suggests we could achieve figures of around 90 per cent were clinicians able to re-triage every one of these A&E referrals within the 20-minute grace period granted by 111 protocols.
During the pandemic, retired GPs and others who had left an increasingly beleaguered NHS responded to an emergency appeal to return to work. The Covid Clinical Assessment Service was the result, with banks of clinicians taking on the triage of Covid cases. Could a similar service be established to re-triage NHS 111 ambulance and A&E referrals?
There would need to be sufficient capacity within primary care to manage the cases appropriately diverted from the emergency services. GP and district nurse capacity will also be needed to support the thousands of earlier hospital discharges that will be enabled by the extra £200m social care funding, something the Department for Health and Social Care has acknowledged yet has no proposals for. There should be a national suspension of the low- and no-value work dictated under programmes such as the Quality and Outcomes Framework and the NHS Health Check, and a reinstatement of measures that reduced bureaucratic burdens on GPs during Covid, freeing time for clinical care.
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These measures will be more than self-funding. Age UK estimates that each day a medically fit patient spends in an NHS bed costs three times as much as if they were to be cared for in a nursing home. In terms of the front door, the King’s Fund estimates each inappropriate ambulance attendance costs in the region of £200, rising to nearly £400 if the patient is conveyed to A&E. Beyond financial considerations, solving front- and back-door problems will mean unwell patients getting a timely paramedic response, assessment in an emergency department with sufficient capacity, and admission when required to an inpatient unit for ongoing treatment.
This winter crisis will abate, but its legacy must be a wholesale rebalancing of the NHS and social care. The deficiencies that have been so fatally exposed will persist throughout these islands unless permanently resolved by central and devolved governments.
Since 2010, every index of NHS performance – from ambulance and A&E waiting times through to the timeliness of cancer treatment – has been deteriorating. David Cameron decided that NHS spending would no longer continue to grow in line with historical trends. As long ago as 2013, David Nicholson, the then NHS chief executive, warned of a £30bn funding gap by 2021 were the NHS to continue to conduct business as usual (the actual figure ended up at £22bn due to an £8bn uplift following a spending review in 2015).
What Cameron hoped would happen – and what Nicholson tried to achieve – was that the NHS, subject to a sustained funding squeeze, would jettison what Nicholson termed “old-style practices and buildings”, and evolve into a different, more cost-effective model of healthcare.
What would this new model have looked like? Essentially, there would have been much less hospital activity, which is by far the most expensive part of the system. Instead, more medical care would have been delivered in or close to patients’ homes, with admissions and outpatient activity confined to cases where severity or complexity meant the full panoply of modern hospital practice was required.
You won’t find too many healthcare professionals disagreeing with this vision. Numerous patients end up in A&E and on wards when their care could have been given in the community. So why didn’t the Nicholson transformation come to pass?
What was needed was a marked expansion in community care – district nurses, social carers, and a rejuvenated cottage hospital and nursing home sector, working alongside a strengthened GP workforce to provide the medical aspects of care. This would have created the conditions under which expensive district general hospital activity could have safely diminished, as well as leading to more holistic and cost-effective patient outcomes. Instead, the effects of austerity on social care, and the progressive loss of GP capacity both in and out of hours has left the district general hospital as the only option for the sick.
The Nicholson vision remains the right destination for the NHS, something that Wes Streeting, the shadow health secretary, indicated during an interview in December. For it to be achieved, social care and community health services need the capacity to support patients during episodes of illness that, while amenable to community treatment, would otherwise destabilise their ability to remain at home. This, at last, is becoming understood. There appears no comparable appreciation that the other key to delivering the Nicholson vision is a restoration of GP capacity – the principal recommendation of the Health and Social Care Select Committee’s inquiry into the future of general practice, which reported in October 2022.
In a recent interview in the Times, Streeting made no reference to this crucial policy area; an omission replicated by Keir Starmer in a recent piece in the Sunday Telegraph. Streeting has talked of the need for radical reform. Labour should drive an expansion in the GP workforce over a ten-year period, targeting a list size of 1,200 patients per medical generalist and incentivising continuity of care.
Get this right and an indisputable body of international evidence – as well as the NHS’s own performance immediately before 2010 – tells us that hospital and emergency service activity will be reduced by 30 per cent, overall system costs will fall and patients’ experience will be enhanced. The legacy will be an NHS once again providing the highest-quality – and cost-effective – patient care.
Following discussion with the medical team, and with my sister able to provide 24-hour care, we brought my mother home the following afternoon. She was exhausted both by her acute illness and the traumatic experience in A&E. I was able to stay for the first night, too. Neither my mum nor my sister would have known what to do with the IV cannula they found in my mother’s arm when she was getting ready for bed. I whipped it out as I’ve done countless others over the course of my long career. Which saved a 111 call and who knows what sequelae as a result.
Dr Phil Whitaker is the NS’s medical editor. His new book “What is a Doctor?” will be published by Canongate in Jul
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This article appears in the 18 Jan 2023 issue of the New Statesman, How to fix Britain’s public health crisis