The piece below, over 1300
words, was written in the year 2000, it is intriguing in the context of the
chance that the 2015 Election will centre on the NHS.
BODIES, BEDS, AND
BOTTLENECKS
Two years ago Local
Authorities were chartering commercial freezer facilities to cope with the
backlog of the deceased awaiting burial or cremation. Part of the problem was the extra long
holiday imposed for the Millennium, the more serious was the increased number
of deaths arising from a widespread epidemic of influenza. There has been a campaign this year to
persuade the old and vulnerable to have their flu’ jabs in good time to reduce
the risk, and this has had a measure of success.
But what if there is a
particularly nasty or unexpected influenza virus about later this winter, and
occurs at the same time as a longer than usual cold spell of weather? The increase in the illness and casualty rate
and the numbers needing urgent treatment may mean that in the hospitals there
could be corpses in the corridors, and bed blocking on an unprecedented scale.
Along with this will be
care establishments in trouble, and people dying in their beds at home waiting
for the doctor or the ambulance, or a caring agency that never comes. The spin will be probably that the casualties
were old and demographics meant that an upward shift in the mortality rates was
predictable statistically and only to be expected. There may be an enquiry, but don’t bet on it.
One of the roots of the
problem is the naivety of the British public in believing what they are
told. The engaging persuasiveness of the
Ministry of Information propaganda films of the late 1940’s on behalf of the
Attlee government on the one hand; and the bullying neurotic tantrums of Nye Bevan
on the other; resulted in too many hopes being placed on a National Health
Service created on the basis of a fundamental error. A local clinic arrangement that had suited a
valley in South Wales, Tredegar, which was Bevan’s own patch, was made the template
of a single structure service for the whole nation, irrespective of the variety
of practice, organisation, and the complex needs of the rest of the country.
As a flexible, responsive,
developing service the NHS was doomed from day one. It began as a static model from the
pre-antibiotic age, when a fester could be fatal. It was not designed to cope with the pace of
research, the new drugs, new surgical techniques, methods, radical changes in
the rate of survival of serious cases, and the ageing of the population. General Practitioners in the early 1950’s
complained that they were conceived of as a kind of shunter, despatching
patients to what tracks were available in the local hospital.
For them the practice of
medicine was organised like the railway marshalling yard, but much worse, and
in ignorance of the destinations of the trains.
The rush to impose the Tredegar Model also meant the creation of
unwieldy and impenetrable bureaucracies from the outset, the characteristic
feature of a Labour reform or reorganisation of any kind. It was the professionalism of the nurses and
doctors, and the dedication of so many other staff and voluntary workers, that
kept the show on the road.
The belief that the NHS
was the best in the world, like our athletes and football teams, made us
reluctant to enquire too deeply about what we were getting for our money for
too long. A good deal of the governments finance available went on other
things. When you see Concorde up in the
sky, tell yourself that is where the money for NHS hospitals went in the 1960’s
and 1970’s. Concorde was a prestige
project designed for the personal benefit of the elite; NHS hospitals were for
the peasants, that telling word heard from the lips of our political and
commercial masters in private so often during that age.
Governments of many hues
and people came and went, only to add to the misery. It is difficult to decide which of the many
reshuffles have been the worst. Possibly
the one induced by Heath The Horrible in 1973-1974 takes the prize, inspired by
the ideas on hospital organisation of John Garlick Llewellyn Poulson; but
Puffer Clarke, the man who chucked it all in the air, runs him a close second.
There is awareness that
all is not right in the hospitals, and the NHS is bracing itself for another
upheaval. One of the key problems is the
bottlenecks in, out, and within, and this is directly related to the
elimination of effective spare capacity under narrowly conceived costing
procedures. The shambles of the Accident
and Emergency arrangements and the admission systems of so many hospitals is
the direct consequence of pretty paper exercises and massaging the figures to
fit the sums laid down at the centre that have taken no account of the
realities.
We hear about the problem
of many people being sent home before their time, but there is another. Once in, it can be extraordinarily difficult
to get out. You have to wait for the
system to function, and because of the strain on the hospitals it rarely
does. How many bed-days are lost because
people are sitting around waiting for a doctor to tap them on the head as they
walk past to say go, or the bit of paper needed cannot be found or has not been
signed by the duty wizard or whoever?
If the basic model, and
the essential constitution of the NHS has been badly flawed from the beginning
how do we begin again? Can any
government inspired review ever bring round a system that cannot work? Is it any longer possible for Britain to have
health provision that matches its needs soon, and is able to keep pace with
change? Will the present NHS ever create
enough operational capacity and flexibility to manage the ups and downs of
demand during each day, never mind each year?
Beyond the hospitals,
there is little appreciation of the disaster enfolding in the provision for the
very old and sick. New laws and
regulations, uncoordinated, and brought in without thought for the long-term
effects have severely reduced the provision in Residential and Nursing Homes at
a time when the population in this category is rising. This is impacting into Care in the Community
now to a level when many services are at breakdown point.
A welter of restrictions
arising from Health and Safety and other limitations has had all sorts of side
effects. When old Mrs. Smith falls over,
wherever it is, if there is no one trained or qualified to hand to pick her up
then she has to stay there until an ambulance crew arrives. If she had a bit of a bump all too often this
means that to cover themselves, the crew haul her off to the local A & E
Department to help fill up the trolleys.
The assumption made in the
calculations of the government that one way or another there would be enough
local carers, voluntary or paid, was badly wrong, and the strains in the system
are all too evident on the ground.
The extended family has
long gone, the new aged had few children, and many of those are now old
themselves or have been though divorce or difficulty that limit the numbers
able to support their parents. The
dumping of the majority of the over fifties from the labour market has
seriously impacted on the ability of most of that age group to help fund the
support and provision for their parents.
It is a dreadful mess, and in one of the coming winters we will all find
out just how bad it is going to be.
There will be no laws or
regulations, and no public authority capable of dealing with the magnitude of
the crisis. The NHS will not be able to,
because it is now at the point when it cannot help itself. So what will Mr. Blair do? Call in the Army to build the pyres again?
Comment:
For Blair read Miliband?