Calling The Doctor

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?