Nick de Bois is a Secretary of the 1922 Committee and MP for Enfield North
Jeremy Hunt’s announcement last week on freeing up GP’s time to advance personal named care for elderly patients is perhaps going to prove to be one of the most significant developments in healthcare under this government. The plan sets out to help deal with the existing dysfunctional nature of healthcare in the country – namely, that we focus too much on treatment rather than prevention, resulting in an ever-spiralling demand that the state is struggling to keep up with.
In 1947, when the National Health Service came into being, the challenges facing both social care and healthcare are were very different to those we faced today. Life expectancy after retiring at 65 was less than three years, and even less for many occupational groups. Delivering state services for personal care to large numbers of frail and elderly people was, therefore, not an issue and such services as were needed were left as the responsibility of local authorities, since these were viewed as being very much part and parcel of the wider issues of poverty and deprivation.
The Times (£) recently reported the huge pressure on acute hospitals caring for the frail and elderly. Last week, we were told in no uncertain terms that A & departments are populated by too many people who don’t really need to be there, including a fair proportion of elderly people not my words, incidentally). Notwithstanding journalist license, the issue of social care and health care remains a huge challenge, but I believe that an opportunity exists if we are bold enough to press on with NHS reform, against this background of a constantly-increasing demand on resources.
The main challenge facing Healthcare in 1947 was that of public health and communicable diseases such as tuberculosis, diphtheria, polio and so on, which by their very nature cause a need for episodic acute care. More bluntly, this meant recovery or death being the norm. The need for the long-term management of multiple chronic diseases through a prolonged period of increasing frailty was never envisaged or catered for when the NHS was planned. In that sense, its developed a National Illness Service as opposed to a National Health Service.
We now face an entirely different challenge which is well documented. The life expectancy of a retiree age 65 is now over twenty years. The number of over 85 year-olds is set to rise from 1.1 to 2.7 million by 2032. The number of 65 to 84 year olds will increase by about four million by 2035. Even allowing for no cuts to health spending by 2020, there will be a potential £30 billion annual gap between the healthcare needs of the population and the service capacity of the NHS, which is largely consumed by this age group.
While these demographic and demand led changes have been evolving, the NHS has remained largely unchanged. However, GPs, who traditionally acted as the filter between community-based need and secondary or hospital services have, thanks mainly to Labour’s contract arrangements, been able to opt out of 24 hour cover – therefore driving people with care needs to acute hospitals. But, in the main, they do not have the appropriate resources and skill mix to deal with the needs of the largely frail and elderly patients being admitted.( Some are trying to adapt by introducing Older Peoples Assessment Units such as my local hospital, Chase Farm. However, while such moves deserve credit, they are dealing with the symptoms and not the cause, since the unit will still capture people after they have been presented at their hospital, and not before.)
Combine this with the continued separation of the resources required for discharge and rehabilitation into the community, and it is not surprising that up to forty per cent of acute hospital beds at any one time are occupied by inappropriate and unnecessary admissions that consume a large proportion of the healthcare budget – which would be better spent providing appropriate and effective community-based services. It’s not unreasonable to conclude that little attention it seems is focussed on the often complex healthcare needs of the frail elderly, who comprise the bulk of the 2.5 per cent of the population that consume up to 30 per cent of healthcare resources.
Hunt, it seems, is willing to restore the gatekeeper role of the GP. The British Medical Association has supported his reform of the contract, but the detail will be crucial if GPs on the ground are actually to deliver the personalised care promised. The contracts to date have been generous. So if they are to change to ensure a role for GPs as gatekeepers who deliver on the ground, they will surely have to incentivise not only GPs but also the wider community services – such as the under-utilised pharmacies, who will need to provide care pathways for this segment of the population. In tandem, however, there must also be the proper co-ordination and delivery of domiciliary-based care so that the present situation can be transformed. Let’s not forget: having fewer people in hospital is a good thing.
The threat of doing nothing was all to obvious in our over-pressed hospitals. The opportunity we now have is not just to ease pressure on the budgets, but also to improve the quality of life for the fast- growing ageing population.