Hugh Byrne is an NHS hospital consultant in London.
An anti-climactic reshuffle happily confirmed Jeremy Hunt as one of the longest serving health ministers with the new title of Secretary of State for Health and Social Care, a title reminiscent of the old Department of Health and Social Security that existed until 1988. Social security implies financial assistance in time of need and is now a more appropriate responsibility of the DWP, but by formalising the social care role into the new title the Government has acknowledged head-on how important this side of healthcare is.
This is also a timely cultural change that is happening against the backdrop of the current winter pressures on hospital beds. The generally healthy public tend to associate the NHS with hospital care rather than the wider function of keeping people out of hospital in the first place, although acute hospitals do dominate the spending of resources. There are many artificial divides in the system, the most important of which is the divide between hospital and social care, hence the correct obsession with achieving the holy grail of truly integrated care in healthcare systems.
Winter pressures on the health service are an annual phenomenon regardless of government and, for the record, the ONS can confirm what the BBC have occasionally acknowledged, which is that in real terms the NHS budget in England continues to increase. What is different this year is that the Government has bravely acknowledged the situation and taken a pragmatic decision to announce that they will allow hospitals to stop elective surgical admissions if they need to, and most jumped at the chance to be able to publicly announce what they do every year anyway. As a surgeon, this did not mean a day off for me with a theatre team standing idle, because we got on with day cases from the waiting list instead. A hospital, like hotel but unlike an airline, works best at about 85 per cent occupancy, because this allows leeway for beds to be (literally) turned over.
The inevitability of this winter pressure on beds should make us look at planning a suspension of elective procedures for a moveable period each year, or rather planning for elective operating for 46-48 weeks of the year rather than the current 50 (I don’t say 52 because we factor in bank holidays and the simple fact that patients don’t want their surgery over Christmas). It would be impractical to make all surgeons take their holidays in January, but elective day case procedures could be performed instead with a limited number of beds available for eventualities. I venture further and say that we could remove the bulk of elective surgery from acute hospitals altogether, with these operations being performed in elective surgical units. Alarmists will say that they need the back up of the acute hospital site for intensive care etc, but the answer to this is to operate on select patients that might need intensive care afterward in the main hospital, and to make ambulance transfer between the two locations easy, or to co-locate the units on the same campus (although in that situation it would be a matter of time before the elective unit became used as an overflow, too).
An elective surgical centre could be run much more efficiently than surgical units embedded in a sprawling multi-speciality hospital. Its services could also be purchased competitively by the healthcare commissioners. The great accusation that will come is that such centres would cherry-pick their cases. They can fill their boots as far as I’m concerned, because the acute hospital would still have the prestige and expertise of dealing with the complicated and out of the ordinary cases. The doctors that worry about cherry-picking are usually the same ones that worry about nurses and other healthcare workers taking on some of their roles and duties. Training and teaching would not be an issue if each NHS trust ran its elective and emergency arms as separate arms of the same body.
While this may sound like fragmentation of the health service when I’ve already said that integration is the way forward, the integration should occur at a higher level where the organisation is rewarded for its overall outcomes rather than asking for payments on a fee-per-service basis. A hospital providing all its own ancillary services in house, rather than being able to use contractors, is at risk of poor accountability and at the mercy of trade unions. There was that scary moment during Andy Burnham’s tenure when he wanted to set up a National Social Care Service which would have become an even more inflexible monolith than the NHS has unfortunately been allowed to become. On Twitter recently, The IEA’S Kristian Niemitz compared the general NHS situation to a microwave: when the latter doesn’t work people generally go out and get a better model, but when the NHS doesn’t work they just get very defensive about it. I’d add that the knee jerk response of the left is that the problem is the ‘Tory cuts’, which is plainly untrue.
The left is also deluded in believing that the day-to-day operations of this huge organisation are controlled by the Secretary of State. The socialist doctors on Twitter repeatedly punctuate their tweets with hysterical exclamations of ‘Mr Hunt’ or ‘Jeremy’ which does nothing but demonstrate their lack of political and financial awareness. He should press on, not least because his longevity in post has been a stabilising influence and a good lesson for them. I’m now going to stand by for minor twitter storm of my own from my socialist colleagues on social media, and I predict that chief accusation will be that I have some sort of vested interest in operations being cancelled. This does nothing but prove my point about their financial naïveté: this would be a very slow and uncertain way for anyone to make money.