Ryan Bourne is the Head of Public Policy at the Institute of Economic Affairs.
Last week, dreadful headlines and stories on A&E waiting times dominated the front pages of almost every national newspaper. If not for the sickening events in Paris the following day, the NHS would have completely dominated the weekend’s political discourse. Make no mistake, the NHS is back as an election issue – alongside the economy and immigration.
This is significant. But in truth, politics is part of the problem. What fallout we have seen from the A&E crisis in the political sphere has been as predictable and uninspiring as it has been unhelpful. For Labour, this crisis is about ‘cuts’ – particularly in social care budgets – and a costly reorganisation of the NHS. For the Conservatives, this is about a dodgy GP contract signed by Labour a decade ago. Asked for actual solutions to the problem, politicians usually look first and foremost to funding issues or things that will cost more money. At a time when we’re still borrowing £100 billion, this doesn’t get us very far.
Unfortunately, it is simply impossible to have a non-politicised debate about a nationalised industry ultimately run by politicians. But that doesn’t mean we can’t first look at the facts. You may have heard or seen it implied, for example, that the crisis is simply a case of more people going to A&E than ever. Yet looking at attendance numbers, none of the last ten weeks come anywhere close to those seen in the busiest ten weeks since November 2010. The big difference between now and the busiest periods is that the admissions rate is much higher. This might be due to a seasonal factor – the demographic composition is likely to be very different in winter when more elderly patients with complex needs are brought in than in the summer peak-attendance periods.
Yet we have winter every year, and the admissions rate is not much different this winter to last. Although this isn’t one of the busiest periods then, this period is much busier than the equivalent period in the previous two years. So we have the structural issues of winter pressures with an ageing population, coupled with higher attendance figures this year.
This mix means that it is impossible really to separate A&E issues with things going on in other parts of the hospital. The number of people waiting four hours or more between a decision being made on them and being admitted has increased dramatically – up 265 per cent on the equivalent ten weeks last year. This suggests substantial problems in finding available beds. Perhaps this is a result in part of inadequate social care or so-called ‘community care’ meaning more elderly people becoming ‘sticky’ patients. Maybe it’s for other reasons.
What we do know with certainty is that these pressures will grow as the population ages. So it is vital our whole healthcare model adapts such that people are treated in the most appropriate setting. For elderly people with complex needs this should primarily be in the home or community, except in emergencies. For many others who go to A&E when it is not really appropriate, using technology to speak to a GP out-of-hours via Skype, for example, may be better. The key is preventing A&E from becoming a generalised repository for healthcare needs.
In other countries they go some way to achieving this through a more subsidiary healthcare system. Rebates and differential tariffs are taken up by some – which requires those who opt for them to, for example, have a telephone consultation before one is able to go to a doctor. Remote diagnosis, incentivised by how much you pay, can improve efficiency. But unless we are going to completely overhaul the way we fund healthcare, this is not an option.
So, is there anything that can be done without costing money? I think there are four things that could help.
The first thing to do would be to recognise the problem of, and abolish, the target itself. As Camilla Cavendish has outlined, the target is distortive – patients are not seen on a timely basis according to their clinical needs. Since non-urgent cases are easier to treat, the four-hour wait 95 per cent target is easily achieved when quick-to-see cases are part of A&E’s total. The National Audit Office has also shown that a quarter of ward admissions from A&E happened in the final ten minutes of the target last year, with substantial gaming to meet it, sometimes leading to inappropriate and costly admissions. This in itself then puts backward pressure on A&E.
Second, we should think of innovative ways of adding capacity without more spending. It’s clear GPs’ contracts cannot be changed overnight. But why not allow GPs that do not have out-of-hours contracts to offer their own patients fee-per-service appointments outside practice hours? This would allow those willing to pay for the convenience of seeing their GP in the evenings or at weekends, expanding capacity without costing the public purse.
Third, we need to think of ways of reducing the moral hazard of patients going to A&E. Where appropriate, especially in city centres et cetera, it might be efficient to put out-of-hours GPs on site at A&E – and provide more bang for the buck for taxpayers. The risk here is normalising the idea of seeing a GP at A&E, but – hey – given many people are going there anyway, what have we lost? Recovering the estimated £200 cost of ambulance trips for those who attend A&E before absconding could be another small but worthy disincentive.
Finally, we should think again on the way we deal with prescriptions. Expanding the number of drugs for certain treatments available on an over-the-counter basis (with prescriptions later for reimbursement purposes) would increase self-medication, releasing pressure on surgeries and making it easier to get timely appointments.
I doubt many readers will agree with all of these ideas. Some jar with people’s values and instincts. But at least they are ideas. We haven’t heard much in the way of solutions from our politicians yet.