Cymru/Wales - intermediate care at the cost of acute care is not the answer
The general election is around the corner but the Wales assembly election is not until May next year. Although health is devolved to the Assembly I believe all countries will recognise the issue facing Wales.
I see considerable merit in the questions for the candidates and next government in the six decisions from excellent health care published by BGS Central. The objectives of the national BGS are reflected in the Constitution of the BGS Wales.
However these look at individual parts of a huge machine that is the NHS and that machine is in serious need of maintenance or a complete overhaul. The recent winter events have caused me to question the strategy of a reduction in hospital beds, investment in community services and a reliance on quality improvement to deal with an ageing population with increasingly complex needs.
I have worked in the NHS since qualifying in 1988 and this is the worst I have ever seen it. When I think about last winter I see hospitals declaring major incidents when dealing with the routine winter workload. I was on call over this period and it was not possible to send people home because they were simply too ill. We had so many sick people in our emergency department we ran out of non-invasive ventilation machines. Primary care was in the same boat with massive demand. In summary the ‘normal’ demand outstripped available services.
Patients sitting in the emergency department were concerned about the wait for a bed but seemed to accept that this is ‘the way it is’. The medical profession did not question the situation. I read an article in the Geriatric Medicine journal about how Accident and Emergency targets had hit the headlines. The title was ‘A&E targets: Nursing levels key to safe care?’ Why is A&E being used as a medical ward in the first place and why was the title not ‘Disgrace that hospital is too full to admit patients’?
I asked our chief executive what the plans were to deal with these pressures in future and I was told it was building community resources and working on quality and patient flows - a message I have been hearing for many years now. ‘More beds’ was not the answer and anyway there were no staff to look after the extra beds. Obviously I was less than reassured by this response and a quote by Albert Einstein came to mind, ‘Insanity: doing the same thing over and over again and expecting different results.’
I have serious concerns about the role of intermediate care. And yes, this is heresy. All the patients I saw were too ill to get any benefit from intermediate care. I have sat in meetings where the aim of an intermediate care service was to stop placement in residential and nursing homes, stop admission to the hospital and to facilitate discharge from hospitals. In reality, the funding and resources were not enough to achieve one of these objectives. While patients have been managed in intermediate care environment I get the distinct feeling the needs of those left in hospital is increasing, as by definition they cannot be managed in intermediate care. If we are hoping intermediate care is going to sort out the crisis hitting our hospitals, we should think again.
The only message I heard on the media from politicians was that hospitals were full of ‘bed blockers’. This seems to refer to the people one might call ‘patients’, most of whom are old. Older people are now the NHS core business so how can they be ‘bed blockers’? Patients know hospitals are still the most efficient way to deal with their problems and that is why they are in so much demand.
It is true medical staff are in short supply and who can blame them when faced with the above? Sadly, the enthusiastic role models that encourage juniors to move into senior positions are demoralised and talking about retirement themselves.
Cutting the number of hospital beds and staff with a view to increasing the throughput in those beds is, in my view, better suited to younger patients with a single condition. This is no longer the core business of the NHS. If the NHS hospitals were a private business and had the same demand, would it be contracting that service or expanding and delivering more of it? Why don’t we question this policy of intermediate care? Is it really wrong to admit older patients to hospital to sort out their co-existent social circumstances and medical issues?
Even recently, modernising medical careers has driven juniors to specialise earlier in their training but increasingly frail patients with multiple conditions which bridge those medical speciality silos need doctors who can treat them holistically.
Yes, we must challenge the government, but do we need to ask ourselves some basic questions before we do so? Are we going to accept mediocrity? I hear no counter arguments to the fall in the number of hospital beds. Is the government’s policy of community care and decreasing hospital beds ageist? Why are we still training any specialist who can’t deal with complex medical and social problems? Why haven’t we stood up and spoken out about the dreadful state of the NHS? What is the plan to deal with these problems?
Until we are able to do this I fear the NHS is in the hands of the dubious motor mechanic who charges too much and won’t show you the parts they have replaced. That, as we know, is the garage to avoid.
BGS Welsh representative on BGS Policy and Communications Committee