Bad decision-making in health service

Date: Monday 7th August 2017

Sir, The injection of £65 million into the North Cumbria health service is to be welcomed (Herald, 22nd July). If properly applied, it will alleviate some of the current shortcomings in both acute and long-term care.

In the future, there will still be competition for resources but we must avoid the false trade-off between hospital care and community services which has bedevilled the system in the past and resulted in gross wastage in both sectors. Hospitals are part of the community and need to be fully integrated.

I entered medical school in 1956, eight years after the NHS was founded. As trainee, then consultant, medical director and for the last 20 years a patient, I have witnessed many changes. Despite the efforts of managers to cut hospital services, the real efficiencies in acute services have come from technical developments.

Complex investigations are now done as an outpatient whereas patients used to be admitted for long periods. Minimally invasive surgery has greatly reduced inpatient length of stay. Hip and knee replacements have restored independence to thousands. Innovations in cardiac and stroke services have transformed the outlook for those who can access them in time.

General practice has had to adapt to all of this and much of what was once hospital-based medicine — diabetes, for example — has been devolved to GPs, community-based nurses and professions allied to medicine.

Over the decades, many more conditions are treatable now with excellent outcomes, a phenomenon driven by developments throughout the civilised world and that process has increased the overall cost of an up to date service.

In most of those areas mentioned above, the introduction of an improved service raised short-term costs, provoking opposition but then produced long-term saving. Health authorities became talking shops, the managers were myopic, the short-term costs were anticipated and the long-term savings were not.

Quality of life and longevity have both improved but the rational insanity which blames the NHS for the extra expense of old age needs to be challenged — it should be set against a wider societal base if we are to avoid Orwellian decisions.

There is a limit to the amount of good that NHS managers can do, but there seems to be no limit to their potential for harm. Short-termism can lead to some very silly decisions.

Whatever theoretical cost saving can be achieved in the short term, before closing beds in community hospitals, the capacity, local availability and quality of an integrated care community (ICC) needs to be clearly stated.

In the acute sector, the value judgements managers make can reach a farcical level. Managers exercise discrimination against people who smoke, drink or are obese, but not against those who self-harm, take drugs, injure themselves doing extreme sports or attend A&E departments for no good reason.

In some parts of the country, patients are being obliged to apply through their GPs to managers for permission to undergo hip replacement. That is a clinical decision best taken by trained doctors.

The Department of Health has suggested that the varying performance of surgeons, which is subject to data inaccuracy and local variations in different parts of the country, be put right by the Royal College of Surgeons; surely that is a challenge for the managers who are in a position to improve information and implement change.

Preserving patient independence keeps them off the books of the NHS. In sparsely populated areas prompt access to care is a premium requirement if the best outcomes are to be achieved. This particularly applies to heart attacks and strokes, so transport links need attention.

The creation of a new cancer centre in Carlisle is good news and I hope it can recruit good staff. At the same time we should remember the other acute and elective services which we take for granted and which need constant attention if access is to be sustained.

Neglecting to treat people who are on the path to disability simply adds to the burden of those providing long-term social care. The cruelty of limiting hip and knee replacements is mindless. Allowing arthritis to go untreated for long periods not only creates dependency but it steals a human being’s quality of life.

Our health managers have an opportunity, let us hope they use it wisely. Yours etc,