It’s very clear: the NHS is in crisis this winter. But in fact, the NHS struggles to cope every winter.
This winter crisis is not new; it has been brewing for years. But this year it seems far worse, because the Covid-19 pandemic has exposed and amplified what many of us already knew: the NHS is no longer able to cope.
The Pandemic has shown us many things but perhaps most stark of all it has shown us that poverty kills; that social and economic deprivation leads to a much greater likelihood of serious illness leading to hospitalisation and death. The poorest in our society are twice as likely to die from Covid-related disease.
Covid has, however, also laid bare the effects of 10 years of austerity measures, introduced in 2010, making us much less able to respond to times of increased demand on the NHS.
I’ve been a GP in the Carlton area for 30 years and I’ve never known things to be so bad.
The NHS used to be a source of great pride to me, as quality and quantity of health provision in this country rose year after year and was second to none. But that has all changed. I am very proud of my colleagues who work within the NHS, but I am increasingly concerned about the level of service we are able to offer.
What does an NHS in crisis look like?
Right now we’re seeing 1000 respiratory admissions to hospital every day, mostly Covid related:
- Hospitals wards and emergency departments are overwhelmed with 999 Ambulances failing to meet their urgent call 18 min response time;
- Patients are waiting for hours at A&E just to be seen, and, once admitted it’s not unusual for patients, even those who are seriously ill, waiting on trolleys in hospital corridors overnight;
- Staff absences are running at around 10%, twice the normal level, through illness and the need to self-isolate;
- Nursing and support staff are leaving in their droves, many though physical and mental ill health, with nurse vacancies across the NHS running into many thousands;
- There are currently six million people on hospital treatment waiting lists, up from 1.2 million pre-Covid.
GP numbers have decreased sharply too, as doctors give-up and choose to retire early or change to less demanding, less stressful jobs. Five years ago we were promised an extra 5000 GPs would be recruited; in that same time the number of GPs has actually fallen by almost 2000. And district nurse numbers have decreased by 50% over the last 10 years. Only a few years ago, waiting time for a GP appointment was 1-2 weeks; now it can be as long as six.
Sadly, this should not come as a surprise, the signs have been there for years. What we’re now seeing is a toxic mix of annual winter pressures, an unprecedented Covid pandemic and the toll of years of underfunding of the NHS.
Make no mistake, patients are dying as a result of delayed tests and missed diagnoses including delayed cancer diagnoses and restricted access to hospital investigations and urgent treatments. A few years ago, my practice was criticised for requesting too many cancer investigation appointments for patients. We were, apparently, one of the highest referring practices in Nottingham. We were also the practice with the lowest rates of “late cancer diagnosis”. You can’t have it both ways!
We are seeing longer waits for orthopaedic procedures, for example hip or knee replacements, likely in excess of two years now, causing high levels of pain and immobility and an increasing number of patients resorting to private health care, at great personal cost.
Mental health services provision is woeful with many desperately ill patients, both adults and children, waiting months for psychiatric or psychological help.
In the last decade we’ve seen significantly reduced NHS funding, averaging at just a 1% increase per annum, against a background of rising costs, making each year a net reduction in funding.
Across the NHS we have fewer doctors and nurses compared to the rest of Europe. For example, for every 1000 of the population, the UK has 8 nurses, Germany has 12. We have 3 doctors, Germany has 4.5.
All this begs the question: is the NHS being prepared for privatisation? Think about it. If the NHS fails, private providers step in. We’re already seeing it in places, both in general practice and in hospitals. We will shortly be at the point when the public will be asking, even demanding change!
So what can we do to save our NHS?
Yes, of course, we need greater funding, that’s a given. And we need it now. But I want to take a deeper, longer term look at what we, as a society can do, to both take the pressure off the NHS and promote greater health within the population.
The Pandemic has clearly shown that “health” doesn’t happen in isolation; it depends on the economy, the environment and education. The poorest people in our communities were more likely die for a reason. Our health starts in our homes, in our schools, in our workplaces and in our communities, long before we see a doctor. And, ultimately, our health is intrinsically connected to our planet.
Our health is a human right, which means everyone has the right to live in dignity and in safe housing, with fulfilling jobs and access to a socially connected community and natural green spaces. This requires us to be able to choose a healthy lifestyle by feeling “in control” of our lives.
We need to renew our national approach, to focus not just on the “prevention of ill health”, but instead focus on the “creation of health”, for everyone, everywhere to be able to live a healthy and dignified life. We need the creation of health to be a national government priority, but it also needs to be our local priority, right here in Gedling borough and across our county. To borrow a phrase from a recent book by Nigel Crisp, “health is made at home, hospitals are for repair”.
But the opportunity for a healthy life is not the same for everyone – those at the top of society live the longest and in the best health; those at the bottom the worst. Because our social circumstances (so-called ‘social determinants of health’ – where we are born, live, grow, work and age) are the largest predictor of our health and how long we live creating a healthy society requires reducing that health gap or ‘health inequities’ (the unfair/avoidable ‘health gap’ between those at the bottom and top of society).
Health inequities have a significant social and economic cost to society. Globally, a child born in Sierra Leone can expect to live to 50, but a child born in Japan will live to 84. This health gap might not be so great in the UK but it does exist!
Children in the poorest parts of our society are twice as likely to die by the age of five than children in the most affluent parts of the country. Across England, avoidable mortality (deaths through accidents, substance abuse, and suicide for example) is three times greater in our poorest communities. Life expectancy had already stopped increasing in the UK for some before Covid struck. But life expectancy has now actually decreased by a further 1.5 years because of Covid. It’s even greater – up to six years – as a Covid by-product, due to suicide, drug poisoning and socio-economic inequality.
Within the Gedling borough area, the gap in life expectancy between the richest and poorest groups is 8.6 years for men, and 6.7 years for women, meaning a man in Netherfield can expect to die eight years earlier than a man in Burton Joyce, and have an even greater disparity of healthy-life expectancy, meaning he would also spend more of his life living with ill health. So, yes, of course, as a nation we need to Build Back, but not just build back better, we need to Build Back Fairer!
Building back “fairer” requires the political will to address socioeconomic inequalities in food, security, housing and education to allow everyone, everywhere, our human right to choose a healthy life. Each step has an impact on the next and can improve the situation overall. For example, if you improve local public transport, the bus service to take one example, people are more able to access jobs and healthy food, they are less likely to use private transport, so they walk more, keep to a healthier weight, rely less on local fast food outlets, our streets are quieter and safer, there is less environmental pollution, less respiratory disease, less demand on the NHS, less hospital admissions, people live longer, free of chronic illness and live longer. Everyone, everywhere!
And in the process of doing so, if we reduce the health gap everyone, everywhere benefits. We need to convince those at the top that reducing the health gap is in everyone’s interests; it’s not about reducing us all to an average, it’s about raising the bar for everyone, improving everyone’s chances to achieve good health, equally.
What Covid has done is provide us with the proof we needed that not only are these measures simply fair, they are also in everyone’s interests – we all benefit if everyone, everywhere is healthy, right up the social ladder – even those at the top!
So what can we do in Gedling that would make a difference?
Lots is being done locally through the health services and by Gedling Borough Council to tackle the “causes” of ill health, which is fantastic, for example smoking cessation services, access to exercise and so on, but we could all do much more to tackle the social determinants of health – the “causes of the causes” of ill-health – and that’s what needs to change.
Here in Carlton and surrounding areas, the local GP practices have successfully brought Citizen’s Advice services and specialist mental health services for young people to our practices; it’s important to treat their mental ill health, but it’s also vital to deal with the housing crisis and financial debt that might be causing it!
Providing drug addiction services to people is important; but if we can improve housing, jobs and education, it means we are less likely to be stressed, struggling mentally, and prone to substance abuse, be it drugs or alcohol or smoking. We would be dealing with the “causes of the causes” of ill-health.
We could emulate other cities across the country, including Manchester, and become a Marmot City. Professor Sir Michael Marmot, the London-based world leading expert in health inequities, has been working with the Manchester Mayor, Andy Burnham to tackle the causes of the causes of ill-health across greater Manchester. And across the United Kingdom there are a growing number of towns and cities joining in the wave of action to transform the way we live, and the way we approach healthcare. We could join this wave of action and be part of something really remarkable.
We could start by recognising the need to do things differently, to build our community based on social fairness, to reduce inequalities of income and wealth and to promote an economy that puts the achievement of health and wellbeing at the heart of local government strategy. We could develop our community to respond to the climate crisis at the same time as achieving greater health equity. We can campaign for greater resources from central government to more our deprived areas.
We could make locally contracted services focus increasingly on preventing problems such as homelessness, school exclusions and low educational achievement; tackle food poverty, debt, poor health and unemployment, before outcomes deteriorate further. We could commit to providing healthy living and working standards for all our residents, including quality of employment, housing, transport and the environment. And we could be encouraging residents to challenge employers, businesses, service providers and local authorities that don’t meet these standards.
One example would be making sure our local companies recruit locally, use local supply chains, protect their local environment, and ensure a minimum income for healthy living.
We should focus on young people and provide support for early years settings in more deprived areas, extend interventions to support young people’s mental health and wellbeing at school and at work, with the ambition for all our young citizens, 18–25 years old, be offered in-work training, employment or post-18 education.
And we should extend those recommendations out to adult health care, housing, transport, employment, social care, and environmental health.
But this is just the start. Ambitious ideals, sure, but if we all want it, it’s achievable. Other countries that already focus on health equity have fared better during the Covid-19 pandemic, with fewer infections and deaths and more stable economies. We need to be brave and choose to give everyone, everywhere, a fair opportunity to have a healthy, fulfilled and long life.
Here in Gedling borough, and across Notts, we need develop a new movement, a new priority, to work hard to enable everyone to live with dignity, as the message is now clear. Your health, my health, everyone’s health and everyone’s future, is intimately linked, and one depends on the other.
It’s in everyone’s interest that we do so.
Dr Ian Campbell is a GP at Jubilee Park Medical Practice
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