In a speech to think tank Policy Exchange in December 2022, Shadow Secretary of State for Health and Social Care Wes Streeting started off badly, calling left-wing critics of his proposals “the true Conservatives” because they oppose his call for reform of the NHS. NHS reform is certainly needed, but it must be reform of the whole system. So, what is the whole system?
Labour and the NHS
Quite rightly, in my view, Streeting, speaking in July 2022 at the Royal Society of Medicine, advocated a policy of prevention, highlighting the need to deal with health conditions, “…when they cost hundreds of pounds and thousands of pounds, rather than hundreds of thousands of pounds, or even a million pounds when you add up the cost of people’s care if we don’t get there soon enough”.
He also addressed delayed hospital discharges. Again, he was quite right to do so, saying that this is the priority that must be addressed. But, instead of proposing a causal analysis, he went straight into an untested solution, i.e. the need for increased integration in order to address the current issue of delayed discharges. “The test for me for ICSs [integrated care systems] as they’re currently constituted is: are they shifting some of that resource now in social care to free up the exit door and improve the flow through the hospital, or are people still thinking in silos?”
This is not thought through. ICS have a minimal impact on delayed discharges. In fact, they are a diversion. Going back to systems thinking, the problem is quite clear, as the diagram below shows, i.e. ‘delayed days’.
The root causes of delays are in social care
It is clear that the place to start is the cause of bed delays, which is in the social care sub-system.
Analysis of the reasons for delays arising in acute care and social care indicate that over 90% are generated in social care. That is where the increasing demand on primary and acute care services comes from. So, it would seem that the first priority needs to be there, starting with ‘Work Packages at Home’ (post-discharge community care) where the increase has been even greater, nearly three times the rate in 2010–2014.
Given that this was around 35% of the bed delays in acute and social care, that is clearly the starting point, especially as the vast majority of the occupants are elderly whose conditions tend to deteriorate rapidly if detained in acute care. However, neither government nor top management has yet to offer a comprehensive plan to tackle it – a total lack of leadership.
In 2017 and 2018 the average monthly ‘delayed days’ was 60,000. The Age UK report published in December, 2019, stated that the average number of people kept in hospital after they were ready to be discharged because of inadequate social care over the period averaged 2,750 every day (2019). That is over 80,000 occasions a month when nurses, doctors, care workers and managers were scrabbling around frantically to try to discharge patients who were fit to be released, while the patients sat around until they were eventually told that they had to stay.
This is a shocking treatment of staff and even worse for the increasingly confused frail patients and frustrated families. What a terrible way to treat our citizens. How demoralising for the staff.
Prevention is better than cure
Streeting might be pleased to know that at the heart of every successful organisation is the policy of prevention. Nothing saves more time, money and dissatisfaction than nipping trouble in the bud.
NHS leaders had every opportunity to investigate the cause and effect of bed delays as a priority as far back as 2015, but did nothing. Yet, the galling thing is that at Sheffield Hallam hospital’s Frailty Unit a team had already proved that the ‘discharge to assess’ (D2A) model was the ideal corrective to home care package delays (2017). This reduced the average transfer time from hospital to home by 77%, from 5.2 to 1.2 days, saving four hospital beds and £14.5mn at one hospital alone. There are over 900 hospitals in the NHS.
You might have thought that Jeremy Hunt (then Secretary of State for Health and Social Care) and Simon Stevens (Chief Executive of NHS England at that time) would have welcomed this with open arms, declaring it to be the policy for all home package transfers. Not a single policy change was for the benefit of patients and staff. It was all political grandstanding from Tory MP Hunt and USA-schooled Stevens, wasting time and money on reorganisations and privatisation. Labour must not do the same.
The financial implications of not fixing social care have a huge impact and the human cost could be tragic for patients, service users and staff. But most of all for the NHS itself. In 2012 it received its highest ratings ever. Today it is in intensive care.
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