At Samizdata, Natalie Solent shares a post written by “ARC” discussing why the National Health Service seems to be under such pressure lately:
1) Flow-though is crucial to A&E: you must get people out the back-end of the process to maintain your rate of input to the front-end. However ever-increasing regulations mean a patient without family cannot be released until a boat-load of checks have been done. This is clogging up the back end. It may be preventing the release of a few who had better not be sent home yet (not much and not often, is the general suspicion) but it is definitely delaying hugely processing the release of all others who could be. All this admin takes time and effort — delaying release and also using up time of staff in non-health work — and costs money.
This effect needs to be understood in the context of the 15-years-older story of the destruction of many non-NHS nursing homes by galloping regulation. These homes were mostly owned and operated by senior ex-NHS nurses and provided low-grade post-operative care. The NHS relied on them as half-way houses to get patients out of NHS hospitals when they no longer needed intensive care but were not yet recovered enough to go home. These nurses did not want to spend time form-filling instead of caring for patients, and for each home there was always one of the 1000+ rules that was particularly hard for that given home to meet without vast expense or complication. So they died one by one. The ‘waiting times have increased’ story of Tony Blair’s early-2000 years — “If the NHS were a patient, she’d be on the critical list” — was caused by this and the resultant bed-blocking more than any other one cause.
The problem with waving the regulatory wand to “solve” a problem like this is that it tends to create perverse incentives so that the artificial target can be achieved — like this post from a couple of years back where the regulators dictated a maximum time a patient could be kept waiting for admission to A&E. The reaction of the people running the system was to change the definition of “admission” so that now patients’ timers don’t start running until they’re unloaded from the ambulance … so the end result is people are spending more time in the back of ambulances waiting outside the hospital until there’s an open slot. This meets the artificial target, but creates a worse situation because patients are still waiting as long (or longer), but now they’re also tying up ambulances from attending other emergency situations.
Back to ARC’s list of NHS problems:
2) The new 111 service is sending many more patients to A&E.
2.1) The service’s advice is very risk averse. The people who set up the process were afraid of the consequences of the statistical 1-in-a-million time when anything other than mega-risk-averse advice would see some consequence that would become a major news story blaming them.
2.2) Thanks to the post-1997 reforms, GPs work less hours on-call but the doctors are not just slacking off and doing nothing. The huge growth in regulation means they are in effect putting in as many hours as before, but on form-filling and admin to provide all the info the NHS and other government demand, to ensure they tick every box, etc. The out-of-hours on-call time they used to have is now swallowed by this work. So they are not in fact working less; it is the balance of what they are working on that has changed: less on healthcare, more on admin. Thus 111 must send people to A&E, not an on-call GP (and, of course, fewer on-call GPs mean more people phone 111).
From context, I assume the 111 service is a telephone health advisory service like Telehealth Ontario.
