The Blog

Mind the Gap


The Spending Review rewards high-tech, hospital services and cuts the less sexy services which are essential to keep Londoners healthy. Next day appointments, named GPs and seven day access are all well and good, but there is neither the time, money or morale for many GPs within the profession to deliver them at present.

Improving access for patients is about getting them to the right destination by creating a flow through the system, not spreading hard pressed staff more thinly over longer opening hours. Most of the time the right destination isn't a hospital, but patients can't keep flowing without high-quality consultations from clinicians who have time to correctly diagnose, community health which is available and has capacity, and social and mental health care professionals, who can effectively manage chronic and long-term conditions.

Front-loading £3.8bn of the government's already promised £8bn additional investment in health by 2020 sounds good, but it's not much when set against the record £2bn sinkhole that has suddenly opened up in secondary care and the ever-growing pressures of winter. £750m of the front-loaded sum will be used to prop-up the GP extended access pilots; part of the rationale for these is reducing A&E admissions, but the pilots cost £45m in order to reduce A&E admissions by the equivalent of only £3.2m. None of this front-loading negates the requirement of £22bn in efficiency savings by 2020, in what is already the world's most efficient health service.

The main concern I have with this year's Spending Review is the cuts are falling in areas which offer the best returns in terms of pounds spent to patients cured, or more to the point not getting ill in the first place. National Audit Office figures show that a one percent increase in spending on community services is associated with a three percent reduction in A&E attendance. Cutting social care and asking councils to make up the difference by raising money directly via extra council tax penalises London's many deprived boroughs, with the greatest need for these services and the least ability to pay for them.

Government figures state that London is the worst area in England for childhood obesity - 11 percent of children in primary school reception classes are obese, rising to 22 percent by year six. This frequently results in diabetes, which will affect 569,000, or nine percent, of Londoners by 2020. Nationally, 2.9 million Britons will live with one or more long-term conditions by 2018, up a million from 2008. Cuts to local council budgets see sports and education programmes axed, removing the preventative measures that are most effective in treating obesity. Public health spending is set to fall by £200m a year, that's £800m in total across the next four years, removing further vital preventative programmes.

With less funding for practices and community services such as mental health workers, social services, district nurses and health visitors, the result is that waiting and consultation rooms get gridlocked, GPs and staff are overwhelmed, and signs of illness can be missed as more consultations are squeezed into less real time. On top of this there is ever expanding NHS bureaucracy, demanding data down to the minutest detail by yesterday, and politically driven requirements with no proven health outcomes, that practices are required to meet. With all this going on it's no wonder that our consultation time is eaten up by the tapping of keys as each figure is recorded and box ticked, before a GP can do what they do best, and treat us as a whole person, not just a collection of symptoms.

Think of the flow through the health system like a journey into London: a bus to the train station, a train to the Tube stop, a Tube into town and a Boris bike to cover the last couple of miles. Everyone knows the iconic Tube, but without all the other parts of the transport infrastructure people don't get where they're going. Once one part fails people get stuck on the other parts, the flow stops and the whole network begins to creak. The government's Spending Review doesn't invest in the whole network, just the headline grabbers, so rails buckle and traffic jams form as patients can't flow through general practice, hospitals and community services. Those with the financial means can get around the blockages, with private healthcare. In the same way a traveller can pay another fare to switch trains or flag a cab, someone can choose to "fast track" through the health system, but the poorest have to keep going with what they have, cycling on crowded roads, staying on the bus because they've already paid or waiting on the platform until they can squeeze into the last remaining gap.

We need to clear the roadblocks, fix the broken signals and get things flowing in the NHS - by stripping those parts of the system which don't add value to, or even drain it away from, the patient having a consultation. We can do this at practice level by prioritising the navigation and coordination of the care patients go through, simplifying complex health and wellbeing journeys. GPs and commissioners need to work together to increase capacity so that the right people are in the right places, providing the right services. Think of when your train arrives at the station and your bus is already on the stand outside. It's not about integrating everything into one single network, it's about coordinating the different networks.

Critically, we need the whole network to work together, acknowledging that neither GPs or hospitals, or social and community care have a monopoly on answers. Any may be the 'stop' on the network where patients get the right care and can exit, but they are just as likely to be the 'stop' where patients change and continue their flow on to the right place for them, not just the system. Together commissioners, providers and local medical committees should work with stakeholders and partners at a local level to promote education and prevention, awareness of community, mental health, social and voluntary services. Developed and collaborative commissioning will then expand or contract services as they are needed, rather than simply as budgetary pressures dictate.

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