Funding Gap

I can feel the creaking in the system every day at work in the last few weeks. There are no spare beds. There is always a bottleneck in healthcare – be it access to the MRI scanner, shortages of antibiotics,* insufficient theatre time or just plain money, but it seems so…pointless to have that bottleneck simply be that there aren’t enough places for sick people to lie down.

Yesterday I was at work. I was on a clerking shift, and I spent most of my shift clerking in new patients not in AMU, but in the emergency department. “Why abandon your department and head for the hills?” you ask? There isn’t space in the hospital to move these patients out of ED, so they sit there, unable to come up. Flow, again.

Obviously the solution to this problem is to have more beds. More beds means you need more nursing staff and more doctors, and ultimately more hospital to put the beds and staff in. More hospital, beds and staff cost more money, and more money is not very forthcoming. In fact, if anything, less money is forthcoming. The government, although they have stated that they are not cutting the NHS, have instigated an efficiency drive in one of the most efficient healthcare systems per unit cash in the world. It was needed – there was some streamlining to be done – but now there is little left to be streamlined or cut without directly impacting front-line services. The efficiency drive continues to be forced and in order to make the savings, direct cuts to the front line are beginning to appear.

Now, lets talk about why is everything falling apart now, when the efficiency drive started ages ago? In part, this is due to moving goalposts – the government reduced the 4-hour target from 98% to 95% during the ‘efficiency drive’ and things have only just caught up. Moving goalposts don’t explain the bed situation, but they do explain why A&E is only now not making targets. Moving goalposts are also irrelevant when you consider that the percentage of patients being seen, treated and either admitted or discharged in 4 hours is now the worst it’s been in a decade.

There’s more. My next point is about ideal bed occupancy – the oft-quoted figure is 85% average occupancy. This allows a decent ‘buffer’ for surges in patient attendances (such as when a particularly virulent ‘flu goes around setting off all the asthmatic/COPD patients) or closed-down beds (such as when norovirus breaks out and closes a ward). Sadly, that 15% extra bed capacity can also be cut to improve efficiency, which is what has happened. It is cheaper to run fewer beds, but when you run at 99% capacity (let alone >100%) and you have a an extra 20 admissions, you’re insta-stuffed.

Speaking of more admissions, more people ARE attending hospital. In terms of A&E, according to NHS England figures, there were 279,375 more attendances between October-December 2014 than one year prior. We can argue about why this is until the cows come home, but you can consider a shortage of GPs, an aging population, and advances in treating chronic conditions initially and see where that takes you. Don’t even get me started on the endless media slating of GPs.

Social care. The NHS may have kept their budget, efficiency drive or no, but the local government councils have not. The social care budget comes out of their pockets, not the NHS, and as a result social care has been cut, actively. This blocks beds from the other end – people needing social care but who are medically fit for discharge (‘MFFD’) are unable to leave hospital and take up acute beds, sometimes for weeks.

If that wasn’t enough to consider, it’s also wintertime. Something to think about. And despite what Mr. Cameron says, this is not just a ‘busy period’. Swindon had to set up a tent in the car park to treat patients. If that is just a busy day then I dread to think what the governments opinion of an actual crisis is.

I’m glad this is all over the news. It needs to be. MAIN-Hospital-Tent*which are surprisingly common…currently it’s chloramphenicol. Earlier this year, vancomycin.


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