The five steps to getting NHS off life support and back to health

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Dr Andy Stein, the author of a forthcoming book, Understanding the NHS, believes the fortunes of the health system could be turned around in five years if the political impetus is there. But it would mean governments from all parties looking beyond their own term in office and at the greater good of the country, he said.

Dr Stein says measures like splitting elective and emergency care and seven-day working would have a huge effect on NHS performance and get rid of most waiting lists.

The social care system needs to be integrated with the NHS and the IT needs to be resolved, he says.

He also calls for a minister of public health, who would oversee provisions for any future pandemic.

Here Dr Stein outlines the moves he believes demonstrate that fixing the NHS needn’t be “a pipe dream”.

He explained: “As we move into a post-Covid world and learn to live with the virus, we now have to deal with the almost six million on the waiting lists for operations.

“That is nearly 10 per cent of the population. We have to realise that we’ve had an imbalance and an over focus on one disease.

“We cannot go back to how we were. The system has passed its tipping point. When a complex system breaks down it is not fixable without slow radical change.

“People are already dying waiting for operations and hip replacements. This is happening because the waiting list is so massive.

“There are five things needed to flip it round but this could take around five years and each needs its own project. The tragedy of healthcare is that governments are generally not in long enough to fix recalcitrant problems of our time.

Also, successive ministers of health come into the role blind, with no experience of healthcare. It takes two years for them to know what to do, then they move on.

“The interesting thing is that all these things are fixable. This is not a pipe dream of unrealistic stuff.”

1. Split emergency and elective care

Without doing this you cannot deal with waiting lists. Full stop. At the moment we mix hot and cold care, which is to say emergency surgery with surgery such as hip operations.

However, because there are not enough beds, we always prioritise the frail and most vulnerable as they are more likely to die. These emergencies come in and mean that elective surgery is cancelled.

But people can die waiting for hip operations and quality of life can be insufferable.

If a cancer operation is delayed for just one month, the patient may die much earlier than they would have done.

In a normal large hospital there are about 20 surgical and 10 orthopaedic emergency operations a day.

They may have 50 planned, with a heavy orthopaedic component as well. And many of these get cancelled.

Through Covid we learnt that private operators could carry out surgery near acute hospitals and we could do this again, so that you have elective surgery carried out in a different building.

We could also build two different buildings side-by-side, separated by a corridor but not wide enough for a trolley, so that emergencies could not supersede. Private operators are good at running such surgical treatment centres (or “hubs”).

2. Seven-day working week

I would run this together with point number one. I believe that 60 percent and perhaps up to 80 percent of NHS problems could be fixed by splitting emergency and elective care, and working seven days a week would save tens of thousands of lives per year.

Because of the lack of a split between emergency and elective care, and the lack of a seven-day working week, when emergencies come at the weekend we don’t discharge patients which clogs up beds in the surgical wards.

The proposed private sector’s surgical treatment centres would never compromise their beds for emergencies.

3. Information technology

Successive governments over the past 15 years have tried to create a national NHS electronic patient record and this has failed. On a local and sub-regional level, the data are not compatible.

GPs, hospitals, pharmacies, mental health and ambulances do not know what each other is doing. This leads to many mistakes, especially related to prescribing medicines.

Theoretically, it’s very simple to do when you have numbers in thousands and tens of thousands.

However, when you have millions of patients with millions of pieces of information, it becomes much more difficult. These things are surmountable with money, and of course Google, Tesco and Amazon have done it.

However, the NHS has substandard systems. Many hospitals are bringing in mainly American IT systems now, including Cerner and EPIC. These are very expensive.

For a large hospital group, even a cheaper system can cost £7million a year to maintain.

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Once you start scaling it up, the cost is large (about £300million a year for England), even though this is tiny compared to the amount of money we spent on Covid.

Just the £16billion we spent on Covid in the first year for test and trace would have paid for surgical hubs, regional IT systems and gone a long way to solving waiting lists.

4. Social care

Twenty percent of patients who leave hospital have complex needs. They are usually frail and elderly and need extra care, either at home or in care homes.

The social care system and health system do not connect between councils and hospitals. For example, if you have a frail and elderly person in a nursing home who fractures their neck or femur and is sent to hospital, they first take priority over planned operations.

Four weeks later when they are ready to go home they are stuck in hospital at £400 a day. Why won’t nursing homes take them back? It is because everyone gets paid.

The hospital is paid £400 a day to keep them there and the nursing home is paid for the bed even if no one is in it. If everyone’s getting paid then there is no incentive to get people back.

Also social care, like health, largely works five days a week. So we cannot discharge these complex patients at weekends, further jamming hospitals and lengthening waiting lists.

The fact that the Department of Health and Social Care is called that is a misnomer. Health does not run social care in the UK. It is the Department for Levelling Up, Housing and Communities (ie local government, the councils).

The budget for health is £139billion a year, versus £29billion for local government. The solution is to put social care into the NHS.

If health and social care really worked as one, hard decisions would have to be made shifting money towards social care.

5. Public health

Public health is also outside the NHS and this is wrong. We need to reinstate the Ministry of Public Health and a minister of Public Health should share an office with Sajid Javid and have equal status in the Cabinet. This is for the prevention of disease and mitigation. Their first task should be to run a pandemic planning exercise week every year. We need to be ready for the next one that could be worse than Covid.

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