Health and Social Care – the Tory Legacy:

 

David Cameron appeared in jovial mood both in the commons and on the steps of number 10 when he recently left office. Cameron joked at his last prime minister’s questions in the House:

“other than one meeting this afternoon with Her Majesty the Queen, my diary for the rest of the day is remarkably light“.

He listed his achievements in office and seemed not to be too bothered to be leaving.

It is not clear whether people, especially frail older people, will be so sanguine about his record.

When it comes to health and social care, ‘the nasty party’s’ record is appalling. Following largely on the heels of the Health and Social Care Act 2012 and Osborne’s deficit reduction targets for the public sector, and in the face of increasing demand, we have what Roy Lilley (2013) predicted, and called, ‘The big blue bit of doom’:

His diagram was prescient, as two reports below indicate. This is having an effect on staffing levels and thus on the quality of care people get.

 Jim Mackay, CEO of NHS Improvement, recently was reported in the Health Service Journal (July 2016):

“…Trusts exceeding the 1:8 nurse to patient ratio could be told “we can’t afford that”.  

Trusts, he suggested, should not automatically spend money on new staff or better facilities on the basis of a CQC report or in an attempt to meet Royal College standards.

Janet Davies CE of the RCN stated in reply

“This gives completely the wrong message to trusts, whose boards are responsible for the care, treatment and safety of their patients, by suggesting that finances are more important than patient care”.

 I’m afraid in the current context that major decision makers do think finances are more important than the quality of patient care.

 

The King’s Fund (2016) reports:

 

1. NHS providers and commissioners ended 2015/16 with a deficit of £1.85 billion – the largest aggregate deficit in NHS history
2. The scale of the deficit signifies a system buckling under the strain of huge financial and operational pressures.
3. The principal cause of the deficit is that funding has not kept pace with the increasing demand for services

 

The 2016 ADASS (Directors of Adult Social Services) budget survey report states:

 

1. Funding doesn’t match increased needs for, and costs of, care for older and disabled people.
2. More people’s lives are affected by reductions in social care funding. The quality of care is compromised: 82% of Directors report that more providers already face quality challenges as a result of the savings being made.
3. Directors are increasingly unclear where the funding needed will come from.
4. The continuity of the care market is under threat. Providers are increasingly selling up, closing homes or handing back the contract for the care they deliver to older or disabled people.
5. Investment in prevention is being further squeezed.
6. Reduction in funding for social care has wider impact. Directors feel that negative consequences due to budget cuts have already been felt right across health and social care and agreed particularly strongly with statements regarding issue faced by the wider sector:

• 85% thought that the NHS is under increased pressure
• 84% thought providers are facing financial difficulty
• 85% thought providers face quality challenges

 

NICE produced the original safe staffing guidance, centred on the idea that 1:8 was acceptable, provided somebody could wave a ‘red-flag’ and additional staff summoned. The guidance was based on the work of Anne Marie Rafferty et-al, who never said 1:8 was safe, it will not be.

Roger Watson (editor of Journal of Advanced Nursing), wrote for The Conversation UK on a recent study:  https://theconversation.com/youre-more-likely-to-survive-hospital-if-your-nurse-has-a-degree-61838 and thus provides more evidence of the strong correlation between education and outcomes. My worry is that in the UK we have drifted into ‘policy’ based evidence rather than EBP. Safe staffing levels may well be decided by finance directors (what can we afford) rather than sound evidence. This reminds me of the climate change ‘debate’ of which Roger Pielke applies the ‘iron law of economics’:

“When policies on emissions reductions collide with policies focused on economic growth, economic growth will win out every time. Climate policies should flow with the current of public opinion rather than against it, and efforts to sell the public on policies that will create short-term economic discomfort cannot succeed if that discomfort is perceived to be too great. Calls for asceticism and sacrifice are a nonstarter.”

So ‘when policies on nurse staffing collide with policies focused on deficit reduction, deficit reduction will win out every time. Staffing policies will flow with the current of finance directors/CEOs opinion, and efforts to sell them policies that may cost them cannot succeed if that cost is perceived to be too great’.

A question is that while there is a perception that degree nurses and lower nurse patient ratios will increase the wage bill, while not providing savings ‘on the bottom line’ then we have a political battle not an evidence battle. The externalities of FDs and CEOs decisions fall onto individuals, families and nurses rather than the organisations balance sheet. Do we have metrics that force the financial externalities back into the equation, or is there evidence that hospitals see this evidence and are changing staffing practice?

The Tory Legacy is that we are still chasing a target of deficit reduction within a wider ideology that is suspicious of public sector provision at best. The drift is towards more private provision with perhaps a base line that the tax payer pays and a system of tops ups and private insurance schemes. This will be sold as “we cannot afford the NHS as it is” to cover for much further privatisation, marketization and a return to individualising, rather than socialising, risk. Health and Social Care as we knew it is over. If you or your parents need caring for in older age, or if you need non urgent surgery, you will need to save more money to pay for it, take out private insurances, top up your pensions or pay more tax.