Why the A&E crisis is a tribute to the health service’s success

The A&E crisis is rapidly becoming the dominant story of the election.
Last week, Ed Miliband and David Cameron laid into each other in
blood-curdling terms. The
Tory denounced as “disgusting” his rival’s plan to
“weaponise” the NHS as a political issue; his Labour rival proclaimed that
this was “a crisis on his watch, as a result of his decisions”.

Then, on Friday, Circle Healthcare announced that it was withdrawing from its
contract to run Hinchingbrooke in Cambridgeshire, the only privately managed
NHS hospital in the country – shortly before the regulator announced that
Hinchingbrooke was being placed in special measures.

The pressures on the system are certainly intense. Last month, I visited the
Queen Elizabeth Hospital in Birmingham, one of the NHS’s flagships. I was
there in A&E on the night that the hospital went to the highest alert
level in its history, as the entire health system across the West Midlands
basically collapsed in the face of unprecedented demand: ambulance services
were overwhelmed, with patients left to bed down in A&E, some of them on
trolleys parked in the corridors.

As
I wrote in the Telegraph, the problem was not just the number of
patients coming in – though it has certainly soared. In the week of December
8-14, 440,428 people walked through the doors of A&E departments in
England. In the equivalent week in 2011, that figure was just 398,930.

But the real issue is the flow: for all manner of reasons, ranging from cuts
to social care to the health and safety culture that has grown up after the
Mid-Staffs disaster, it is becoming much harder to get people out of
hospital once they’re in it. As a result, perfectly fit people are sitting
in hospital beds, taking up space that’s desperately needed by new patients.
As the pressure on the system grows, the problems only grow worse.

Yet rather than blaming all this on politicians, or on structural failings
within the NHS, there’s another way to look at it – that it’s actually a
tribute to the health service’s success.

This may sound unlikely, but bear with me. The fundamental truth is that the
patients putting the squeeze on the NHS’s budget aren’t the ones with minor
injuries, who should have waited to see their GP – though they certainly
aren’t helping. No, the real problem patients are the ones I saw being
wheeled past me that night: the old, the cold and the frail. The majority of
the health budget, doctors’ time and hospital bed space is devoted to such
patients, especially those with chronic conditions such as dementia,
diabetes, arthritis and hypertension. It was telling that, of the dozens of
people who came in to be treated on that particular A&E shift, the ones
who actually needed a bed – and were left stranded when none were available
– were, to a man or woman, over the age of 75.

This is, obviously, due to the fact that we are all living longer. But that’s
not something that’s just magically happening. It’s due to improvements in
lifestyle, and in medical care.

“We had a junior doctor fairly recently who had never seen a heart attack,
because they’re now so rare,” says Dame Julie Moore, the hospital’s chief
executive. “Twenty or 30 years ago, loads of people in their forties or
fifties would be dropping dead. That’s a success for the NHS.”

You can see this on the wards. When I tried to guess the age of the patients,
I was invariably out by a good decade. Older people are spryer and healthier
than ever: one ward told me their eldest ever patient, aged 103, was still
not just driving a car but flying a plane.

We’re also getting better at looking after such patients when they do fall
ill. Margaret Harries, the nurse in charge of elderly care at the Queen
Elizabeth Hospital, explained how her team had won an award for developing a
way to help dementia sufferers and other vulnerable elderly people to eat
and drink. It was as simple as pouring them tea in proper cups and saucers,
at tables, rather than forcing them to drink from beakers in their beds.
Once they’d had a sip, they reached automatically for the biscuits, and
started chatting to their neighbours.

The wards under Harries’s supervision were carefully designed to be
dementia-friendly: there was a picture of a toilet on the door as well as
the usual WC symbol; dark strips had been removed from the floors because
they confused patients; doors were clearly outlined in paint; there were
bright, comfortable chairs at regular intervals in the corridors, so
patients could stop and watch the world go by.

The problem, of course, is that treating this demographic comes at a price.
Instead of dying cheaply of strokes and heart attacks brought on by drinking
and smoking, people arrive at hospital decades later, suffering from much
more complicated – and expensive – conditions. Caring for them after they’ve
left hospital also becomes more difficult – which is one reason why the
social care system is such a mess, with consequences that are reverberating
back into hospitals in the form of delayed discharges and blocked beds.

This is also where the fashionable theory that you can do much more care in
the community runs into difficulties. Yes, it would be great to expand
preventive medicine – to fit handrails costing tens of pounds that avert hip
operations that cost hundreds or thousands. But when you get into your
eighties and nineties, things will very often go wrong – with your heart or
lungs, say – that require a hospital to treat.

“We need to be doing the right things nearer to people’s homes, and ensuring
that we’ve got a plan for them,” says Harries. “But I think we’re kidding
ourselves if we think for one moment that with the increasing frailty and
complexity and age of the population we’ve got, we’re not going to be in a
situation where we ever won’t need to have older people in hospital. There
will always be people who have acute episodes, and therefore need this type
of care. But there are things we can put in place to optimise their care in
the community.”

In the longest of long terms, the NHS is engaged in a Sisyphean task – trying
to run up a down escalator, as Ken Clarke, a former health secretary, has
put it.

Tim Jones, one of the senior executives at the Queen Elizabeth Hospital,
outlined some of the exciting advances in prospect: personalised medicine,
the fact that devices adapted from computer games consoles can now be used
to monitor patients’ health at home. But he also acknowledged that helping
people to stay alive even longer may mean “they get diseases we never
thought of. People with multiple organ failure, which we’re now seeing in
intensive care – we never thought we’d get that.”

The NHS is by no means perfect. Off the top of my head, I could think of a
dozen ways to make the system work better, even just within the field of
elderly care: getting postmen to check on the local OAPs, as they do in
Jersey; giving patients iPad clones or webcams to connect them with their
GP, as they did in Airedale in Yorkshire; and above all un-gumming the
social care system to move fit but frail patients out of hospital faster.

But it’s worth reflecting, as the stories about an NHS crisis mount up, that
the problems we’re confronting are the problems of success – not so much of
a larger population, as of a population we’ve become so much better at
keeping alive.