This week somehow my blog got into Pulse ( a national GP medical magazine )and got some comments… I wondered if I should reply there but decide to here instead….
It is true that to say closing beds in acute hospitals and moving people into the community isn’t the whole answer. Of course it isn’t. The problems in the NHS are complex. As I have discussed before: if there were easy fixes we would have found them, done them by now. The problems for North Yorkshire are complex too and we are trying to do the right things to begin to fix them, not believing there is a magic answer.
I know two things though. Most people would like to stay at home if they could, when they get ill. In our area a recent bed audit showed us that on average 30% of people were in beds they didn’t need to be in and 90% of the patients in one of our community hospitals could have been cared for at home if the care was available.
Hospitals are changing. The pressures put on them like changes in doctors’ hours, training, working life aspirations and safety standards mean that you need larger hospitals to sustain services. For a rural area that means people travelling further for their care. But does everyone have to travel further?
We call it “gone off their legs” when a (usually) elderly person who has been managing at home okay suddenly doesn’t. It is often caused by something relatively small happening, medically speaking: a urine infection, a minor fall, and suddenly someone who was doing okay isn’t anymore. Off their legs that can’t go to the bathroom, get themselves food, change their clothes. Not able to cope, they end up in hospital Going into hospital can make things worse, It is unfamiliar, and confusing and that person who has “ gone off their legs” then becomes “confused” as well, and it can take weeks to get them home. We should try and keep them at home in the first place but we can’t, because we don’t have enough staff in the community to take care of them.
Over the years staffing levels in community services in our area have been reduced because of the financial situation, whilst spending in acute hospitals continued to increase. Why? Well it was simple really. The community services and those services were paid by “block” which means they were given a lump of money and had to manage within it to do everything asked of them. By contrast Acute trusts (providing hospital based services) are paid for each bit of work they do.
It is like taking two people: one being paid a salary for the job they do and a second being paid by the number of things they make each day. When demand is increasing and there isn’t any more money it is easier not increase the salaried person wage because they will just go on doing the job anyway, doing more for the same money whilst the person paid per thing will simply be paid more as the number of things they do each day increases. Add to that the fact that there is no restriction on the number of things that person is allowed to do in a day, so no control over what they can earn. Who would you rather be in difficult times? So community services got left behind.
No one is saying hospital care is bad and community care is good. What I am saying is people shouldn’t be in hospitals if they don’t need to be.
Will it sort out our costs? Probably not. Maybe it is a small step on the way. In a large rural area with people having to travel long distances to hospital anyway it is surely a good thing to do as long as it provides high quality care and doesn’t cost any more money.
I am a GP and I am a practical problem-solver by trade. Give me a problem - I will try to sort it out. There are lots of bits of the system I can’t change. I can’t change the funding formula. I can’t change the system which pays for care. I can, however, look at a small bit of our system that looks broken and try to mend it. No one knows what the outcome of that fix might be, or what the unintended consequences might be; we can only try and then move on, then fix the next bit.
Will that fundamentally mend the system? I am not naive enough to think so. But, if I can make things a little better for some of the people who live in this area, then that is something worth doing. If someone goes off their legs can be managed at home and helped to get better in their own place with their usual food and clothes and surroundings and they get better, then it was worth doing.. And it is better than spending endless hours arguing about how we make things better on a grade scale and changing nothing.
