Healthcare: hospitals at home

By Richard North - January 21, 2024

“Even as international emergencies rage and the cost-of-living crisis bites, the NHS will be one of the defining issues at the general election”, says The Sunday Times.

The paper immediately goes on to tell us that, “with waiting lists sky high, A&E departments overwhelmed and GPs struggling to keep up with demand, Labour will do all it can to capitalise on public concern and staff discontent”.

This is part of the opening salvo of a long interview of Starmer in the current edition, devoted to the leader of the opposition’s plans “to reform our broken NHS”, an issue which is already being given considerable attention in the legacy media.

One recent contribution comes from the Telegraph’s Janet Daley who shares the pessimism of the ST but has her own take on the reason why the service is failing. “GPs have all the wrong priorities”, her headline complains, adding that “it’s slowly killing the NHS”.

More specifically, her beef is that doctors say they are too busy to see patients, yet they are “hard at work drumming up business from healthy people”, running all kinds of preventative schemes, the needs of the present having to compete “with a new and probably unrealistic ambition to eliminate, or drastically reduce, future need”.

By way of an alternative, if you prefer, you can have the low drone of Polly Toynbee who also focuses on GPs, telling us that, “as the Tories slash primary-care funding, our doctors are doing their best in terrible circumstances”.

Here thesis is that the “rightwing press” is dumping much of the blame for the inadequacies of the NHS on the lack of GP access, citing the Mail as her usual hate figure, and not without a certain amount of justification.

Late last year, that paper was parading the headline: “Just when you thought it couldn’t get any harder to see a GP!”, bemoaning a call by “Doctors’ leaders” for a “safe limit” of 25 appointments a day, leaving campaigners to warn that patients will “flood A&E”, while accusing practices of “doing what they like”.

There well be merit in both stances, although Daley gets taken to task in her own comments, as one post tells her that most of the preventative work carried out by GP surgeries does not require GP engagement, largely handled by nurses and other ancillary staff.

As for Toynbee, she cites the Health Services Journal which told us in January that the share of NHS spending on GPs was falling to its lowest in eight years, at only 8.4 percent of the budget, but even then the picture does not seem to be as straightforward as she would have us believe.

For instance, in late November, the Department of Health and Social Care announced that for the year to October 2023, there had been 50.9 million additional GP appointments delivered when compared to October 2019.

Furthermore, the DHSC says, the government’s delivery plan for primary care is providing GPs with £240 million to support measures which will improve GP contact arrangements.

This ebb and flow of argument, however, typifies the political nature of the healthcare debate, which took on a sharp edge last week when an edited Sky News clip apparently (but falsely) showed Sunak laughing at an ex-NHS worker who confronted him on a walkabout over lengthy waiting lists.

For the impending general election campaign, this is probably going to be the shape of things to come, although I was slightly encouraged by Labour’s “Mission Plan” which commits to shifting services out of hospitals and into the community.

The plan, as I noted earlier, is to transform the NHS into a “Neighbourhood Health Service”, as much as it is a National Health Service, “with healthcare on your doorstep, there for you when you need it. For nearly every sick person the best bed for them to recover in is their own – in their home”.

Speaking personally, I am convinced that this is the right way to go, not least from my personal experience of hospital care about which I wrote in July last, when I had the misfortune to suffer from a severe dose of cellulitis.

This is an infection triggered (in the main) by Streptococcus Group A bacteria (labelled GAS), which have the interesting property of being able to evade the normal immune response. If left untreated, the condition can develop very quickly into a systemic infection with a 25 percent mortality rate, which tends to concentrate the mind.

Unfortunately, the same properties which enable the bacteria to evade the immune response means there is very little acquired immunity, so reinfection after initial recovery is relatively common and  just as debilitating.

Currently, I’m going through my fourth episode, after the infection flared up mid-week last. By mid-evening, with the aid of past experience, I had decided it was looking dangerous so, with the GP surgery closed, I phoned the (much-under-rated) 111 service.

I got an intelligent, calm responder who talked me through the issues and then, despite my willingness to drive to an out-of-hours clinic, insisted on sending an ambulance.

This arrived in 20 minutes, with two crew who could not have been more helpful. They were able to confirm the condition and called into their system for advice. A senior paramedic was despatched who arrived shortly afterwards and was able to supply a life-saving holding dose of antibiotics.

Following through the next morning, I rang my GP appointment line and got through in about 40 minutes after three tries. The call handler listened, checked with her supervisor and came back to offer me a doctor’s appointment for six minutes ahead – yes, six minutes. I live a block away from the GP and have to admit that I was two minutes late.

The doctor was superb, checked me over, gave some advice and issued a prescription for a full course of antibiotics. A quick drive to the pharmacy and I was back home, job sorted and on the mend. Despite all the complaints and publicity on NHS decline, the service was flawless. One could not ask for more.

In my experiences over the last six months (with the continuous episodes of cellulitis), community services, including the superbly efficient district nurse service, have worked extremely well.

In conversation with one of the ambulance crew, last week, he pointed out that crews were often able to treat a wide range of conditions on-scene, using their vehicle as a mobile treatment centre.

This is a concept which has been pioneered by the military, even to the extent of kitting out helicopters as emergency operating theatres.

Even now, many conditions (even quite serious) can be treated, initially in civilian ambulances or in patients’ home (with community nursing follow-up), assisted by modern technology such as video links to medical specialists and online interfaces for monitoring equipment.

The ambulance crew who attended me acknowledged that many people are being admitted to hospitals who didn’t need to be there, who could be treated more economically outside the hospital system.

Sometimes this is because the patients themselves insist on being admitted, and there do appear to be socio-economic influences behind treatment preferences, which need to be addressed.

Latterly, the home care concept has morphed into something more ambitious as the virtual ward system, of which – amongst others – the Economist writes favourably, although patients prefer the more user-friendly label of “hospital at home”.

It is readily conceded that virtual wards are not “a silver bullet”, despite their value in reducing hospital admissions and cutting bed occupancy.

To my mind, the NHS should not allow itself to be mesmerised by technology and expand this concept into a vast, new bureaucratic system. Rather, there should be organic change, with development and improvement of existing home services.

Nevertheless, Starmer’s inclusion of a provision for greater investment in community care is good news. The current system, centred on huge district hospitals, soaks up money on bricks and mortar, and bloated establishments. I would demolish at least half of them and reinvest the savings on real patient care. Military medicine has shown what can be done in the field. We should follow its lead.

Sadly, though, in his interview with the ST, Starmer mentions the shift away from hospitals towards community care only once, and then is passing. He mentioned it not at all in his New Year speech which makes me wonder whether he is personally committed to the idea.

However, if the politicians wanted “clear blue water” on NHS policy, this would be a useful avenue to explore, as a relief from the usual bickering over more money and beds. It would certainly have my vote.