Thursday 2 April 2015

Availability - do we really need a 24 hour health service?

The ICE has been trying to stimulate debate about the availability of infrastructure: for example, to what extent is it more resilient or cost effective to allow trains not to run or close a main road in cases of extreme weather? During the 2007 floods, most of Gloucestershire lost power (some people were not reconnected for 12 days). Most people believe this is not acceptable, but the answer may not lie solely in making the national grid so robust it can cope with high winds and powerful water currents, but also by beefing up secondary sources of power (whether generators or solar panels) and accepting that no system works 100% of the time.

After all, there is no railway signal box in the country that relies on only one source of power: most have some combination of having two cables in from different power sources, an 8 or 12 hour battery, a small transformer to get low voltage supply off the 25kV traction power lines and a plug at the back where you can turn up and plug in a generator. And business continuity matters too: suppliers to Network Rail must demonstrate that they have a business continuity plan in place.

This was demonstrated to me one day when there was a power cut for several hours in central York. Most people in my engineering design office went home as the computers were off, but I took my laptop over the road to Network Rail’s office, where I could hot-desk with my Network Rail counterparts as part of collaborative working arrangements on a major project. No sign of a power cut there: the back up generator kicked in with a few seconds and powered essential systems so that the hub of the North Eastern region was still up and running.

So, what is an acceptable level of “availability”? Doctors have been raising the same question about the health service. Under pressure to run services all the time, the BMA have been asking for a debate about how available we need healthcare to be.
Obviously no-one is arguing about whether hospitals and A&E need to provide 24 hour cover 365 days of the year, and we certainly need to ensure safe staffing levels at all times (it is fairly shocking that you are more likely to die after surgery if you have an operation at the weekend rather than during the week, due to poor staffing). But at a time when our NHS is under increasing strain, is this really necessary for GPs or routine operations?

While I massively appreciate being able to do routine appointments such as asthma review and flu jab at the late night or early morning surgeries so that it doesn't interfere too much with my working life, my doctor doesn't need to work late or early more than once a week to meet this demand. If I was suffering from an acute illness, I wouldn't be at work anyway. Most GPs find that it is mainly the very young and very old take up most of their time, neither of which are unavailable during office hours. There are concerns from many people that it is very difficult to get an appointment with their GP, but I would really like to see these figures divided into acute and routine cases, as it is otherwise hard to draw any conclusions. And is the solution really going to be extended GP opening hours every day, rather than more GPs employed during normal working hours to meet the demand?

The problem is, there are costs involved with long hours not only financially but affecting morale and the staff who work under great pressure. It is ironic that the NHS are experts in treating mental health but working there makes you ill: rates of stress, depression and anxiety among NHS staff are reaching record levels. Over New Year, a friend was talking about the difficulty of being an NHS manager with a 24 hour rota to fill, where budget constraints mean she cannot employ any extra staff to fill the rotas but many staff are not able to work certain shifts (some due to ill health affecting their ability to work night shifts, others due to family responsibilities).

So how do you achieve a safe level of staffing for GPs and hospitals without pushing your staff over the edge? The general election is likely to see a lot of debate about the role and funding for the NHS, and I’d like to see much more openness about the difficulties faced by the NHS right now, and perhaps some more reasonable expectations about when and how we receive our healthcare.

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