10 Point Plan to Save Emergency Care

Saturday, January 14, 2017
Dr. Jon Stanley


Crisis, crisis, oh the humanity, it's unprecedented I tell you, the roof is caving in, urgent care is broken...actually none of this is true.

The NHS is doing its job as a state monopsony, reducing spending to the absolute minimum as defined by outrage that builds to the point of the government losing power at the next election. Crisis is the sensor of monopsony in a democracy and those who rail against the government are just another cog in the machine, the Zion in the Matrix that keeps the machines in control. 

That Labour is so useless and that we increasingly see bonds between the old and young in our society fragment mean the "crisis" just has to be a lot worse than normal. We need to hear more screams, more pain, more disaster to care enough to demand something is done. Or the machine has to be made more sensitive to the noise of the crowd.

This does not mean that urgent care cannot be far better than it already is. There is much that can be done but it specifically needs to move away from using crisis as a sensor for government and speak directly to those senior levels of management and work with them to have a machine that is fit for purpose: making the sensor more sensitive.

We need to accept we are seeing a creditor/debtor stand-off of a very focal kind: those with property who are gaining without labouring and those without property who are labouring without gaining, something that used to be at the heart of both Labour and Conservative policy. In place of labour taxation, we must return to the contributory principle, where those able to pay will and in times of immense capital gains made possible through the credit system we have to do things a little different.

We must now see the same narrow perspective and clever accounting that saw branch lines and little stations closed to save cash during the Beeching Axe now applied to remote and rural A&Es, as well as to some in the capital where services are deemed "condensable". Instead of branch line closure, simply cut passenger flows to large stations. So too does closing smaller A&Es mean patients move to other centres already struggling, and they do so using ambulances.

So here is my ten point plan. There will be many mooted of course but none will look specifically at the sensor. 

1. Stop cutting urgent care capacity.

There can really be no suggestion now given this annual self-abuse we see in A&E that any more A&Es can be cut. Some indeed should be reopened.

2. Stop defrauding A&E.

The marginal rate rule that deliberately underpays for A&E episodes is fraudulent when audits show the money saved is simply disappearing down the drain in GP land.

3. Abolish the four hour wait, at least during winter.

We know now quite conclusively that this can only at best be a three season a year target so why try and prove the point otherwise? It's over, really.

4. Transfer at least £500 million pounds to CCGs directly from the DfID.

Start with that portion not yet even spent but sitting in bank accounts. We know from various estimates at least this amount goes unclaimed every year. So just pay up. All unpaid medical bills from foreigners should be recovered too their countries' aid programmes and the details sent back to those governments to collect their aid back from their citizens. They are not our citizens and frankly not our problem.

5. Split all urgent care providers away from Foundation Trusts and A&Es.

Merge all ambulance trusts with these direct contact centres and establish special board that covers all over England. This would be the one stop shop for all unplanned care and could be integrated. It would also take over all GP out of hours services and be run regionally, as ambulances are now. Crucially and perhaps most controversially, this new board should be headed by a cabinet minister that may or may not be the Secretary of State for Health but would nonetheless chair COBRA meetings and be directly responsible for resilience of emergency healthcare. This amplifies the sensor as it focuses the minister on this sector of healthcare.

This proposes making unplanned care operationally independent of the NHS and treating it as, literally, the third emergency service.

6. Stop blaming foreigners.

That DfID money mentioned above will cover this population anyway and the main issue afterwards for clinical staff is actually how good a patients English is. This is an immigration issue. We should not be letting people in who cannot speak English unless they have a robust means of communication. Interpreters in A&E is extremely disruptive and telephone interpretations are no substitute to direct elicitation patient history. I've been there and done it and it results in a poor service and creates delays. The Bow Group has published how government can ensure foreigners pay their way fairly.

7. Senior specialty registrars in their final two years of training can have their training extended by six months and then serve two three month Urgent Care secondments.

So they would do nine months on training, 3 months on urgent care twice. This would ease stresses on registrars whose current on calls result in arduous and a highly variable workload. Many more could be non-resident on call if a senior registrar was based in A&E. The same registrars could then be removed from A&E if urgent surgery or procedures were required. Given how precious these training places are there is no reason these secondments could not be written into training contracts.

8. Redefine the boundaries of CCGs so overly those of local authorities and have councillors appointed onto CCG boards so that all commissioning is run by local authorities.

That is the only credible way health and social care can now be merged. This would prevent local authorities gaming the system by not providing cheaper social care beds to decant patients from hospital. One local authority budget for social care and for commissioning.

9. Initiatives proven to reduce admissions such as improvements to domestic heating to cut admissions for chest problems need funding through these combined health and social care authorities.

This is not social prescribing and GPs should be left alone to be ordinary attendant physicians in the community rather than dilute their role with social administration. We have been doing this the wrong way round for a long time.

10. Be honest about our tax system and how property owners have enjoyed incredible capital gains at the expense of young people.

If we are not prepared to care about this we cannot expect young people to care about the state of public services. Many countries from Denmark to Hong Kong have property value taxation as part of raising overall revenues and in a globalised world ever higher taxes on income does not seem wise. That tax could be applied only to say the equity of the property and not to the mortgaged portion.

There are many more ideas of course, too many to list. This is not a crisis we are seeing but simply a choice we have as a nation chosen to make.

We don't want to pay anymore in income taxes. We cherish government targets, or seem to. We refuse to accept that an ageing population requires almost as much social and medical input over time.

We haven't even touched on how no-default divorce has left us with a legacy of silver singles and single parents who have no back up when they struggle. That's an article all by itself. 

This is perfectly soluble if we wish it to be, most other countries seem to cope very well.

Dr. Jon Stanley is Health Research Fellow at the Bow Group, a Junior Doctor and a Member of the Royal College of Surgeons