The mystery at the heart of the National Health Service
IIT’S NOON in Milton Keynes, and a young woman returns after vocal cord surgery. Her breathing was controlled during the operation, so she is woken up cautiously, surrounded by bruised doctors. A chronic smoker, she gives off a series of dry coughs, trying to clear the accumulated phlegm – and doctors are once again exposed to any illnesses she may be carrying.
Throat surgery is known by a newly popular acronym: it is a AGP, or aerosol-generating procedure. The goal of ear, nose and throat surgery, explains Hamid Manji, clinical director of surgery at Milton Keynes University Hospital, is “to disturb this lining of the airways, whether pharyngeal, nasal or in this case vocal ”. This releases viruses, which is a problem during a pandemic.
A lot of this kind of surgery stopped last year. Now rooms are thoroughly cleaned between procedures, and patients must self-isolate and take a covid-19 test before arriving. The result is a huge backlog. Across England, and across all specialties, more than 5.1 million operations are waiting to be completed, the longest list since the records began. And expectations are getting longer: nearly 400,000 of these operations have been planned for more than a year, against 1,500 before the pandemic.
These numbers only tell part of the story. Some 4.6 million fewer people completed elective treatment in 2020 compared to the previous year, as patients avoided their GPs and hospitals closed to all but the sickest. The trend has not weakened this year (see graph). No one knows when, in what condition and in number, these missing patients will eventually present themselves. But a year without treatment will certainly have taken its toll.
All of this makes politicians nervous. “The public fully understands that the cause is now covid,” said a senior Conservative official. “The most difficult to explain is that [waiting lists] will continue to rise. Sajid Javid, the new Secretary of State for Health and Social Affairs, began to prepare the ground, warning in an article for the Mail on Sunday that the backlog will “get worse before it gets better.” The last time the lines were so long, under Tony Blair’s Labor government, polls showed that no issues bothered voters more.
In the early 2000s, Blair sought to reduce waiting lists by increasing inflation-adjusted health care spending by at least 6% per year. Boris Johnson’s government has so far pledged an additional £ 1.2bn ($ 1.7bn), or less than 1% of the pre-pandemic health services budget. More is expected in the next spending review, scheduled for later in the year. By then, the true length of the queue should be clearer. The same goes for the health service‘s ability to cope. “We have to figure out how fast we can go,” says Chris Hopson, CEO of NHS Suppliers, which represents hospitals.
One requirement will be to increase capacity. England has less CT or MRI scanners per person than any other European country, for example, so money has been set aside for 44 new community diagnostic centers over the next fiscal year. This should free up material for patients in hospitals. Additional funding from Covid-19 allows hospitals to recruit local private providers. But the hope is that the health service can also become more efficient.
“They now call us Bones R Us ”, laughs Krishna Vemulapalli, surgeon in east London. Last year, her hospital held a “bone week” to see how many joint replacements could be done in seven days and to identify bottlenecks. In six theaters, ten consultants worked from 8 a.m. to 8 p.m. An additional porter made sure there was no downtime between patients. Lunch breaks were staggered. The goal was 100 arthroplasties; they managed 135, most of the patients returning home the same day. The hospital has also attempted a “resentment week” (to maximize endoscopies) and is planning “”ENT 3.0 “(three times the normal number of ear, nose and throat surgeries).
Bone week was an extreme example of ‘high volume, low complexity’ (HVLC) surgery. The approach originated in London, helping to explain why the capital has been faster than other places in reducing waiting lists. The surgical process is broken down into stages, from when patients arrive at the hospital until their recovery, with hospitals being compared to the top 10% in terms of results and efficiency. By streamlining simple things, time is freed up for more delicate operations. The health service now wants to expand HVLC throughout the country and in all specialties.
NHS council papers promise “air cover” (extra money) to reward the best and support the laggards. However, money is not the only obstacle. Covid-19 continues to be another, as hospitalizations consume resources, cases lead to staff absences, and precautions slow things down. “Even though it only takes five minutes to clean the outpatient room, that’s five minutes out of 20 patients, and all of a sudden you’ve wasted an hour and a half,” says Joe Harrison, general manager of Milton Keynes Hospital Trust.
Mr Harrison credits free parking and coffee to all staff for helping with recruiting at Milton Keynes. Across the country, however, hiring problems will limit the recovery. Recruitment from abroad is increasingly difficult due to global shortages, notes Siva Anandaciva of the King’s Fund, a think tank. “You can start to expand the training places; you can start building medical schools, like the government is doing, ”he adds. “But will it bear fruit by the end of the legislature?” Probably not.”
Recovery is not the only task facing hospital managers, either. A new NHS The bill released on July 7 forces them to move forward with plans to take health care out of hospitals and better integrate it with social care. “I was talking to an operations manager,” says Mr. Anandaciva, “and he was like,“ I feel like I have two jobs: one is to go for the largest elective order book in two decades; the other is to make the biggest transformational change in the way health care is planned and delivered in 20 years.
Indeed, the reforms introduced in the early 2000s by Labor to deal with waiting lists are now being undone. Even with the emphasis on waiting lists and a lot of money, it took the Labor Party the best part of a decade to achieve its goals. Few people expect a quick resolution this time around, but a date is looming. “Health officials know ministers will focus on the next general election,” Hopson said. The government came to power promising to protect NHS. Any breach of this obligation will be penalized. ■
This article appeared in the Great Britain section of the print edition under the headline ‘The Mystery at the Heart of the NHS’