Sunday 11 January 2015

When Saturday Comes: Politics, Health and Football

The NHS is political football, whatever David Cameron says. Healthcare policy is realised through relentless, tribal warfare of deep-seated ideologies and the fierce factional loyalties of rival die-hard supporters. Like Rangers v Celtic, Real Madrid v Barcelona, in the Healthcare Championship, there is an historic struggle of ideas and identity going on, but with vested financial and political interests manipulating the conflict in the background. The players on the pitch, the NHS staff, want to put in a shift, score goals and defend well, but the refereeing is inconsistent and frankly a little suspect.

Over recent weeks, many grudge matches have been played out over the UK A&E overcrowding crisis. Every lobby group jumps in to the tackles with their own theory as to the cause. According to them, it is variously the fault of the public for attending with trivial hang-nails, the GPs for not liking being out in the dark or working weekends, the A&E staff for being risk averse and admitting everybody, the closure of local hospitals by cynical politicians, the global financial crisis, the Barnet formula in Scotland, the elderly population, collapse of social care, insufficient district nursing and so on. Every side sets out to secure maximum points and their win bonuses, but no one gets shown a yellow card if the play was unsporting or goals should have been clearly disallowed. Maybe the game could be massively improved if referees looked to reliable data and reproducible evidence rather than the shrill appeals for penalties from the partisan stands or players on the pitch.

In Scotland (using Auditor General data), the numbers of emergency attendances have been going up, but only gradually and slowly (15% in 10 years). On the other hand, the number of elective (planned) admissions has risen rapidly (36%) to meet crowd-pleasing treatment guarantees. The length of stay has dropped in keeping with a degree of modernisation, but this has been way offset by a substantial reduction in bed numbers (7%). The net effect of these changes is increased occupancy, and progressively fewer beds to put emergency patients in. Once a crucial hospital occupancy tipping point is reached, the system collapses because patients are admitted here, there and everywhere, get poorer care and stay longer thus compounding the bed problem exponentially. The Emergency Department then becomes a holding warehouse for new admissions, the staff get burnt out and irritable, and the occasional patient who wanders in with a minor complaint (even though international evidence clearly shows that this group do not ever cause overcrowding) gets the blame for the whole debacle. Losing every week like this has been enough to cause some staff to quit their NHS club and look for an overseas team.

The use of impartial evidence focusing on capacity and occupancy could therefore be the match-winning strategy to resolve the issue of A&E overcrowding. Globally though, the biggest healthcare game is between the self-reliance, competition and market forces of the private sector versus the equity, co-operation and cost-effectiveness of publicly provided services. Here too, use of scores from fairly conducted matches rather than the opinion of pundits may improve the sport for everyone. In a recent properly refereed international play-off, for example, the Commonwealth Fund reported the UK NHS to have been the most cost-effective and equitable healthcare system in the world. Some heavily sponsored teams setting out to take on the NHS may indeed find a level playing field difficult to manage. In fact one such team, Circle United in Cambridge, recently suffered such a humiliating defeat that they voluntarily dropped out of the entire league and are now restricting themselves to playing Rounders.

When Saturday comes, the NHS staff will boot-up and trot onto the pitch. Their long-term performance in the league will crucially depend on their manager, the board of the club but also critically, the backing of the fans.